Medical policy updates

Read about the latest medical policy changes for 2024. You can also see medical policy changes for 2023

New and updated policies effective November 1, 2024

 

 

Policy Title

 

Policy#

 

Status

1

Bariatric Surgery

7.01.47

Major Update

2

Ablation of Peripheral Nerves to Treat Pain

7.01.154

Minor Update

3

Amniotic Membrane and Amniotic Fluid

7.01.149

Admin Update

4

Aqueous Shunts and Stents for Glaucoma

9.03.21

Minor Update

5

Balloon Dilation of the Eustachian Tube

7.01.158

Minor Update

6

Bioengineered Skin and Soft Tissue Substitutes

7.01.113

Admin Update

7

Biofeedback for Miscellaneous Indications

2.01.53

Admin Update

8

Bone Mineral Density Studies

6.01.01

Minor Update

9

Cardiac Applications of Positron Emission Tomography Scanning

6.01.20

Minor Update

10

Computed Tomography Perfusion Imaging of the Brain

6.01.49

Minor Update

11

Cranial Electrotherapy Stimulation and Auricular Electrostimulation

8.01.58

Admin Update

12

Cryosurgical Ablation of Primary or Metastatic Liver Tumors

7.01.75

Minor Update

13

Drug Testing in Pain Management and Substance Use Disorder Treatment

2.04.98

Admin Update

14

Dynamic Spinal Visualization and Vertebral Motion Analysis

6.01.46

Minor Update

15

Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer

6.01.58

Minor Update

16

Focal Treatments for Prostate Cancer

8.01.61

Minor Update

17

Functional Magnetic Resonance Imaging of the Brain


6.01.47

Minor Update

18

Genetic Testing: Kidney Disorders

BSC_CON_2.22

Admin Update

19

Genetic Testing: Pharmacogenetics

BSC_CON_2.12

Admin Update

20

Genetic Testing: Preimplantation Genetic Testing

BSC_CON_2.03

Admin Update

21

Hyperbaric Oxygen Therapy

2.01.04

Minor Update

22

Identification of Microorganisms Using Nucleic Acid Probes

2.04.10

Admin Update

23

Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment

6.01.51

Minor Update

24

Interventions for Progressive Scoliosis

2.01.83

Admin Update

25

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

5.01.16

Archived

26

Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes

7.03.12

Minor Update

27

Knee Braces (Custom)

BSC1.05

Admin Update

28

Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer

6.01.29

Minor Update

29

Magnetic Resonance Imaging-Targeted Biopsy of the Prostate

7.01.152

Archived

30

Measurement of Serum Antibodies to Selected Biologic Agents

2.04.84

Admin Update

31

Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis

2.04.127

Admin Update

32

Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure

6.01.56

Minor Update

33

Oncology: Algorithmic Testing

BSC_CON_2.05

Admin Update

34

Oncology: Cancer Screening

BSC_CON_2.09

Admin Update

35

Oncology: Molecular Analysis Of Solid Tumors And Hematologic Malignancies

BSC_CON_2.04

Admin Update

36

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions

1.01.15

Admin Update

37

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

1.01.17

Admin Update

38

Percutaneous and Subcutaneous Tibial Nerve Stimulation

7.01.106

Admin Update

39

Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

1.01.28

Admin Update

40

Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities

1.03.04

Admin Update

41

Radioactive Seed Localization of Nonpalpable Breast Lesions

6.01.57

Minor Update

42

Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

7.01.95

Minor Update

43

Risk-Reducing Mastectomy

7.01.09

Minor Update

44

Scintimammography and Gamma Imaging of the Breast and Axilla

6.01.18

Minor Update

45

Thermography

6.01.12

Minor Update

46

Virtual Colonoscopy/Computed Tomography Colonography

6.01.32

Minor Update

47

Whole Body Dual X-Ray Absorptiometry to Determine Body Composition

6.01.40

Minor Update

48

Whole Gland Cryoablation of Prostate Cancer

7.01.79

Archived

Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

 

New and updated policies effective October 1, 2024

 

 

Policy Title

 

Policy#

 

Status

1

High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell's Palsy

2.01.108

New

2

Allogeneic Pancreas Transplant

7.03.02

Minor Update

3

Biofeedback as a Treatment of Urinary Incontinence in Adults

2.01.27

Minor Update

4

Composite Tissue Allotransplantation of the Hand and Face

7.03.13

Minor Update

5

Endovascular Stent Grafts for Disorders of the Thoracic Aorta

7.01.86

Minor Update

6

Gender Affirmation Surgery

BSC7.02

Admin Update

7

Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1)

