Medical policy updates
Read about the medical policy changes for 2023. You can also see the latest medical policy changes for 2024.
New and updated policies effective December 1, 2023
|
Policy Title – December 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Genetic testing: Eye disorders |
BSC_CON_2.20 |
|
2 |
Genetic testing: General approach to genetic and molecular testing |
BSC_CON_2.27 |
|
3 |
Genetic testing: Immune, autoimmune, and rheumatoid disorders |
BSC_CON_2.21 |
|
4 |
Genetic testing: Lung disorders |
BSC_CON_2.23 |
|
5 |
Genetic testing: Skeletal dysplasia and rare bone disorders |
BSC_CON_2.26 |
|
6 |
Oncology: Cytogenetic testing |
BSC_CON_2.11 |
|
7 |
Suture button suspensionplasty fixation system for thumb carpometacarpal osteoarthritis |
7.01.176 |
|
8 |
Home non-Invasive positive airway pressure devices for the treatment of respiratory insufficiency and failure |
8.01.64 |
|
9 |
Microwave tumor ablation |
7.01.133 |
|
10 |
Transcranial magnetic stimulation as a treatment of depression and other psychiatric/neurologic disorders |
2.01.50 |
|
11 |
Treatment of varicose veins/venous insufficiency |
7.01.124 |
|
12 |
Absorbable nasal implant for treatment of nasal valve collapse |
7.01.163 |
Minor update |
13 |
Bioengineered skin and soft tissue substitutes |
7.01.113 |
Admin update |
14 |
Biventricular pacemakers (cardiac resynchronization therapy) for the treatment of heart failure |
2.02.10 |
Admin update |
15 |
Diagnosis of obstructive sleep apnea syndrome |
2.01.18 |
Admin update |
16 |
Digital health therapies for substance use disorders |
5.01.35 |
Archived |
17 |
Endovascular stent grafts for disorders of the thoracic aorta |
7.01.86 |
Minor update |
18 |
Evaluation of biomarkers for Alzheimer disease |
2.04.14 |
Minor update |
19 |
General approach to evaluating the utility of genetic panels |
2.04.92 |
Archived |
20 |
General approach to genetic testing |
2.04.91 |
Archived |
21 |
Genetic cancer susceptibility panels using next-generation sequencing |
2.04.93 |
Minor update |
22 |
Genetic testing for Alzheimer disease |
2.04.13 |
Minor update |
23 |
Genetic testing for developmental delay/intellectual disability, autism spectrum disorder, and congenital anomalies |
2.04.59 |
Minor update |
24 |
Genetic testing for Lynch syndrome and other inherited colon cancer syndromes |
2.04.08 |
Minor update |
25 |
Injectable bulking agents for the treatment of urinary and fecal incontinence |
7.01.19 |
Minor update |
26 |
Knee arthroplasty for adults |
BSC7.10 |
Minor update |
27 |
Knee arthroscopy in knee osteoarthritis |
BSC7.16 |
Minor update |
28 |
Laboratory tests post transplant and for heart failure |
2.01.68 |
Minor update |
29 |
Magnetic resonance spectroscopy |
6.01.24 |
Minor update |
30 |
Medical management of obstructive sleep apnea syndrome |
8.01.67 |
Admin update |
31 |
Miscellaneous (noncardiac, nononcologic) applications of fluorine 18 fluorodeoxyglucose positron emission tomography |
6.01.06 |
Minor update |
32 |
Multibiomarker disease activity blood test for rheumatoid arthritis |
2.04.119 |
Archived |
33 |
Quantitative electroencephalography as a diagnostic aid for attention-deficit/hyperactivity disorder |
3.01.03 |
Minor update |
34 |
Radiofrequency ablation of the renal sympathetic nerves as a treatment for uncontrolled hypertension |
7.01.136 |
Minor update |
35 |
Remote electrical neuromodulation for migraines |
7.01.171 |
Minor update |
36 |
Selected positron emission tomography technologies for evaluation of Alzheimer disease |
6.01.55 |
Minor update |
37 |
Surgical treatment of snoring and obstructive sleep apnea syndrome |
7.01.101 |
Admin 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 November 1, 2023
|
Policy Title – November 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Endobronchial ultrasound for diagnosis and staging of lung cancer |
6.01.58 |
|
2 |
Ovarian and internal iliac vein endovascular occlusion as a treatment of pelvic congestion syndrome |
4.01.18 |
|
3 |
Percutaneous and subcutaneous tibial nerve stimulation |
7.01.106 |
|
4 |
Radioactive seed localization of nonpalpable breast lesions |
6.01.57 |
|
5 |
Thermography |
6.01.12 |
|
6 |
Whole body dual X-ray absorptiometry to determine body composition |
6.01.40 |
|
7 |
Ablation of peripheral nerves to treat pain |
7.01.154 |
Minor update |
8 |
Amniotic membrane and amniotic fluid |
7.01.149 |
Admin coding |
9 |
Aqueous shunts and stents for glaucoma |
9.03.21 |
Minor update |
10 |
Balloon dilation of the eustachian tube |
7.01.158 |
Minor update |
11 |
Bone mineral density studies |
6.01.01 |
Minor update |
12 |
Cardiac applications of positron emission tomography scanning |
6.01.20 |
Minor update |
13 |
Cardiovascular risk panels |
2.04.100 |
Admin coding |
14 |
Computed tomography perfusion imaging of the brain |
6.01.49 |
Minor update |
15 |
Cryosurgical ablation of primary or metastatic liver tumors |
7.01.75 |
Minor update |
16 |
Dynamic spinal visualization and vertebral motion analysis |
6.01.46 |
Minor update |
17 |
Evaluation of biomarkers for Alzheimer disease |
2.04.14 |
Admin coding |
18 |
Focal treatments for prostate cancer |
8.01.61 |
Minor update |
19 |
Functional magnetic resonance imaging of the brain |
6.01.47 |
Minor update |
20 |
Genetic testing for diagnosis and management of mental health conditions |
2.04.110 |
Admin coding |
21 |
Genetic testing for mitochondrial disorders |
2.04.117 |
Minor update |
22 |
Germline and somatic biomarker testing (including liquid biopsy) for targeted treatment in ovarian cancer (BRCA1, BRCA2, homologous recombination deficiency) |
2.04.156 |
Minor update |
23 |
Germline genetic testing for hereditary breast/ovarian cancer syndrome and other high-risk cancers (BRCA1, BRCA2, PALB2) |
2.04.02 |
Minor update |
24 |
