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

New

2

Genetic testing: General approach to genetic and molecular testing

BSC_CON_2.27

New

3

Genetic testing: Immune, autoimmune, and rheumatoid disorders

BSC_CON_2.21

New

4

Genetic testing: Lung disorders

BSC_CON_2.23

New

5

Genetic testing: Skeletal dysplasia and rare bone disorders

BSC_CON_2.26

New

6

Oncology: Cytogenetic testing

BSC_CON_2.11

New

7

Suture button suspensionplasty fixation system for thumb carpometacarpal osteoarthritis

7.01.176

New

8

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

8.01.64

Major update

9

Microwave tumor ablation

7.01.133

Major update

10

Transcranial magnetic stimulation as a treatment of depression and other psychiatric/neurologic disorders

2.01.50

Major update

11

Treatment of varicose veins/venous insufficiency

7.01.124

Major update

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

New

2

Ovarian and internal iliac vein endovascular occlusion as a treatment of pelvic congestion syndrome

4.01.18

New

3

Percutaneous and subcutaneous tibial nerve stimulation

7.01.106

New

4

Radioactive seed localization of nonpalpable breast lesions

6.01.57

New

5

Thermography

6.01.12

New

6

Whole body dual X-ray absorptiometry to determine body composition

6.01.40

New

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   

Major update

2

Composite tissue allotransplantation of the hand and face

7.03.13

New

3

Magnetic resonance imaging-targeted biopsy of the prostate

7.01.152

New

4

Periureteral bulking agents as a treatment of vesicoureteral reflux

7.01.102

New

5

Prostatic urethral lift

7.01.151

New

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

Major update

2

Automated ambulatory blood pressure monitoring for diagnosis of hypertension in patients with elevated office blood pressure

1.01.02

New

3

Electromagnetic navigational bronchoscopy

7.01.122

New

4

Hyperthermic intraperitoneal chemotherapy for select intra-abdominal and pelvic malignancies

2.03.07

New

5

Multicancer early detection testing

2.04.158

New

6

Neurofeedback

2.01.28

New

7

Percutaneous electrical nerve stimulation, percutaneous neuromodulation therapy, and restorative neurostimulation therapy

7.01.29

New

8

Proteogenomic testing for patients with cancer

2.04.140

New

9

Risk-reducing mastectomy

7.01.09

New

10

Tumor treating fields therapy

1.01.29

New

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

Major update

2

Autonomic nervous system testing

2.01.96

New

3

Closure devices for patent foramen ovale and atrial septal defects

2.02.09

New

4

Electromyography and nerve conduction studies

2.01.95

New

5

Endovascular stent grafts for abdominal aortic aneurysms

7.01.67

New

6

Gene expression profiling for cutaneous melanoma          

2.04.146    

New

7

Genetic testing for alpha thalassemia

2.04.104

New

8

Genetic testing for Rett syndrome

2.04.81

New

9

Home cardiorespiratory monitoring

1.01.06

New

10

Low level laser therapy

2.01.56

New

11

Oncology: Algorithmic (genetic expression) testing

BSC_CON_2.05

New

12

Percutaneous left atrial appendage closure devices for stroke prevention in atrial fibrillation

2.02.26

New

13

Polysomnography for non-respiratory sleep disorders

2.01.99

New

14

Progenitor cell therapy for the treatment of damaged myocardium due to ischemia

2.02.18

New

15

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

2.04.123

New

16

Transurethral water vapor thermal therapy and transurethral water jet ablation (aquablation) for benign prostatic hypertrophy

2.01.49

New

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

Major update

2

Implantable cardioverter defibrillators 

7.01.44
Major update

3

Oncology: Molecular analysis of solid tumors and hematologic malignancies

BSC_CON_2.04

Major update

4

Coronary computed tomography angiography with selective noninvasive fractional flow reserve

6.01.59

New

5

Dry needling of trigger points for myofascial pain

2.01.100

New

6

Electrical bone growth stimulation of the appendicular skeleton 

7.01.07

New

7

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

7.01.85

New

8

Genetic testing for hereditary hemochromatosis

2.04.80

New

9

Genetic testing for limb-girdle muscular dystrophies

2.04.132

New

10

Immediate and delayed lymphatic reconstruction surgery

BSC7.18

New

11

Interventions for progressive scoliosis

2.01.83

New

12

Intradialytic parenteral nutrition

8.01.44

New

13

Leadless cardiac pacemakers

2.02.32

New

14

Meniscal allografts and other meniscal implants

7.01.15

New

15

Percutaneous electrical nerve field stimulation for irritable bowel syndrome

2.01.106

New

16

Spinal cord and dorsal root ganglion stimulation

7.01.25

New

17

Transcatheter mitral valve repair

2.02.30

New

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

Major update

2

Germline and somatic biomarker testing for targeted treatment and immunotherapy in breast cancer