2.04.154

Archived

8

Heart Transplant

7.03.09

Minor Update

9

Heart/Lung Transplant

7.03.08

Minor Update

10

Hip Arthroplasty for Adults

BSC7.11 

Minor Update

11

Isolated Small Bowel Transplant

7.03.04

Minor Update

12

Kidney Transplant

7.03.01

Minor Update

13

Lipid Apheresis

BSC8.07

Archived

14

Liver Transplant and Combined Liver-Kidney Transplant

7.03.06

Minor Update

15

Lung and Lobar Lung Transplant

7.03.07

Minor Update

16

Magnetic Resonance Imaging-Targeted Biopsy of the Prostate

7.01.152

Minor Update

17

Magnetoencephalography/Magnetic Source Imaging

BSC6.05

Minor Update

18

Navigated Transcranial Magnetic Stimulation

2.01.90

Archived

19

Neurofeedback

2.01.28

Archived

20

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions

1.01.15

Minor Update

21

Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome

4.01.18

Minor Update

22

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

1.01.17

Minor Update

23

Percutaneous and Subcutaneous Tibial Nerve Stimulation

7.01.106

Minor Update

24

Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome

2.01.106

Minor Update

25

Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux

7.01.102

Minor Update

26

Prostatic Urethral Lift 

7.01.151  

Minor Update

27

Radiation Oncology

BSC8.06

Admin Update

28

Reconstructive Breast Surgery/Management of Breast Implants

7.01.22

Admin Update

29

Reproductive Techniques

4.02.04

Minor Update

30

Retinal Prosthesis

9.03.15  

Archived

31

Serologic Genetic and Molecular Screening for Colorectal Cancer

2.04.150

Archived

32

Small Bowel/Liver and Multivisceral Transplant

7.03.05

Minor Update

33

Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

6.01.10

Admin Update

34

Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation

7.01.172

Minor Update

35

Total Artificial Hearts and Implantable Ventricular Assist Devices

7.03.11

Minor Update

36

Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis

2.02.16

Archived

37

Uterus Transplantation for Absolute Uterine Factor Infertility

4.02.06

Minor Update

38

Whole Gland Cryoablation of Prostate Cancer

7.01.79

Minor Update

Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

 

New and updated policies effective August 1, 2024

 

 

Policy Title

 

Policy#

 

Status

1

Reconstructive Breast Surgery/Management of Breast Implants

7.01.22

Major Update

2

Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders

2.01.61

New

3

Actigraphy

2.01.73

Minor Update

4

Autonomic Nervous System Testing

2.01.96

Minor Update

5

Bronchial Thermoplasty

7.01.127

Minor Update

6

Bronchial Valves

7.01.128

Minor Update

7

Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting

2.02.24

Minor Update

8

Diagnosis of Obstructive Sleep Apnea Syndrome

2.01.18

Minor Update

9

Electromagnetic Navigational Bronchoscopy

7.01.122

Minor Update

10

Electromyography and Nerve Conduction Studies

2.01.95

Minor Update

11

External Insulin Infusion Pump

BSC1.03

Minor Update

12

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

2.01.40

Minor Update

13

Gender Affirmation Surgery

BSC7.02

Admin Update

14

Genetic Testing for Alpha Thalassemia

2.04.104

Archived

15

Home Cardiorespiratory Monitoring

1.01.06

Minor Update

16

Hyperbaric Oxygen Therapy

2.01.04

Minor Update

17

Identification of Microorganisms Using Nucleic Acid Probes

2.04.10

Minor Update

18

Interferential Current Stimulation

1.01.24

Minor Update

19

Low-Level Laser Therapy

2.01.56

Minor Update

20

Lung Volume Reduction Surgery for Severe Emphysema

7.01.71

Minor Update

21

Medical Management of Obstructive Sleep Apnea Syndrome

8.01.67

Minor Update

22

Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas

7.01.147

Minor Update

23

Multicancer Early Detection Testing

2.04.158

Minor Update

24

Navigated Transcranial Magnetic Stimulation

2.01.90

Minor Update

25

Neurofeedback

2.01.28

Minor Update

26

Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain

2.01.35

Minor Update

27

Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy

7.01.29

Minor Update

28

Polysomnography for Non-Respiratory Sleep Disorders

2.01.99

Minor Update

29

Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia

2.02.18

Archived

30

Proteogenomic Testing for Patients With Cancer

2.04.140

Minor Update

31

Quantitative Sensory Testing

2.01.39

Minor Update

32

Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases

2.04.123

Minor Update

33

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

7.01.101

Minor Update

34

Transcatheter Pulmonary Valve Implantation

7.01.131

Minor Update

35

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy

2.01.49

Minor Update

36

Treatment of Hyperhidrosis

8.01.19

Minor Update

Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

 

New and updated policies effective July 1, 2024

 

Policy Title – July 1, 2024

Policy#

Status

1

Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay

BSC_CON_2.13

New

2

Cervical Spine Surgery

BSC_NIA_CG_307

Major Update

3

Epidural Spine Injections

BSC_NIA_CG_300

Major Update

4

Gender Affirmation Surgery

BSC7.02

Major Update

5

Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders

BSC_CON_2.02

Major Update

6

Genetic Testing: Immune, Autoimmune, And Rheumatoid Disorders 

BSC_CON_2.21

Major Update

7

Genetic Testing: Kidney Disorders 

BSC_CON_2.22

Major Update

8

Genetic Testing: Lung Disorders 

BSC_CON_2.23

Major Update

9

Genetic Testing: Pharmacogenetics

BSC_CON_2.12

Major Update

10

Implantable Cardioverter Defibrillators

7.01.44

Major Update

11

Lumbar Spine Surgery

BSC_NIA_CG_304

Major Update

12

Oncology: Algorithmic (Genetic Expression) Testing

BSC_CON_2.05

Major Update

13

Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)