Identification of microorganisms using nucleic acid probes |
2.04.10 |
Admin coding |
25 |
Interim positron emission tomography scanning in oncology to detect early response during treatment |
6.01.51 |
Minor update |
26 |
Islet transplantation for chronic pancreatitis and donislecel-jujn for type 1 diabetes |
7.03.12 |
Minor update |
27 |
Lower limb prostheses |
BSC1.01 |
Admin coding |
28 |
Magnetic resonance imaging for detection and diagnosis of breast cancer |
6.01.29 |
Minor update |
29 |
Myocardial sympathetic innervation imaging in patients with heart failure |
6.01.56 |
Minor update |
30 |
Oncologic applications of positron emission tomography scanning |
6.01.26 |
Minor update |
31 |
Oncology: Algorithmic (genetic expression) testing |
BSC_CON_2.05 |
Admin coding |
32 |
Oncology: Circulating Ttmor DNA and circulating tumor cells (liquid biopsy) |
BSC_CON_2.10 |
Admin coding |
33 |
Oncology: Molecular analysis of solid tumors and hematologic malignancies |
BSC_CON_2.04 |
Admin coding |
34 |
Positional magnetic resonance imaging |
6.01.48 |
Minor update |
35 |
Radiofrequency ablation of miscellaneous solid tumors excluding liver tumors |
7.01.95 |
Minor update |
36 |
Scintimammography and gamma imaging of the breast and axilla |
6.01.18 |
Minor update |
37 |
Stationary ultrasonic diathermy devices |
7.01.174 |
Admin coding |
38 |
Synthetic cartilage implants for joint pain |
7.01.160 |
Minor update |
39 |
Vertebral fracture assessment with densitometry |
6.01.44 |
Minor update |
40 |
Virtual colonoscopy/computed tomography colonography |
6.01.32 |
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 October 1, 2023
|
Policy Title – October 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Bariatric surgery |
7.01.47 |
|
2 |
Composite tissue allotransplantation of the hand and face |
7.03.13 |
|
3 |
Magnetic resonance imaging-targeted biopsy of the prostate |
7.01.152 |
|
4 |
Periureteral bulking agents as a treatment of vesicoureteral reflux |
7.01.102 |
|
5 |
Prostatic urethral lift |
7.01.151 |
|
6 |
Allogeneic pancreas transplant |
7.03.02 |
Minor update |
7 |
Biofeedback as a treatment of urinary incontinence in adults |
2.01.27 |
Minor update |
8 |
Digital health technologies for attention deficit/hyperactivity disorder |
3.03.03 |
Minor update |
9 |
Digital health technologies: Diagnostic applications |
3.03.01 |
Minor update |
10 |
Facet joint denervation |
7.01.116 |
Archived |
11 |
Gender affirmation surgery |
BSC7.02 |
Admin coding |
12 |
Gene expression profile testing and circulating tumor DNA testing for predicting recurrence in colon cancer |
2.04.61 |
Minor update |
13 |
Gene expression profiling for cutaneous melanoma |
2.04.146 |
Archived |
14 |
Genetic testing for macular degeneration |
2.04.103 |
Archived |
15 |
Germline genetic testing for gene variants associated with breast cancer in individuals at high breast cancer risk (CHEK2, ATM, and BARD1) |
2.04.126 |
Minor update |
16 |
Germline genetic testing for hereditary diffuse gastric cancer (CDH1, CTNNA1) |
2.04.154 |
Minor update |
17 |
Germline genetic testing for ovarian cancer risk (BRIP1, RAD51C, RAD51D, NBN) |
2.04.149 |
Minor update |
18 |
Heart transplant |
7.03.09 |
Minor update |
19 |
Heart/lung transplant |
7.03.08 |
Minor update |
20 |
Hip arthroplasty for adults |
BSC7.11 |
Minor update |
21 |
Isolated small bowel transplant |
7.03.04 |
Minor update |
22 |
Kidney transplant |
7.03.01 |
Minor update |
23 |
Liver transplant and combined liver-kidney transplant |
7.03.06 |
Minor update |
24 |
Lung and lobar lung transplant |
7.03.07 |
Minor update |
25 |
Lung volume reduction surgery for severe emphysema |
7.01.71 |
Minor update |
26 |
Magnetoencephalography/magnetic source imaging |
BSC6.05 |
Minor update |
27 |
Medical cannabis for the treatment of pain and spasticity |
5.01.32 |
Archived |
28 |
Non-invasive positive airway pressure for chronic obstructive pulmonary disease |
8.01.64 |
Minor update |
29 |
Pelvic floor stimulation as a treatment of urinary and fecal incontinence |
1.01.17 |
Minor update |
30 |
Remote electrical neuromodulation for migraine |
7.01.171 |
Minor update |
31 |
Reproductive techniques |
4.02.04 |
Minor update |
32 |
Small bowel/liver and multivisceral transplant |
7.03.05 |
Minor update |
33 |
Surgical left atrial appendage occlusion devices for stroke prevention in atrial fibrillation |
7.01.172 |
Minor update |
34 |
Total artificial hearts and implantable ventricular assist devices |
7.03.11 |
Minor update |
35 |
Uterus transplantation for absolute uterine factor infertility |
4.02.06 |
Minor update |
36 |
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 September 1, 2023
|
Policy Title – September 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Oncology: Molecular analysis of solid tumors and hematologic malignancies |
BSC_CON_2.04 |
|
2 |
Automated ambulatory blood pressure monitoring for diagnosis of hypertension in patients with elevated office blood pressure |
1.01.02 |
|
3 |
Electromagnetic navigational bronchoscopy |
7.01.122 |
|
4 |
Hyperthermic intraperitoneal chemotherapy for select intra-abdominal and pelvic malignancies |
2.03.07 |
|
5 |
Multicancer early detection testing |
2.04.158 |
|
6 |
Neurofeedback |
2.01.28 |
|
7 |
Percutaneous electrical nerve stimulation, percutaneous neuromodulation therapy, and restorative neurostimulation therapy |
7.01.29 |
|
8 |
Proteogenomic testing for patients with cancer |
2.04.140 |
|
9 |
Risk-reducing mastectomy |
7.01.09 |
|
10 |
Tumor treating fields therapy |
1.01.29 |
|
11 |
Brachytherapy for clinically localized prostate cancer using permanently implanted seeds |
8.01.14 |
Minor update |
12 |
Cellular immunotherapy for prostate cancer |
8.01.53 |
Minor update |
13 |
Continuous glucose monitoring |
1.01.20 |
Admin update |
