Medical policy updates

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

	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.

	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.

	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.

	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.

	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.

	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.

	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.

	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.

	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.

	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.

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