BSC_CON_2.10

Major Update

14

Oncology: Cytogenetic Testing

BSC_CON_2.11

Major Update

15

Oncology: Molecular Analysis Of Solid Tumors And Hematologic Malignancies

BSC_CON_2.04

Major Update

16

Paravertebral Facet Joint Injections or Blocks

BSC_NIA_CG_301

Major Update

17

Sacroiliac Joint Injections

BSC_NIA_CG_305

Major Update

18

Wearable Cardioverter Defibrillators

2.02.15

Major Update

19

Allograft Injection for Degenerative Disc Disease

7.01.166

Minor Update

20

Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

2.02.08

Minor Update

21

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

7.01.78

Minor Update

22

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

7.01.48

Minor Update

23

Baroreflex Stimulation Devices

8.01.57

Minor Update

24

Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure

2.02.10

Minor Update

25

Closure Devices for Patent Foramen Ovale and Atrial Septal Defects

2.02.09

Minor Update

26

Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy

9.03.05

Archived

27

Digital Health Technologies: Therapeutic Applications

3.03.02

Minor Update

28

Electrical Bone Growth Stimulation of the Appendicular Skeleton

7.01.07

Minor Update

29

Endovascular Stent Grafts for Abdominal Aortic Aneurysms

7.01.67

Minor Update

30

Endovascular Therapies for Extracranial Vertebral Artery Disease

7.01.148

Minor Update

31

Enhanced External Counterpulsation

2.02.06

Minor Update

32

Extracorporeal Membrane Oxygenation for Adult Conditions

8.01.60

Minor Update

33

Extracranial Carotid Artery Stenting

7.01.68

Minor Update

34

Gene Expression Profile Testing and Circulating Tumor DNA Testing  for Predicting Recurrence in Colon Cancer 

2.04.61

Archived

35

Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies

2.04.59

Archived

36

Germline and Somatic Biomarker Testing for Targeted Treatment and Immunotherapy in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, Tumor Mutational Burden, Microsatellite Instability/Mismatch Repair)

2.04.156

Archived

37

Germline and Somatic Biomarker Testing for Targeted Treatment and Immunotherapy in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, Microsatellite Instability/Mismatch Repair, Tumor Mutational Burden)

2.04.155

Archived

38

Immediate and Delayed Lymphatic Reconstruction Surgery

BSC7.18

Minor Update

39

Inhaled Nitric Oxide

8.01.37

Minor Update

40

Interventions for Progressive Scoliosis

2.01.83

Minor Update

41

Intradialytic Parenteral Nutrition

8.01.44

Minor Update

42

Intraoperative Neurophysiologic Monitoring

7.01.58

Minor Update

43

Leadless Cardiac Pacemakers

2.02.32

Minor Update

44

Lower Limb Prostheses

BSC1.01

Minor Update

45

Myocardial Strain Imaging

2.02.31

Minor Update

46

Neuropsychological Testing

BSC2.06

Minor Update

47

Orthoptic Training for the Treatment of Vision or Learning Disabilities

9.03.03

Archived

48

Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

2.02.26

Minor Update

49

Phrenic Nerve Stimulation for Central Sleep Apnea

2.02.33

Minor Update

50

Power Wheelchairs and Power Operated Vehicles for Permanent Use

BSC1.02

Minor Update

51

Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia

2.02.18

Minor Update

52

Speech Therapy

BSC8.02

Minor Update

53

Thoracic Spine Surgery

BSC_NIA_CG_308

Minor Update

54

Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis

2.02.16

Minor Update

Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

 

New and updated policies effective June 1, 2024

 

Policy Title – June 1, 2024

Policy#

Status

1

Minimally invasive approaches to vertebral fractures and osteolytic lesions of the spine

6.01.25

Major update

2

Genetic testing: Epilepsy, neurodegenerative, and neuromuscular disorders

BSC_CON_2.14

New

3

Behavioral health treatment for autism spectrum disorders

BSC3.01

Minor update

4

Bone morphogenetic protein

7.01.100

Minor update

5

Catheter ablation for cardiac arrhythmias

BSC2.12

Minor update

6

Deep brain stimulation

7.01.63

Minor update

7

Diabetes prevention program

BSC2.11

Minor update

8

Dry needling of trigger points for myofascial pain

2.01.100

Minor update

9

Electrical stimulation of the spine as an adjunct to spinal fusion procedures

7.01.85

Minor update

10

Endovascular procedures for intracranial arterial disease (atherosclerosis and aneurysms)