14 |
Cryoablation of tumors located in the kidney, lung, breast, pancreas, or bone |
7.01.92 |
Minor update |
15 |
Elective invasive coronary angiography (ICA) |
BSC2.13 |
Minor update |
16 |
Elective percutaneous coronary intervention (PCI) |
BSC6.02 |
Minor update |
17 |
Electronic brachytherapy for nonmelanoma skin cancer |
8.01.62 |
Minor update |
18 |
Endobronchial brachytherapy |
8.03.11 |
Minor update |
19 |
Genetic testing for diagnosis and management of mental health conditions |
2.04.110 |
Minor update |
20 |
Genotype-guided tamoxifen treatment |
2.04.51 |
Minor update |
21 |
Intensity-modulated radiotherapy of the breast and lung |
8.01.46 |
Admin coding |
22 |
Intensity-modulated radiotherapy of the prostate |
8.01.47 |
Admin coding |
23 |
Intensity-modulated radiotherapy: Abdomen, pelvis and chest |
8.01.49 |
Admin coding |
24 |
Intensity-modulated radiotherapy: Cancer of the head and neck or thyroid |
8.01.48 |
Admin coding |
25 |
Intensity-modulated radiotherapy: Central nervous system tumors |
8.01.59 |
Admin coding |
26 |
Intracavitary balloon catheter brain brachytherapy for malignant gliomas or metastasis to the brain |
8.01.45 |
Minor update |
27 |
Intraoperative radiotherapy |
8.01.08 |
Minor update |
28 |
Magnetic resonance-guided focused ultrasound |
7.01.109 |
Minor update |
29 |
Oncologic applications of photodynamic ttherapy, including Barrett esophagus |
8.01.06 |
Minor update |
30 |
Radioembolization for primary and metastatic tumors of the liver |
8.01.43 |
Minor update |
31 |
Radiofrequency ablation of primary or metastatic liver tumors |
7.01.91 |
Minor update |
32 |
Saturation biopsy for diagnosis, staging, and management of prostate cancer |
7.01.121 |
Minor update |
33 |
Serologic genetic and molecular screening for colorectal cancer |
2.04.150 |
Minor update |
34 |
Stereotactic radiosurgery and stereotactic body radiotherapy |
6.01.10 |
Admin coding |
35 |
Transcatheter arterial chemoembolization to treat primary or metastatic liver malignancies |
8.01.11 |
Minor update |
36 |
Treatment of varicose veins/venous insufficiency |
7.01.124 |
Admin coding |
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, 2023
|
Policy Title – August 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Cytochrome P450 genotype-guided treatment strategy |
2.04.38 |
|
2 |
Autonomic nervous system testing |
2.01.96 |
|
3 |
Closure devices for patent foramen ovale and atrial septal defects |
2.02.09 |
|
4 |
Electromyography and nerve conduction studies |
2.01.95 |
|
5 |
Endovascular stent grafts for abdominal aortic aneurysms |
7.01.67 |
|
6 |
Gene expression profiling for cutaneous melanoma |
2.04.146 |
|
7 |
Genetic testing for alpha thalassemia |
2.04.104 |
|
8 |
Genetic testing for Rett syndrome |
2.04.81 |
|
9 |
Home cardiorespiratory monitoring |
1.01.06 |
|
10 |
Low level laser therapy |
2.01.56 |
|
11 |
Oncology: Algorithmic (genetic expression) testing |
BSC_CON_2.05 |
|
12 |
Percutaneous left atrial appendage closure devices for stroke prevention in atrial fibrillation |
2.02.26 |
|
13 |
Polysomnography for non-respiratory sleep disorders |
2.01.99 |
|
14 |
Progenitor cell therapy for the treatment of damaged myocardium due to ischemia |
2.02.18 |
|
15 |
Serum biomarker panel testing for systemic lupus erythematosus and other connective tissue diseases |
2.04.123 |
|
16 |
Transurethral water vapor thermal therapy and transurethral water jet ablation (aquablation) for benign prostatic hypertrophy |
2.01.49 |
|
17 |
Actigraphy |
2.01.73 |
Minor update |
18 |
Amniotic membrane and amniotic fluid |
7.01.149 |
Admin coding |
19 |
Assays of genetic expression in tumor tissue as a technique to determine prognosis in atients with breast cancer |
2.04.36 |
Archived |
20 |
Autologous platelet-derived growth factors for wound healing and other non-orthopedic conditions |
2.01.16 |
Admin coding |
21 |
Bariatric surgery |
7.01.47 |
Minor update |
22 |
Biventricular pacemakers (cardiac resynchronization therapy) for the treatment of heart failure |
2.02.10 |
Admin coding |
23 |
Bronchial thermoplasty |
7.01.127 |
Minor update |
24 |
Bronchial valves |
7.01.128 |
Minor update |
25 |
Cardiac hemodynamic monitoring for the management of heart failure in the outpatient setting |
2.02.24 |
Minor update |
26 |
Cardiovascular risk panels |
2.04.100 |
Admin coding |
27 |
Cognitive rehabilitation |
8.03.10 |
Admin coding |
28 |
Diagnosis of obstructive sleep apnea syndrome |
2.01.18 |
Minor update |
29 |
Drug testing in pain management and substance use disorder treatment |
2.04.98 |
Admin coding |
30 |
Dry hydrotherapy for chronic pain conditions |
2.01.105 |
Minor update |
31 |
Endovascular stent grafts for disorders of the thoracic aorta |
7.01.86 |
Minor Update |
32 |
Evaluation of biomarkers for Alzheimer disease |
2.04.14 |
Admin coding |
33 |
External insulin infusion pump |
BSC1.03 |
Minor update |
34 |
Extracorporeal shock wave treatment for plantar fasciitis and other musculoskeletal conditions |
2.01.40 |
Minor update |
35 |
Gene expression profiling and protein biomarkers for prostate cancer management |
2.04.111 |
Archived |
36 |
Gene expression-based assays for cancers of unknown primary |
2.04.54 |
Archived |
37 |
General approach to genetic testing |
2.04.91 |
Admin coding |
38 |
Genetic and protein biomarkers for the diagnosis and cancer risk assessment of prostate cancer |
2.04.33 |
Archived |
39 |
Genetic testing: Preimplantation genetic testing |
BSC_CON_2.03 |
Admin coding |
40 |
Genetic testing: Prenatal and preconception carrier screening |
BSC_CON_2.07 |
Admin coding |
41 |
Genotype-guided Warfarin dosing |
2.04.48 |
Minor update |
42 |
Hyperbaric oxygen therapy |
2.01.04 |
Minor update |
43 |
Identification of microorganisms using nucleic acid probes |
2.04.10 |