2.04.151

Major update

3

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

Major update

4

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

Major update

5

Intensity-modulated radiotherapy of the prostate

8.01.47

Major update

6

Adjustable cranial orthoses for positional plagiocephaly and craniosynostoses

1.01.11

New

7

Bone morphogenetic protein

7.01.100

New

8

Cardiac rehabilitation in the outpatient setting

8.03.08

New

9

Cognitive rehabilitation

8.03.10

New

10

Cooling devices used in the outpatient setting

1.01.26

New

11

Corneal topography/computer-assisted corneal topography/photokeratoscopy

9.03.05

New

12

Deep brain stimulation 

7.01.63

New

13

Digital health technologies: therapeutic applications

3.03.02

New

14

Genetic testing for Duchenne and Becker muscular dystrophy

2.04.86

New

15

Genetic testing for hereditary hearing loss

2.04.87

New

16

Genetic testing of CADASIL syndrome

2.04.75

New

17

Keratoprosthesis

9.03.01

New

18

Intraocular radiotherapy for age-related macular degeneration

9.03.20

New

19

Multitarget polymerase chain reaction testing for diagnosis of bacterial vaginosis

2.04.127

New

20

Nerve graft with radical prostatectomy

7.01.81

New

21

Occipital nerve stimulation

7.01.125

New

22

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

BSC_CON_2.10

New

23

Oncology: Molecular analysis of solid tumors and hematologic malignancies

BSC_CON_2.04

New

24

Outpatient pulmonary rehabilitation

8.03.05

New

25

Percutaneous balloon kyphoplasty, radiofrequency kyphoplasty, and mechanical vertebral augmentation

6.01.38

New

26

Peripheral subcutaneous field stimulation

7.01.139

New

27

Photodynamic therapy for choroidal neovascularization

9.03.08

New

28

Responsive neurostimulation for the treatment of refractory focal epilepsy

7.01.143

New

29

Retinal telescreening for diabetic retinopathy

9.03.13

New

30

Sacral nerve neuromodulation/stimulation

7.01.69

New

31

Vertical expandable prosthetic titanium rib

7.01.110

New

32

Viscocanalostomy and canaloplasty

9.03.26

New

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

Major update

2

Partial thickness rotator cuff tears and acromioplasty/subacromial decompression

BSC7.14

Major update

3

Postsurgical home use of limb compression devices for venous thromboembolism prophylaxis

1.01.28

Major update

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

Major update

2

Hematopoietic cell transplantation for non-Hodgkin lymphomas

8.01.20

Major update

3

Stationary ultrasonic diathermy devices

7.01.174

New

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

Major update

2

Germline and somatic biomarker testing (including liquid biopsy) for targeted treatment and immunotherapy in breast cancer

2.04.151

Major update

3

Negative pressure wound therapy in the outpatient setting

1.01.16

Major update

 4

Tumor-informed circulating tumor DNA testing for cancer management

BSC2.18

Major update

5

Facet joint denervation

7.01.116

New

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

Major update

No

2

Intensity-modulated radiotherapy of the prostate

8.01.47

Major update

No

3

Intensity-modulated radiotherapy: Abdomen, pelvis and chest

8.01.49

Major update

No

4

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

8.01.48

Major update

No

5

Intensity-modulated radiotherapy: Central nervous system tumors

8.01.59

Major update

No

6

Radiation oncology

BSC8.06

Major update

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

Major update

No

8

Stereotactic radiosurgery and stereotactic body radiotherapy

6.01.10

Major update

No

9

Axillary reverse mapping for prevention of breast cancer-related lymphedema

7.01.173

New

No

10

Genetic testing: Prenatal and preconception carrier screening

BSC_CON_2.07

New

No

11

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

BSC_CON_2.06

New

No

12

Oncology: Cancer screening

BSC_CON_2.09

New

No

13

Temporarily implanted nitinol device (iTind) for benign prostatic hyperplasia

7.01.175

New

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

Major update

2

Epidural spine injections

BSC_NIA_CG_300

Major update

3

Esophageal pH monitoring

2.01.20

Major update

4

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

BSC_CON_2.08

New

5

Genetic testing: Preimplantation genetic testing

BSC_CON_2.03

New

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.

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