2.01.54

Minor update

11

Facet arthroplasty

7.01.120

Minor update

12

Genetic testing for Alzheimer's disease

2.04.13

Archived

13

Genetic testing for Duchenne and Becker muscular dystrophy

2.04.86

Archived

14

Genetic testing for Limb-Girdle muscular dystrophies

2.04.132

Archived

15

Genetic testing for Rett syndrome

2.04.81

Archived

16

Genetic testing of CADASIL syndrome

2.04.75

Archived

17

Hip resurfacing

7.01.80

Minor update

18

Image-guided minimally invasive decompression for spinal stenosis

7.01.126

Minor update

19

Intensity-modulated radiotherapy of the prostate

8.01.47

Minor update

20

Lipid apheresis

BSC8.07

Minor update

21

Manipulation under anesthesia

8.01.40

Minor update

22

Meniscal allografts and other meniscal implants

7.01.15

Minor update

23

Nerve graft with radical prostatectomy

7.01.81

Minor update

24

Occipital nerve stimulation

7.01.125

Minor update

25

Orthopedic applications of platelet-rich plasma

2.01.98

Minor update

26

Percutaneous balloon kyphoplasty, radiofrequency kyphoplasty, and mechanical vertebral augmentation

6.01.38

Archived

27

Peripheral subcutaneous field stimulation

7.01.139

Minor update

28

Physical therapy

BSC8.03

Minor update

29

Power morcellation for the treatment of uterine fibroids

BSC7.06

Minor update

30

Reconstructive Ssrvices

BSC7.08

Minor update

31

Responsive neurostimulation for the treatment of refractory focal epilepsy

7.01.143

Minor update

32

Sacral nerve neuromodulation/stimulation

7.01.69

Minor update

33

Spinal cord and dorsal root ganglion stimulation

7.01.25

Minor update

34

Subtalar arthroereisis

7.01.104

Minor update

35

Surgical treatment of femoroacetabular impingement

7.01.118

Minor update

36

Trigger point and tender point injections

2.01.103

Minor update

37

Vertebral axial decompression

8.03.09

Minor update

38

Vertical expandable prosthetic titanium rib 

7.01.110

Minor update

Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

 

New and updated policies effective May 1, 2024

 

Policy Title – May 1, 2024

Policy#

Status

1

Cardiac rehabilitation in the outpatient setting

8.03.08

Major update

2

Myoelectric prosthetic and orthotic components for the upper limb

1.04.04

Major Update

3

Functional endoscopic sinus surgery for chronic rhinosinusitis

7.01.155

New

4

Genetic testing: Gastroenterologic disorders (non-cancerous)

BSC_CON_2.17

New

5

Genetic testing: Hereditary cancer susceptibility

BSC_CON_2.01

New

6

Transmyocardial revascularization

7.01.54

New

7

Vestibular function testing

2.01.104

New

8

Adjustable cranial orthoses for positional plagiocephaly and craniosynostoses

1.01.11

Minor update

9

Amniotic membrane and amniotic fluid

7.01.149

Minor update

10

Bioengineered skin and soft tissue substitutes

7.01.113

Minor update

11

Cognitive rehabilitation

8.03.10

Minor update

12

Continuous passive motion in the home setting

1.01.10

Minor update

13

Cooling devices used in the outpatient setting

1.01.26

Minor update

14

Corneal collagen cross-linking

9.03.28

Minor update

15

Corneal topography/computer-assisted corneal topography/photokeratoscopy

9.03.05

Minor update

16

Cryoablation, radiofrequency ablation, and laser ablation for treatment of chronic rhinitis

7.01.168

Minor update

17

Electrical and electromagnetic stimulation for the treatment of arthritis

1.01.27

Minor update

18

Endothelial keratoplasty

9.03.22

Minor update

19

Evaluation of biomarkers for Alzheimer disease

2.04.14

Admin coding update

20

Eyelid thermal pulsation for the treatment of dry eye syndrome

9.03.29

Minor update

21

Functional neuromuscular electrical stimulation

8.03.01

Minor update

22

Genetic cancer susceptibility panels using next-generation sequencing

2.04.93

Archived

23

Genetic testing for Duchenne and Becker muscular dystrophy

2.04.86

Minor update

24

Genetic testing for hereditary hemochromatosis

2.04.80

Archived

25

Genetic testing for lactase insufficiency

2.04.94

Archived

26

Genetic testing for Lynch syndrome and other inherited colon cancer syndromes

2.04.08

Archived

27

Genetic testing: Prenatal and preconception carrier screening

BSC_CON_2.07

Admin coding update

28

Germline genetic testing for familial cutaneous malignant melanoma (CDKN2A, CDK4)

2.04.44

Archived

29

Germline genetic testing for gene variants associated with breast cancer in individuals at high breast cancer risk (CHEK2, ATM, and BARD1)

2.04.126

Archived

30

Germline genetic testing for hereditary breast/ovarian cancer syndrome and other high-risk cancers (BRCA1, BRCA2, PALB2)

2.04.02

Archived

31

Germline genetic testing for ovarian cancer risk (BRIP1, RAD51C, RAD51D, NBN)

2.04.149

Archived

32

Germline genetic testing for pancreatic cancer susceptibility genes (ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, and TP53)

2.04.148

Archived

33

Hippotherapy

8.03.12

Minor update

34

Home non-invasive positive airway pressure devices for the treatment of respiratory insufficiency and failure