Minor update |
44 |
Interferential current stimulation |
1.01.24 |
Minor update |
45 |
Lung volume reduction surgery for severe emphysema |
7.01.71 |
Minor update |
46 |
Maternal serum biomarkers for prediction of adverse obstetric outcomes |
2.04.152 |
Admin coding |
47 |
Medical cannabis for the treatment of pain and spasticity |
5.01.32 |
Minor update |
48 |
Medical management of obstructive sleep apnea syndrome |
8.01.67 |
Minor update |
49 |
Minimally invasive ablation procedures for Morton and other peripheral neuromas |
7.01.147 |
Minor update |
50 |
Molecular testing in the management of pulmonary nodules |
2.04.142 |
Archived |
51 |
Multibiomarker disease activity blood test for rheumatoid arthritis |
2.04.119 |
Minor update |
52 |
Multimarker serum testing related to ovarian cancer |
2.04.62 |
Archived |
53 |
Navigated transcranial magnetic stimulation |
2.01.90 |
Minor update |
54 |
Oscillatory devices for the treatment of cystic fibrosis and other respiratory conditions |
1.01.15 |
Minor update |
55 |
Paraspinal surface electromyography to evaluate and monitor back pain |
2.01.35 |
Minor update |
56 |
Quantitative sensory testing |
2.01.39 |
Minor update |
57 |
Reconstructive breast surgery/management of breast |
7.01.22 |
Minor update |
58 |
Surgical treatment of snoring and obstructive sleep apnea syndrome |
7.01.101 |
Minor update |
59 |
Transcatheter pulmonary valve implantation |
7.01.131 |
Minor update |
60 |
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, 2023
Policy Title – July 1, 2023 |
Policy# |
Status |
|
---|---|---|---|
1 | Biventricular pacemakers (cardiac resynchronization therapy) for the treatment of heart failure | 2.02.10 | |
2 |
Implantable cardioverter defibrillators |
7.01.44 |
Major update |
3 |
Oncology: Molecular analysis of solid tumors and hematologic malignancies |
BSC_CON_2.04 |
|
4 |
Coronary computed tomography angiography with selective noninvasive fractional flow reserve |
6.01.59 |
|
5 |
Dry needling of trigger points for myofascial pain |
2.01.100 |
|
6 |
Electrical bone growth stimulation of the appendicular skeleton |
7.01.07 |
|
7 |
Electrical stimulation of the spine as an adjunct to spinal fusion procedures |
7.01.85 |
|
8 |
Genetic testing for hereditary hemochromatosis |
2.04.80 |
|
9 |
Genetic testing for limb-girdle muscular dystrophies |
2.04.132 |
|
10 |
Immediate and delayed lymphatic reconstruction surgery |
BSC7.18 |
|
11 |
Interventions for progressive scoliosis |
2.01.83 |
|
12 |
Intradialytic parenteral nutrition |
8.01.44 |
|
13 |
Leadless cardiac pacemakers |
2.02.32 |
|
14 |
Meniscal allografts and other meniscal implants |
7.01.15 |
|
15 |
Percutaneous electrical nerve field stimulation for irritable bowel syndrome |
2.01.106 |
|
16 |
Spinal cord and dorsal root ganglion stimulation |
7.01.25 |
|
17 |
Transcatheter mitral valve repair |
2.02.30 |
|
18 |
Allograft injection for degenerative disc disease |
7.01.166 |
Minor update |
19 |
Ambulatory event monitors and mobile cardiac outpatient telemetry |
2.02.08 |
Minor update |
20 |
Autografts and allografts in the treatment of focal articular cartilage lesions |
7.01.78 |
Minor update |
21 |
Autologous chondrocyte implantation for focal articular cartilage lesions |
7.01.48 |
Minor update |
22 |
Baroreflex stimulation devices |
8.01.57 |
Minor update |
23 |
Cardiac rehabilitation in the outpatient setting |
8.03.08 |
Admin update |
24 |
Catheter ablation as treatment for atrial fibrillation |
2.02.19 |
Minor update |
25 |
Endovascular therapies for extracranial vertebral artery disease |
7.01.148 |
Minor update |
26 |
Enhanced external counterpulsation |
2.02.06 |
Minor update |
27 |
Extracorporeal membrane oxygenation for adult conditions |
8.01.60 |
Minor update |
28 |
Extracranial carotid artery stenting |
7.01.68 |
Minor update |
29 |
Genetic testing for inherited thrombophilia |
2.04.82 |
Minor update |
30 |
Genetic testing for lactase insufficiency |
2.04.94 |
Minor update |
31 |
Inhaled nitric oxide |
8.01.37 |
Minor update |
32 |
Lower limb prostheses |
BSC1.01 |
Minor update |
33 |
Myocardial strain imaging |
2.02.31 |
Minor update |
34 |
Neuropsychological testin+14:22g |
BSC2.06 |
Minor update |
35 |
Oncology: Circulating tumor DNA and circulating tumor cells (liquid biopsy) |
BSC_CON_2.10 |
Admin update |
36 |
Open and thoracoscopic approaches to treat atrial fibrillation and atrial flutter (maze and related procedures) |
7.01.14 |
Minor update |
37 |
Phrenic nerve stimulation for central sleep apnea |
2.02.33 |
Minor update |
38 |
Power wheelchairs and power-operated vehicles for permanent use |
BSC1.02 |
Minor update |
39 |
Speech therapy |
BSC8.02 |
Minor update |
40 |
Surgical treatments for breast cancer-related lymphedema |
7.01.162 |
Archived |
41 |
Treatment of varicose veins/venous insufficiency |
7.01.124 |
Minor update |
42 |
Tumor-informed circulating tumor DNA testing for cancer management |
BSC2.18 |
Archived |
43 |
Ultrasonographic measurement of carotid intimal-medial thickness as an assessment of subclinical atherosclerosis |
2.02.16 |
Minor update |
44 |
Wearable cardioverter defibrillators |
2.02.15 |
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, 2023
|
Policy Title –June 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Genetic testing for Lynch syndrome and other inherited colon cancer syndromes |
2.04.08 |
|
2 |
Germline and somatic biomarker testing for targeted treatment and immunotherapy in breast cancer |
2.04.151 |
|
3 |
Germline and somatic biomarker testing for targeted treatment and immunotherapy in ovarian cancer |
2.04.156 |
|
4 |
Germline and somatic biomarker testing for targeted treatment and immunotherapy in prostate cancer |
2.04.155 |
|
5 |
Intensity-modulated radiotherapy of the prostate |
8.01.47 |
|
6 |
Adjustable cranial orthoses for positional plagiocephaly and craniosynostoses |
1.01.11 |
|
7 |
Bone morphogenetic protein |
7.01.100 |
|
8 |
Cardiac rehabilitation in the outpatient setting |
8.03.08 |
|
9 |
Cognitive rehabilitation |
8.03.10 |
|
10 |
Cooling devices used in the outpatient setting |
1.01.26 |
|
11 |
Corneal topography/computer-assisted corneal topography/photokeratoscopy |
9.03.05 |
|
12 |
Deep brain stimulation |
7.01.63 |
|
13 |
Digital health technologies: therapeutic applications |
3.03.02 |
|
14 |
Genetic testing for Duchenne and Becker muscular dystrophy |
2.04.86 |
|
15 |
Genetic testing for hereditary hearing loss |
2.04.87 |
|
16 |
Genetic testing of CADASIL syndrome |
2.04.75 |
|
17 |
Keratoprosthesis |
9.03.01 |
|
18 |
Intraocular radiotherapy for age-related macular degeneration |
9.03.20 |
|
19 |
Multitarget polymerase chain reaction testing for diagnosis of bacterial vaginosis |
2.04.127 |
|
20 |
Nerve graft with radical prostatectomy |
7.01.81 |
|
21 |
Occipital nerve stimulation |
7.01.125 |
|
22 |
Oncology: Circulating tumor DNA and circulating tumor cells (liquid biopsy) |
BSC_CON_2.10 |
|
23 |
Oncology: Molecular analysis of solid tumors and hematologic malignancies |
BSC_CON_2.04 |
|
24 |
Outpatient pulmonary rehabilitation |
8.03.05 |
|
25 |
Percutaneous balloon kyphoplasty, radiofrequency kyphoplasty, and mechanical vertebral augmentation |
6.01.38 |
|
26 |
Peripheral subcutaneous field stimulation |
7.01.139 |
|
27 |
Photodynamic therapy for choroidal neovascularization |
9.03.08 |
|
28 |
Responsive neurostimulation for the treatment of refractory focal epilepsy |
7.01.143 |
|
29 |
Retinal telescreening for diabetic retinopathy |
9.03.13 |
|
30 |
Sacral nerve neuromodulation/stimulation |
7.01.69 |
|
31 |
Vertical expandable prosthetic titanium rib |
7.01.110 |
|
32 |
Viscocanalostomy and canaloplasty |
9.03.26 |
|
33 |
Behavioral health treatment for autism spectrum disorders |
BSC3.01 |
Minor update |
34 |
Bioengineered skin and soft tissue substitutes |
7.01.113 |
Admin coding |
35 |
Cardiovascular risk panels |
2.04.100 |
Admin coding |
36 |
Catheter ablation for cardiac arrhythmias |
BSC2.12 |
Minor update |
37 |
Circulating tumor DNA and circulating tumor cells for cancer management (liquid biopsy) |
2.04.141 |
Archived |
38 |
Comprehensive genomic profiling for selecting targeted cancer therapies |
2.04.115 |
Archived |
39 |
Cranial electrotherapy stimulation and auricular slectrostimulation |
8.01.58 |
Admin coding |
40 |
Diabetes prevention program |
BSC2.11 |
Minor update |
41 |
Endovascular procedures for intracranial arterial disease (atherosclerosis and aneurysms) |
2.01.54 |
Minor update |
42 |
Facet arthroplasty |
7.01.120 |
Minor update |
43 |
General approach to genetic testing |
2.04.91 |
Admin coding |
44 |
Genetic and protein biomarkers for the diagnosis and cancer risk assessment of prostate cancer |
2.04.33 |
Admin coding |
45 |
Genetic testing for FLT3, NPM1, and CEBPA variants in cytogenetically normal acute myeloid leukemia |
2.04.124 |
Archived |
46 |
Genetic testing: Exome and genome sequencing for the diagnosis of genetic disorders |
BSC_CON_2.02 |
Minor update |
47 |
Hip femoroacetabular impingement (FAI) surgical treatment |
7.01.118 |
Minor update |
48 |
Hip resurfacing |
7.01.80 |
Minor update |
49 |
Identification of microorganisms using nucleic acid probes |
2.04.10 |
Admin coding |
50 |
Image-guided minimally invasive decompression for spinal stenosis |
7.01.126 |
Minor update |
51 |
Intensity-modulated radiotherapy of the breast and lung |
8.01.46 |
Admin coding |
52 |
Intensity-modulated radiotherapy: Abdomen, pelvis and chest |
8.01.49 |
Admin coding |
53 |
Intensity-modulated radiotherapy: Cancer of the head and neck or thyroid |
8.01.48 |
Admin coding |
54 |
Intensity-modulated radiotherapy: Central nervous system Tumors |
8.01.59 |
Admin coding |
55 |
Intraoperative neurophysiologic monitoring |
7.01.58 |
Minor update |
56 |
JAK2, MPL, and CALR testing for myeloproliferative neoplasms |
2.04.60 |
Archived |
57 |
Lipid apheresis |
BSC8.07 |
Minor update |
58 |
Manipulation under anesthesia |
8.01.40 |
Minor update |
59 |
Measurement of lipoprotein-associated phospholipase A2 in the assessment of cardiovascular risk |
2.04.32 |
Admin coding |
60 |
Medical management of obstructive sleep apnea syndrome |
8.01.67 |
Admin coding |
61 |
Multimarker serum testing related to ovarian cancer |
2.04.62 |
Admin coding |
62 |
Orthopedic applications of platelet-rich plasma |
2.01.98 |
Minor update |
63 |
Percutaneous vertebroplasty and sacroplasty |
6.01.25 |
Minor update |
64 |
Physical therapy |
BSC8.03 |
Minor update |
65 |
Power morcellation for the treatment of uterine fibroids |
BSC7.06 |
Minor update |
66 |
Reconstructive services |
BSC7.08 |
Minor update |
67 |
Somatic (tumor) biomarker testing (including liquid biopsy) for targeted treatment and immunotherapy in non-small-cell lung cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, HER2, PD-L1, TMB) |
2.04.45 |
Archived |
68 |
Subtalar arthroereisis |
7.01.104 |
Minor update |
69 |
Trigger point and tender point injections |
2.01.103 |
Minor update |
70 |
Uterus transplantation for absolute uterine factor infertility |
4.02.06 |
Minor update |
71 |
Vertebral axial decompression |
8.03.09 |
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, 2023
|
Policy Title – May 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Bariatric surgery |
7.01.47 |
|
2 |
Partial thickness rotator cuff tears and acromioplasty/subacromial decompression |
BSC7.14 |
|
3 |
Postsurgical home use of limb compression devices for venous thromboembolism prophylaxis |
1.01.28 |
|
4 |
Amniotic membrane and amniotic fluid |
7.01.149 |
Admin update |
5 |
Continuous passive motion in the home setting |
1.01.10 |