8.01.64

Minor update

35

Human leukocyte antigen testing for celiac disease

2.04.95

Archived

36

Identification of microorganisms using nucleic acid probes

2.04.10

Admin coding update

37

Intraocular radiotherapy for age-related macular degeneration

9.03.20

Minor update

38

Keratoprosthesis

9.03.01

Minor update

39

Knee braces (custom)

BSC1.05

Minor update

40

Lifestyle modification program for reversing heart disease

BSC8.01

Minor update

41

Low intensity pulsed ultrasound fracture healing device

1.01.05

Minor update

42

Microprocessor-controlled prostheses for the lower limb

1.04.05

Minor update

43

Noninvasive techniques for the evaluation and monitoring of patients with chronic liver disease

2.04.41

Archived

44

Oncology: Molecular analysis of solid tumors and hematologic malignancies

BSC_CON_2.04

Admin coding update

45

Ophthalmologic techniques that evaluate the posterior segment for glaucoma

9.03.06

Minor update

46

Optical coherence tomography of the anterior eye segment

9.03.18

Minor update

47

Orthognathic surgery

BSC7.03

Minor update

48

Orthoptic training for the treatment of vision or learning disabilities

9.03.03

Minor update

49

Outpatient pulmonary rehabilitation

8.03.05

Minor update

50

Panniculectomy, abdominoplasty, and surgical management of diastasis recti

BSC7.04

Minor update

51

Partial thickness rotator cuff tears and acromioplasty/subacromial decompression

BSC7.14

Minor update

52

Patient-controlled end range of motion stretching devices

1.03.05

Minor update

53

Personalized breast cancer screening clinical trial

BSC2.08

Minor update

54

Photodynamic therapy for choroidal neovascularization

9.03.08

Minor update

55

Pneumatic compression pumps for treatment of lymphedema and venous ulcers

1.01.18

Minor update

56

Postsurgical home use of limb compression devices for venous thromboembolism prophylaxis

1.01.28

Minor update

57

Power wheelchairs and power operated vehicles for permanent use

BSC1.02

Admin coding update

58

Powered exoskeleton for ambulation in patients with lower-limb disabilities

1.03.04

Minor update

59

Retinal prosthesis

9.03.15

Minor update

60

Retinal telescreening for diabetic retinopathy

9.03.13

Minor update

61

Sacral nerve neuromodulation/stimulation

7.01.69

Admin coding update

62

Sensory integration therapy and auditory integration therapy

8.03.13

Minor update

63

Serum biomarker panel testing for systemic lupus erythematosus and other connective tissue diseases

2.04.123

Admin coding update

64

Treatment of varicose veins/venous insufficiency

7.01.124

Admin coding update

65

Vagus nerve stimulation

7.01.20

Admin coding update

66

Viscocanalostomy and canaloplasty

9.03.26

Minor update

Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

 

New and updated policies effective April 1, 2024

 

Policy Title – April 1, 2024

Policy#

Status

1

Auditory brainstem implant

7.01.83

Major update

2

Biomarker testing in risk assessment and management of cardiovascular disease

2.04.65

Major Update

3

Transcatheter aortic-valve implantation for aortic stenosis

7.01.132

Major update

4

Cochlear implant

7.01.05

New

5

Fractional carbon dioxide (CO2) laser ablation treatment of hypertrophic scars or keloids for functional improvement

2.01.107

New

6

Genetic testing: Hematologic conditions (non-cancerous)

BSC_CON_2.15

New

7

Genetic testing: Kidney disorders

BSC_CON_2.22

New

8

Genetic testing: Metabolic, endocrine, and mitochondrial disorders

BSC_CON_2.24

New

9

Hematopoietic cell transplantation for epithelial ovarian cancer

8.01.23

New

10

Hematopoietic cell transplantation for miscellaneous solid tumors in adults

8.01.24

New

11

Surgery for groin pain in athletes

7.01.142

New

12

Treatment of tinnitus

8.01.39

New

13

Vagus nerve stimulation

7.01.20

New

14

Allogeneic hematopoietic cell transplantation for myelodysplastic syndromes and myeloproliferative neoplasms

8.01.21

Minor update

15

Ambulatory surgery center

BSC10.01

Minor update

16

Balloon ostial dilation for treatment of chronic and recurrent acute rhinosinusitis

7.01.105

Minor update

17

Cardiovascular risk panels

2.04.100

Archived

18

Chelation therapy for off-label uses

8.01.02

Minor update

19

Chronic intermittent intravenous insulin therapy

2.01.43

Minor update

20

Cleft palate – Dental related services

BSC2.01

Minor update

21

Continuous glucose monitoring

1.01.20

Minor update

22

Cranial electrotherapy stimulation and auricular electrostimulation

8.01.58

Minor update

23

Dental anesthesia

BSC2.02

Minor update

24

Dynamic posturography

2.01.02

Minor update

25

Gastric electrical stimulation

7.01.73

Minor update

26

Gender affirmation surgery

BSC7.02

Minor update

27

Genetic testing for inherited thrombophilia

2.04.82

Archived

28

Genetic testing for mitochondrial disorders

2.04.117

Archived

29

Handheld radiofrequency spectroscopy for intraoperative assessment of surgical margins during breast-conserving surgery