Minor update |
6 |
Corneal collagen cross-linking |
9.03.28 |
Minor update |
7 |
Diagnosis of obstructive sleep apnea syndrome |
2.01.18 |
Admin update |
8 |
Electrical and electromagnetic stimulation for the treatment of arthritis |
1.01.27 |
Minor update |
9 |
Endothelial keratoplasty |
9.03.22 |
Minor update |
10 |
Eyelid thermal pulsation for the treatment of dry eye syndrome |
9.03.29 |
Minor update |
11 |
Functional neuromuscular electrical stimulation |
8.03.01 |
Minor update |
12 |
Gene expression-based assays for cancers of unknown primary |
2.04.54 |
Minor update |
13 |
Genetic testing for macular degeneration |
2.04.103 |
Minor update |
14 |
Genetic testing for predisposition to inherited hypertrophic cardiomyopathy |
2.02.28 |
Minor update |
15 |
Germline genetic testing for familial cutaneous malignant melanoma (CDKN2A, CDK4) |
2.04.44 |
Minor update |
16 |
Hippotherapy |
8.03.12 |
Minor update |
17 |
Knee braces (custom) |
BSC1.05 |
Minor update |
18 |
Laboratory and genetic testing for use of 5-fluorouracil in patients with cancer |
2.04.68 |
Minor update |
19 |
Lifestyle modification program for reversing heart disease |
BSC8.01 |
Minor update |
20 |
Low intensity pulsed ultrasound fracture healing device |
1.01.05 |
Minor update |
21 |
Microprocessor-controlled prostheses for the lower limb |
1.04.05 |
Minor update |
22 |
Myoelectric prosthetic and orthotic components for the upper limb |
1.04.04 |
Minor update |
23 |
Oncology: Cancer screening |
BSC_CON_2.09 |
Admin update |
24 |
Ophthalmologic techniques that evaluate the posterior segment for glaucoma |
9.03.06 |
Minor update |
25 |
Optical coherence tomography of the anterior eye segment |
9.03.18 |
Minor update |
26 |
Orthognathic surgery |
BSC7.03 |
Minor update |
27 |
Orthoptic training for the treatment of vision or learning disabilities |
9.03.03 |
Minor update |
28 |
Panniculectomy, abdominoplasty, and surgical management of diastasis recti |
BSC7.04 |
Minor update |
29 |
Patient-controlled end range of motion stretching devices |
1.03.05 |
Minor update |
30 |
Personalized breast cancer screening clinical trial |
BSC2.08 |
Minor update |
31 |
Pneumatic compression pumps for treatment of lymphedema and venous ulcers |
1.01.18 |
Minor update |
32 |
Powered exoskeleton for ambulation in patients with lower-limb disabilities |
1.03.04 |
Minor update |
33 |
Retinal prosthesis |
9.03.15 |
Minor update |
34 |
Sensory integration therapy and auditory integration therapy |
8.03.13 |
Minor update |
New and updated policies effective April 1, 2023
|
Policy Title – April 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Continuous glucose monitoring |
1.01.20 |
|
2 |
Hematopoietic cell transplantation for non-Hodgkin lymphomas |
8.01.20 |
|
3 |
Stationary ultrasonic diathermy devices |
7.01.174 |
|
4 |
Allogeneic hematopoietic cell transplantation for myelodysplastic syndromes and myeloproliferative neoplasms |
8.01.21 |
Minor update |
5 |
Ambulatory surgery center |
BSC10.01 |
Minor update |
6 |
Amniotic membrane and amniotic fluid |
7.01.149 |
Minor update |
7 |
Auditory brainstem implant |
7.01.83 |
Minor update |
8 |
Balloon ostial dilation for treatment of chronic and recurrent acute rhinosinusitis |
7.01.105 |
Minor update |
9 |
Chelation therapy for off-label uses |
8.01.02 |
Minor update |
10 |
Chronic intermittent intravenous insulin therapy |
2.01.43 |
Minor update |
11 |
Cleft palate – dental related services |
BSC2.01 |
Minor update |
12 |
Cranial electrotherapy stimulation and auricular electrostimulation |
8.01.58 |
Minor update |
13 |
Cryoablation, radiofrequency ablation, and laser ablation for treatment of chronic rhinitis |
7.01.168 |
Minor update |
14 |
Dental anesthesia |
BSC2.02 |
Minor update |
15 |
Dynamic posturography |
2.01.02 |
Minor update |
16 |
Elective invasive coronary angiography (ICA) |
BSC2.13 |
Admin coding |
17 |
Gastric electrical stimulation |
7.01.73 |
Minor update |
18 |
General approach to evaluating the utility of genetic panels |
2.04.92 |
Minor update |
19 |
General approach to genetic testing |
2.04.91 |
Minor update |
20 |
Germline genetic testing for pancreatic cancer susceptibility genes (ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, and TP53) |
2.04.148 |
Minor update |
21 |
Handheld radiofrequency apectroscopy for intraoperative assessment of surgical margins during breast-conserving surgery |
7.01.140 |
Minor update |
22 |
Hematopoietic cell transplantation for acute lymphoblastic leukemia |
8.01.32 |
Minor update |
23 |
Hematopoietic cell transplantation for acute myeloid leukemia |
8.01.26 |
Minor update |
24 |
Hematopoietic cell transplantation for autoimmune diseases |
8.01.25 |
Minor update |
25 |
Hematopoietic cell transplantation for central nervous system embryonal tumors and ependymoma |
8.01.28 |
Minor update |
26 |
Hematopoietic cell transplantation for chronic lymphocytic leukemia/small lymphocytic lymphoma |
8.01.15 |
Minor update |
27 |
Hematopoietic cell transplantation for chronic myeloid leukemia |
8.01.30 |
Minor update |
28 |
Hematopoietic cell transplantation for Hodgkin lymphoma |
8.01.29 |
Minor update |
29 |
Hematopoietic cell transplantation for plasma cell dyscrasias, including multiple myeloma and POEMS syndrome |
8.01.17 |
Minor update |
30 |
Hematopoietic cell transplantation for primary amyloidosis |
8.01.42 |
Minor update |
31 |
Hematopoietic cell transplantation for solid tumors of childhood |
8.01.34 |
Minor update |
32 |
Hematopoietic cell transplantation in the treatment of germ cell tumors |
8.01.35 |
Minor update |
33 |
Hysterectomy surgery for benign conditions BSC7.09 |
BSC2.02 |
Minor update |
34 |
Implantable bone-conduction and bone-anchored hearing aids |
7.01.03 |
Minor update |
35 |
Laparoscopic, percutaneous, and transcervical techniques for uterine fibroid myolysis |
4.01.19 |
Minor update |
36 |
Maternal serum biomarkers for prediction of adverse obstetric outcomes |
2.04.152 |
Minor update |
37 |
Placental and umbilical cord blood as a source of stem cells |
7.01.50 |
Archived |
38 |
Reduction mammaplasty for breast-related symptoms |
7.01.21 |
Minor update |
39 |
Semi-implantable and fully implantable middle ear hearing aids |
7.01.84 |
Minor update |
40 |
Stem cell therapy for peripheral arterial disease |
8.01.55 |
Minor update |
41 |
Steroid-eluting sinus stents and implants |
7.01.134 |
Minor update |
42 |
Surgical deactivation of headache trigger sites |
7.01.135 |
Minor update |
43 |
Surgical ventricular restoration |
7.01.103 |
Minor update |
44 |
Temporomandibular joint disorder |
2.01.21 |
Minor update |
45 |
Transcatheter aortic-valve implantation for aortic stenosis |
7.01.132 |
Minor update |
46 |
Vagus nerve blocking therapy for treatment of obesity |
BSC7.17 |
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 March 1, 2023
|
Policy Title – March 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Charged-particle (proton or helium ion) radiotherapy for neoplastic conditions |
BSC8.04 |
|
2 |
Germline and somatic biomarker testing (including liquid biopsy) for targeted treatment and immunotherapy in breast cancer |
2.04.151 |
|
3 |
Negative pressure wound therapy in the outpatient setting |
1.01.16 |
|
4 |
Tumor-informed circulating tumor DNA testing for cancer management |
BSC2.18 |
|
5 |
Facet joint denervation |
7.01.116 |
|
6 |
Adipose-derived stem cells in autologous fat grafting to the breast |
7.01.153 |
Minor update |
7 |
Ambulatory event monitors and mobile cardiac uutpatient telemetry |
2.02.08 |
Admin update |
8 |
Amniotic membrane and amniotic fluid |
7.01.149 |
Admin update |
9 |
Autologous platelet-derived growth factors for wound healing and other non-orthopedic conditions |
2.01.16 |
Minor update |
10 |
Bioengineered skin and soft tissue substitutes |
7.01.113 |
Minor update |
11 |
Bioimpedance devices for detection and management of lymphedema |
2.01.82 |
Minor update |
12 |
Blepharoplasty, blepharoptosis repair (levator resection) and brow lift (repair of brow ptosis) |
BSC7.01 |
Minor update |
13 |
Bone turnover markers for the diagnosis and management of osteoporosis and diseases associated with high bone turnover |
2.04.15 |
Minor update |
14 |
Catheter ablation for cardiac arrhythmias |
BSC2.12 |
Admin update |
15 |
Corneal collagen cross-linking |
9.03.28 |
Admin update |
16 |
Cranial electrotherapy stimulation and auricular electrostimulation |
8.01.58 |
Admin update |
17 |
Digital health therapies for substance use disorders |
5.01.35 |
Admin update |
18 |
Electrostimulation and electromagnetic therapy for treating wounds |
2.01.57 |
Minor update |
19 |
Esophageal pH monitoring |
2.01.20 |
Admin update |
20 |
Evaluation of biomarkers for Alzheimer disease |
2.04.14 |
Admin update |
21 |
Focal treatments for prostate cancer |
8.01.61 |
Admin update |
22 |
Gender affirmation surgery |
BSC7.02 |
Minor update |
23 |
General approach to avaluating the utility of genetic panels |
2.04.92 |
Admin update |
24 |
Genetic and protein biomarkers for the diagnosis and cancer risk assessment of prostate cancer |
2.04.33 |
Admin update |
25 |
Genetic testing for Alzheimer disease |
2.04.13 |
Admin update |
26 |
Genetic testing for cardiac ion channelopathies |
2.04.43 |
Minor update |
27 |
Genetic testing for diagnosis and management of mental health condition |
2.04.110 |
Admin update |
28 |
Genetic testing for FLT3, NPM1, and CEBPA variants in cytogenetically normal acute myeloid leukemia |
2.04.124 |
Minor update |
29 |
Genetic testing: Exome and genome sequencing for the diagnosis of genetic disorders |
BSC_CON_2.02 |
Admin update |
30 |
Hyperbaric oxygen therapy |
2.01.04 |
Minor update |
31 |
Identification of microorganisms using nucleic acid probes |
2.04.10 |
Admin update |
32 |
Implantable bone-conduction and bone-anchored hearing aids |
7.01.03 |
Admin update |
33 |
Ingestible pH and pressure capsule |
BSC2.17 |
Minor update |
34 |
Interferential current stimulation |
1.01.24 |
Admin update |
35 |
Lumbar spine surgery |
BSC_NIA_CG_304 |
Admin update |
36 |
Lysis of epidural adhesions |
BSC8.05 |
Minor update |
37 |
Manipulation under anesthesia |
8.01.40 |
Admin update |
38 |
Noncontact ultrasound treatment for wounds |
2.01.79 |
Minor update |
39 |
Oncology: Cancer screening |
BSC_CON_2.09 |
Admin update |
40 |
Orthopedic Applications of stem cell therapy (including allografts and bone substitutes used with autologous bone marrow) |
8.01.52 |
Minor update |
41 |
Orthoptic training for the treatment of vision or learning disabilities |
9.03.03 |
Admin update |
42 |
Percutaneous vertebroplasty and sacroplasty |
6.01.25 |
Admin update |
43 |
Pharmacogenomic and metabolite markers for patients treated with thiopurines |
2.04.19 |
Admin update |
44 |
Reduction mammaplasty |
7.01.21 |
Admin update |
45 |
Retinal prosthesis |
9.03.15 |
Admin update |
46 |
Scintimammography and gamma imaging of the breast and axilla |
6.01.18 |
Admin update |
47 |
Surgical treatment of gynecomastia |
BSC7.13 |
Minor update |
48 |
Vagus nerve blocking therapy for treatment of obesity |
BSC7.17 |
Admin 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, 2023
|
Policy Title – February 1, 2023 |
Policy# |
Status |
Vendor |
---|---|---|---|---|
1 |
Intensity-modulated radiotherapy of the breast and lung |
8.01.46 |
No |
|
2 |
Intensity-modulated radiotherapy of the prostate |
8.01.47 |
No |
|
3 |
Intensity-modulated radiotherapy: Abdomen, pelvis and chest |
8.01.49 |
No |
|
4 |
Intensity-modulated radiotherapy: Cancer of the head and neck or thyroid |
8.01.48 |
No |
|
5 |