7.01.140

Minor update

30

Hematopoietic cell transplantation for acute lymphoblastic leukemia

8.01.32

Minor update

31

Hematopoietic cell transplantation for acute myeloid leukemia

8.01.26

Minor update

32

Hematopoietic cell transplantation for autoimmune diseases

8.01.25

Minor update

33

Hematopoietic cell transplantation for central nervous system embryonal tumors and ependymoma

8.01.28

Minor update

34

Hematopoietic cell transplantation for chronic lymphocytic leukemia/small lymphocytic lymphoma

8.01.15

Minor update

35

Hematopoietic cell transplantation for chronic myeloid leukemia

8.01.30

Minor update

36

Hematopoietic cell transplantation for Hodgkin lymphoma

8.01.29

Minor update

37

Hematopoietic cell transplantation for non-Hodgkin lymphomas

8.01.20

Minor update

38

Hematopoietic cell transplantation for plasma cell dyscrasias, including multiple myeloma and POEMS syndrome

8.01.17

Minor update

39

Hematopoietic cell transplantation for primary amyloidosis

8.01.42

Minor update

40

Hematopoietic cell transplantation for solid tumors of childhood

8.01.34

Minor update

41

Hematopoietic cell transplantation in the treatment of germ cell tumors

8.01.35

Minor update

42

Hysterectomy surgery for benign conditions

BSC7.09

Minor update

43

Implantable bone-conduction and bone-anchored hearing aids

7.01.03

Minor update

44

Laboratory tests post transplant and for heart failure

2.01.68

Archived

45

Laparoscopic, percutaneous, and transcervical techniques for uterine fibroid myolysis

4.01.19

Minor update

46

Maternal serum biomarkers for prediction of adverse obstetric outcomes

2.04.152

Minor update

47

Measurement of lipoprotein-sssociated phospholipase A2 in the assessment of cardiovascular risk

2.04.32

Archived

48

Radiation oncology

BSC8.06

Admin update

49

Reduction mammaplasty for breast-related symptoms

7.01.21

Minor update

50

Semi-implantable and fully implantable middle ear hearing aids

7.01.84

Minor update

51

Steroid-eluting sinus stents and implants

7.01.134

Minor update

52

Surgical deactivation of headache trigger sites

7.01.135

Minor update

53

Surgical ventricular restoration

7.01.103

Minor update

54

Temporomandibular joint disorder

2.01.21

Minor update

Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

 

New and updated policies effective March 1, 2024

 

Policy Title – March 1, 2024

Policy#

Status

1

Treatment of varicose veins/venous insufficiency

7.01.124

Major update

2

Chemical peels

8.01.16

New

3

Fecal calprotectin testing

2.04.69

New

4

Homocysteine testing in the screening, diagnosis, and management of cardiovascular disease and venous thromboembolic disorders

2.04.23

New

5

Intracellular micronutrient analysis

2.04.73

New

6

Radiofrequency coblation tenotomy for musculoskeletal conditions

7.01.165

New

7

Targeted phototherapy and psoralen with ultraviolet A for vitiligo

2.01.86

New

8

Adipose-derived stem cells in autologous fat grafting to the breast

7.01.153

Minor update

9

Amniotic membrane and amniotic fluid

7.01.149

Admin coding update

10

Autologous platelet-derived growth factors for wound healing and other non-orthopedic conditions

2.01.16

Minor update

11

Bioimpedance devices for detection and management of lymphedema

2.01.82

Minor update

12

Biventricular pacemakers (cardiac resynchronization therapy) for the treatment of heart failure

2.02.10

Admin coding update

13

Blepharoplasty, blepharoptosis repair (levator resection) and brow lift (repair of brow ptosis)

BSC7.01

Minor update

14

Bone turnover markers for the diagnosis and management of osteoporosis and diseases associated with high bone turnover

2.04.15

Minor update

15

Charged-particle (proton or helium ion) radiotherapy for neoplastic conditions

BSC8.04

Minor update

16

Cranial electrotherapy stimulation and auricular electrostimulation

8.01.58

Admin coding update

17

Cryoablation, radiofrequency ablation, and laser ablation for treatment of chronic rhinitis

7.01.168

Admin coding update

18

Electrostimulation and electromagnetic therapy for treating wounds

2.01.57

Minor update

19

Gastric electrical stimulation

7.01.73

Admin coding update

20

Genetic testing: Exome and genome sequencing for the diagnosis of genetic disorders

BSC_CON_2.02

Admin coding update

21

Genetic testing: Pharmacogenetics

BSC_CON_2.12

Admin coding update

22

Germline genetic testing for pancreatic cancer susceptibility genes (ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, and TP53)

2.04.148

Admin coding update

23

Hyperthermic intraperitoneal chemotherapy for select intra-abdominal and pelvic malignancies

2.03.07

Admin coding update

24

Ingestible pH and pressure capsule

BSC2.17

Minor update

25

Intensity-modulated radiotherapy of the breast and lung

8.01.46

Minor update

26

Intensity-modulated radiotherapy: Abdomen, pelvis and chest

8.01.49

Minor update

27

Intensity-modulated radiotherapy: Cancer of the head and neck or thyroid

8.01.48

Minor update

28

Intensity-modulated radiotherapy: Central nervous system tumors

8.01.59

Minor update

29

Interventions for progressive scoliosis

2.01.83

Admin coding update

30

Laparoscopic, percutaneous, and transcervical techniques for uterine fibroid myolysis

4.01.19

Admin coding update

31

Lower limb prostheses

BSC1.01

Admin coding update

32

Low-level laser therapy

2.01.56

Admin coding update

33

Lysis of epidural adhesions

BSC8.05

Minor update

34

Medical management of obstructive sleep apnea syndrome

8.01.67

Admin coding update

35

Microprocessor-controlled prostheses for the lower limb

1.04.05

Admin coding update

36

Negative pressure wound therapy in the outpatient setting

1.01.16

Minor update

37

Noncontact ultrasound treatment for wounds

2.01.79

Minor update

38

Noninvasive techniques for the evaluation and monitoring of patients with chronic liver disease

2.04.41

Admin coding update

39

Oncology: Algorithmic (genetic expression) testing

BSC_CON_2.05

Admin coding update

40

Oncology: Circulating tumor DNA and circulating tumor cells (liquid biopsy)

BSC_CON_2.10

Admin coding update

41

Oncology: Molecular analysis of solid tumors and hematologic malignancies

BSC_CON_2.04

Admin coding update

42

Orthopedic applications of stem cell therapy (Including allografts and bone substitutes used with autologous bone marrow)

8.01.52

Minor update

43

Percutaneous and subcutaneous tibial nerve stimulation

7.01.106

Admin coding update

44

Phrenic nerve stimulation for central sleep apnea

2.02.33

Admin coding update

45

Pneumatic compression pumps for treatment of lymphedema and venous ulcers

1.01.18

Admin coding update

46

Radiation oncology

BSC8.06

Minor update

47

Remote electrical neuromodulation for migraines

7.01.171

Admin coding update

48

Responsive neurostimulation for the treatment of refractory focal epilepsy

7.01.143

Admin coding update

49

Sacral nerve neuromodulation/stimulation

7.01.69

Admin coding update

50

Spinal cord and dorsal root ganglion stimulation

7.01.25

Admin coding update

51

Stem cell therapy for peripheral arterial disease

8.01.55

Minor update

52

Stereotactic radiosurgery and stereotactic body radiotherapy

6.01.10

Minor update

53

Surgical treatment of gynecomastia

BSC7.13

Minor update

54

Surgical treatment of snoring and obstructive sleep apnea syndrome

7.01.101

Admin coding update

55

Temporarily implanted nitinol device (iTind) for benign prostatic hyperplasia

7.01.175

Minor update

Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

 

New and updated policies effective February 1, 2024

 

Policy Title – February 1, 2024

Policy#

Status

1

Genetic testing: General approach to genetic and molecular testing

BSC_CON_2.27

Major update

2

Genetic testing: Prenatal and preconception carrier screening

BSC_CON_2.07

Major update

3

Genetic Testing: Prenatal diagnosis (via amniocentesis, CVS, or PUBS) and pregnancy loss

BSC_CON_2.06

Major update

4

Testing serum vitamin D levels

2.04.135

Major update

5

Biofeedback as a treatment of chronic pain

2.01.30

New

6

Biofeedback as a treatment of fecal incontinence or constipation

2.01.64

New

7

Biofeedback as a treatment of headache

2.01.29

New

8

Biofeedback for miscellaneous indications

2.01.53

New

9

Chromoendoscopy as an adjunct to colonoscopy

2.01.84

New

10

Fecal microbiota transplantation

2.01.92

New

11

Genetic Testing: Dermatologic conditions

BSC_CON_2.25

New

12

Genetic testing: Hearing loss

BSC_CON_2.16

New

13

Genetic testing: Pharmacogenetics

BSC_CON_2.12

New

14

Human leukocyte antigen testing for celiac disease

2.04.95

New

15

Intravenous anesthetics for the treatment of chronic pain and psychiatric disorders

5.01.16

New

16

Laser treatment of onychomycosis

2.01.89

New

17

Nerve fiber density measurement

2.04.58

New

18

Neural therapy

2.01.85

New

19

Nutrient/nutritional panel testing

2.04.136

New

20

Peroral endoscopic myotomy for treatment of esophageal achalasia and gastroparesis