Intensity-modulated radiotherapy: Central nervous system tumors |
8.01.59 |
No |
|
6 |
Radiation oncology |
BSC8.06 |
No |
|
7 |
Somatic (tumor) biomarker testing (including liquid biopsy) for targeted treatment and immunotherapy in non-small-cell lung cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, HER2, PD-L1, TMB) |
2.04.45 |
No |
|
8 |
Stereotactic radiosurgery and stereotactic body radiotherapy |
6.01.10 |
No |
|
9 |
Axillary reverse mapping for prevention of breast cancer-related lymphedema |
7.01.173 |
No |
|
10 |
Genetic testing: Prenatal and preconception carrier screening |
BSC_CON_2.07 |
No |
|
11 |
Genetic testing: Prenatal diagnosis (via amniocentesis, CVS, or PUBS) and pregnancy loss |
BSC_CON_2.06 |
No |
|
12 |
Oncology: Cancer screening |
BSC_CON_2.09 |
No |
|
13 |
Temporarily implanted nitinol device (iTind) for benign prostatic hyperplasia |
7.01.175 |
No |
|
14 |
Bariatric surgery |
7.01.47 |
Minor update |
No |
15 |
Cardiovascular risk panels |
2.04.100 |
Minor update |
No |
16 |
Carrier screening for genetic diseases |
2.04.107 |
ARCHIVED |
No |
17 |
Dermatologic applications of photodynamic therapy |
2.01.44 |
Minor update |
No |
18 |
Fecal analysis in the diagnosis of intestinal dysbiosis |
2.04.26 |
Minor update |
No |
19 |
Genetic and protein biomarkers for the diagnosis and cancer risk assessment of prostate cancer |
2.04.33 |
Minor update |
No |
20 |
Immune cell function assay |
2.04.56 |
Minor update |
No |
21 |
Invasive prenatal (fetal) diagnostic testing |
2.04.116 |
Archived |
No |
22 |
Laser interstitial thermal therapy for neurological conditions |
7.01.170 |
Minor update |
No |
23 |
Measurement of lipoprotein-associated phospholipase A2 in the assessment of cardiovascular risk |
2.04.32 |
Minor update |
No |
24 |
Multimarker serum testing related to ovarian cancer |
2.04.62 |
Minor update |
No |
25 |
Nonpharmacologic treatment of rosacea |
2.01.71 |
Minor update |
No |
26 |
Novel biomarkers in risk assessment and management of cardiovascular disease |
2.04.65 |
Minor update |
No |
27 |
Proteomic testing for targeted therapy in non-small-cell lung cancer |
2.04.125 |
Minor update |
No |
28 |
Serum biomarker human epididymis protein 4 |
2.04.66 |
Minor update |
No |
29 |
Testing serum vitamin D levels |
2.04.135 |
Minor update |
No |
30 |
Transesophageal endoscopic therapies for gastroesophageal reflux disease |
2.01.38 |
Minor update |
No |
31 |
Urinary biomarkers for cancer screening, diagnosis, and surveillance |
2.04.07 |
Archived |
No |
32 |
Wireless capsule endoscopy for gastrointestinal (GI) disorders |
6.01.33 |
Minor update |
No |
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, 2023
|
Policy Title – January 1, 2023 |
Policy# |
Status |
---|---|---|---|
1 |
Assays of genetic expression in tumor tissue as a technique to determine prognosis in patients with breast cancer |
2.04.36 |
|
2 |
Epidural spine injections |
BSC_NIA_CG_300 |
|
3 |
Esophageal pH monitoring |
2.01.20 |
|
4 |
Genetic testing: Non-Invasive prenatal screening (NIPS)/non-invasive prenatal testing (NIPT) |
BSC_CON_2.08 |
|
5 |
Genetic testing: Preimplantation genetic testing |
BSC_CON_2.03 |
|
6 |
Bariatric surgery |
7.01.47 |
Minor update |
7 |
Cervical spine surgery |
BSC_NIA_CG_307 |
Minor update |
8 |
Confocal laser endomicroscopy |
2.01.87 |
Minor update |
9 |
Drug testing in pain management and substance use disorder treatment |
2.04.98 |
Minor update |
10 |
Endoscopic radiofrequency ablation or cryoablation for Barrett esophagus |
2.01.80 |
Minor update |
11 |
Gene expression profiling and protein biomarkers for prostate cancer management |
2.04.111 |
Minor update |
12 |
Lumbar spinal surgery |
BSC_NIA_CG_304 |
Minor update |
13 |
Magnetic esophageal sphincter augmentation to treat gastroesophageal reflux disease |
7.01.137 |
Minor update |
14 |
Measurement of serum antibodies to selected biologic agents |
2.04.84 |
Minor update |
15 |
Monitored anesthesia care |
7.02.01 |
Minor update |
16 |
Noninvasive prenatal screening for fetal aneuploidies, microdeletions, single-gene disorders, and twin zygosity using cell-free fetal DNA |
4.01.21 |
Archived |
17 |
Noninvasive techniques for the evaluation and monitoring of patients with chronic liver disease |
2.04.41 |
Minor update |
18 |
Paravertebral facet joint injections or blocks |
BSC_NIA_CG_301 |
Minor update |
19 |
Pharmacogenetic testing for pain management |
2.04.131 |
Minor update |
20 |
Pharmacogenomic and metabolite markers for patients treated with thiopurines |
2.04.19 |
Minor update |
21 |
Plugs for anal fistula repair |
7.01.123 |
Minor update |
22 |
Preimplantation genetic testing |
4.02.05 |
Archived |
23 |
Prolotherapy |
2.01.26 |
Minor update |
24 |
Sacroiliac joint injections |
BSC_NIA_CG_305 |
Minor update |
25 |
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 is compliant with SB 535 and has removed prior authorization for biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, as well, in cases where the organization is financially responsible for those services.
Please note that when prior authorization is not required for a service for which Blue Shield is financially responsible, this does not represent a guarantee of coverage or payment. A final coverage determination is made “post-service,” after the claim has been received and reviewed by Blue Shield. The review is based on member eligibility, medical necessity, such as medical or medication policy or site of service, and other limitations or exclusions in the member’s health coverage plan that may apply. 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
Find Medical Benefit Drug Policy for Medicare and Commercial Plans
Technical evaluation and assessment
Find out about our process of evaluating coverage for new technologies and new applications of existing technologies.