2.01.91

New

21

Sphenopalatine ganglion block for headache

7.01.159

New

22

Transanal endoscopic microsurgery

7.01.112

New

23

Transcutaneous electrical nerve stimulation

1.01.09

New

24

Biomarker testing in risk assessment and management of cardiovascular disease

2.04.65

Minor update

25

Cardiovascular risk panels

2.04.100

Minor update

26

Cytochrome P450 genotype-guided treatment strategy

2.04.38

Archived

27

Dermatologic applications of photodynamic therapy

2.01.44

Minor update

28

Fecal analysis in the diagnosis of intestinal dysbiosis

2.04.26

Minor update

29

Genetic testing for diagnosis and management of mental health conditions

2.04.110

Archived

30

Genetic testing for hereditary hearing loss

2.04.87

Archived

31

Genotype-guided tamoxifen treatment

2.04.51

Archived

32

Genotype-guided warfarin dosing

2.04.48

Archived

33

Immune cell function assay

2.04.56

Minor update

34

Laboratory and genetic testing for use of 5-fluorouracil in patients with cancer

2.04.68

Archived

35

Laser interstitial thermal therapy for neurological conditions

7.01.170

Minor update

36

Measurement of lipoprotein-associated phospholipase A2 in the assessment of cardiovascular risk

2.04.32

Minor update

37

Multitarget polymerase chain reaction testing for diagnosis of bacterial vaginosis

2.04.127

Minor update

38

Nonpharmacologic treatment of rosacea

2.01.71

Minor update

39

Oncologic applications of positron emission tomography scanning (genitourinary)

6.01.26

Archived

40

Oncology: Cancer screening

BSC_CON_2.09

Minor update

41

Pharmacogenetic testing for pain management

2.04.131

Archived

42

Pharmacogenomic and metabolite markers for patients treated with thiopurines

2.04.19

Archived

43

Positional magnetic resonance imaging

6.01.48

Archived

44

Serum biomarker human epididymis protein 4

2.04.66

Minor update

45

Transesophageal endoscopic therapies for gastroesophageal reflux disease

2.01.38

Minor update

46

Wireless capsule endoscopy for gastrointestinal (GI) disorders

6.01.33

Minor update


Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services: 

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services. 

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider

New and updated policies effective January 1, 2024

 

Policy Title – January 1, 2024

Policy#

Status

1

Genetic testing: Preimplantation genetic testing

BSC_CON_2.03

Major update

2

Dopamine transporter single-photon emission computed tomography

6.01.54

New

3

Extracorporeal photopheresis

8.01.36

New

4

Genetic testing: Aortopathies and connective tissue disorders

BSC_CON_2.19

New

5

Genetic testing: Cardiac disorders

BSC_CON_2.18

New

6

Axillary reverse mapping for prevention of breast cancer-related lymphedema

7.01.173

Minor update

7

Cervical spine surgery

BSC_NIA_CG_307

Minor update

8

Computed tomography to detect coronary artery calcification

6.01.03 

Archived

9

Confocal laser endomicroscopy

2.01.87

Minor update

10

Contrast-enhanced coronary computed tomography angiography for coronary artery evaluation

6.01.43  

Archived

11

Coronary computed tomography angiography with selective noninvasive fractional flow reserve

6.01.59 

Archived

12

Drug testing in pain management and substance use disorder treatment 

2.04.98

Minor update

13

Dry hydrotherapy for chronic pain conditions

2.01.105

Minor update

14

Endoscopic radiofrequency ablation or cryoablation for Barrett esophagus

2.01.80

Minor update

15

Epidural spine injections

BSC_NIA_CG_300

Minor update

16

Esophageal pH monitoring

2.01.20

Minor update

17

Genetic testing for cardiac ion channelopathies

2.04.43

Archived

18

Genetic testing for predisposition to inherited hypertrophic cardiomyopathy

2.02.28

Archived

19

Genetic testing: Non-invasive prenatal screening (NIPS)/Non-invasive prenatal testing (NIPT)

BSC_CON_2.08

Minor update

20

Lumbar spine surgery

BSC_NIA_CG_304

Minor update

21

Magnetic esophageal sphincter augmentation to treat gastroesophageal reflux disease

7.01.137

Minor update

22

Measurement of serum antibodies to selected biologic agents

2.04.84

Minor update

23

Monitored anesthesia care

7.02.01

Minor update

24

Noninvasive techniques for the evaluation and monitoring of patients with chronic liver disease

2.04.41

Minor update

25

Paravertebral facet joint injections or blocks

BSC_NIA_CG_301

Minor update

26

Pharmacogenetic testing for pain management

2.04.131

Minor update

27

Pharmacogenomic and metabolite markers for patients treated with thiopurines

2.04.19

Minor update

28

Plugs for anal fistula repair

7.01.123

Minor update

29

Prolotherapy

2.01.26

Minor update

30

Proteomic testing for targeted therapy in non-small cell lung cancer

2.04.125

Minor update

31

Sacroiliac joint injections

BSC_NIA_CG_305         

Minor update

32

Thoracic spine surgery

BSC_NIA_CG_308

Minor update

Please Note:

California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services: 

  • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
  • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

Blue Shield of California has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services. 

For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider

Medical policy list

Use these alphabetical lists to find Blue Shield medical policies, and review requirements and criteria for new technologies, devices and procedures.

Find medical policy for Blue Shield of California plans

View clinical policies and procedures for Blue Shield of California Promise Health Plan

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Find out about our process of evaluating coverage for new technologies and new applications of existing technologies.

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