Look up Medical and Payment Policies

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Draft Medical Policies
Aduhelm (Aducanumab)
DRAFT Acupuncture Services for Commercial Products
DRAFT COVID-19 Monoclonal Antibody Treatment
DRAFT Prolonged Physician Services
Lactation Consultations Effective 1/01/2022
Measurement of Ocular Blood Flow for Glaucoma - Effective 1.1.2022 (Former Policy Title: Ophthalmologic Techniques that Evaluate the Posterior Segment for Glaucoma)
Prescription Digital Health Therapies for Attention Deficit/Hyperactivity Disorder- Effective 1/1/2022
Scanning Computerized Ophthalmic Diagnostic Imaging - Effective 1.1.22
Serologic Genetic and Molecular Screening for Colorectal Cancer- Effective 1/1/2022
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
Adrenal-to-Brain Transplantation
Allergy Testing
Ambulance: Ground Transport
Ambulatory Blood Pressure Monitoring
Amniotic Membrane and Amniotic Fluid
Aqueous Shunts and Stents for Glaucoma
Artificial Intervertebral Disc Insertion Lumbar Spine
Auditory Brain Stem Implant
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Autologous Platelet-Derived Growth Factors (PRP)
Automated Point of Care Nerve Conduction Tests
Autonomic Nervous System Testing Using Portable Automated Devices
Axial Lumbosacral Interbody Fusion
Benign Skin Lesion and Viral Infectious Lesion Removal
Bioimpedance Devices for Detection and Management of Lymphedema
Bone Mineral Density Studies
Bone Mineral Density Studies
Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover
Breast Ductal Lavage for Detection of Breast Cancer
Bronchial Thermoplasty
Bronchial Valves
Buprenorphine Implant for Treatment of Opioid Dependence
Cardiac Hemodynamic Monitoring
Carotid Angioplasty/Stenting Without Embolic Protection
Chelation Therapy for Off-Label Uses
Chronic Intermittent Intravenous Insulin Therapy
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
Clinical Trials Mandate Commercial
Clinical Trials Medicare Advantage Plans
Cochlear Implants
Colorectal Screening Mandate
Colorectal Screening Mandate Effective 1.1.22
Confocal Laser Endomicroscopy
Constraint-Induced Movement Therapy
Contraceptive Drugs and Devices Mandate
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
Cranial Electrotherapy Stimulation and Auricular Electrostimulation
Cranial Orthoses (Adjustable) for Positional Plagiocephaly and Craniosynostoses
Cryosurgical Ablation of Miscellaneous Solid Tumors other than Renal, Liver and Prostate Effective 12/1/2021
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Daily Management of Epidurals
Dermatological Applications of Photodynamic Therapy
Desensitization Treatment for Peanut Allergies
Diabetes Self-Management Education Mandate
Disposable Negative Pressure Wound Therapy (Former Title: Non-Powered Negative Pressure Wound Therapy
Dry Needling of Trigger Point for Myofascial Pain
Dynamic Posturography
Dynamic Spinal Visualization and Vertebral Motion Analysis
Early Intervention Services Mandate
Electrical Bone Growth Stimulation of the Appendicular Skeleton- Implantable and Semi Invasive
Electrical Stimulation and Electromagnetic Therapy for Wound Treatment
Electrical Stimulation for Treatment of Arthritis
Electrical Stimulation for Treatment of Arthritis
Electrogastrography (EGG)
Electromagnetic Navigation Bronchoscopy
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Endometrial Ablation
Enhanced External Counterpulsation
Esophageal pH Monitoring
Evaluation of Biomarkers for Alzheimer's Disease
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
Fecal Calprotectin Testing
Fetal Surgery for Prenatally Diagnosed Malformations
First -Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment
Focal Treatments for Prostate Cancer
Gait Analysis
Gastric Electrical Stimulation - Insertion
Glucose Monitoring - Continuous
Hearing Aid Mandate
Home Prothrombin Time Monitoring
Home Spirometry
Home Uterine Activity Monitoring
Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease
Human Leukocyte Antigen (HLA) Testing Mandate
Hydrogel Spacer Use During Radiotherapy for Prostate Cancer
Hyperbaric Oxygen Therapy (HBO)
Hyperthermia for Cancer Therapy
Image Guided Minimally Invasive Spinal Decompression for Spinal Stenosis
Immune Cell Function Assay
Implantable Bone Conduction and Bone Anchored Hearing Aids
In Vitro Chemoresistance and Chemosensitivity Assays
Ingestible pH and Pressure Capsule
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Interferential Current Stimulation
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
Intra-Articular Hyaluronan Injection for Osteoarthritis
Intracellular Micronutrient Analysis
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Conditions
Intravitreal and Punctum Corticosteroid Implants
Islet Cell Transplant
Laparoscopic and Percutaneous Techniques for the Myolysis of Uternie Fibroids
Laser Treatment of Onychomycosis
Low-Level Laser Therapy
Lyme Disease Diagnosis and Treatment Mandate
Lysis of Epidural Adhesions
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease GERD
Mammograms and Pap Smears Mandate
Manipulation Under Anesthesia
Mastectomy Treatment, Breast Reconstruction and Hospital Stays Mandates
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
Measurement of Serum Antibodies to Selected Biologic Agents
Measurement of Small Low Density Lipoprotein Particles
Medical Necessity
Meniscal Allograft Transplantation and Collagen Meniscus Implants
Mental Illness and Substance Use Disorders Mandate
Mental Illness and Substance Use Disorders Mandate - Effective 1/01/2022
Microvolt T-Wave Alternans Testing
Minimally Invasive Coronary Artery Bypass Graft Surgery
Minimally Invasive Intradiscal and Annular Procedures for Back Pain
Mobile Cardiac Outpatient Telemetry (MCOT)
Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
Multimarker Serum Testing Related to Ovarian Cancer
Myoelectric Assist Orthoses for the Upper Limb
Navigated Transcranial Magnetic Stimulation
Nerve Graft With Radical Prostatectomy
Neural Therapy
New Technology and Miscellaneous Services - Effective 5.1.21
Newborn Metabolic, Endocrine, and Hemoglobinopathy, and the Newborn Hearing Loss Screening Programs Mandate
Non-Contact Ultrasound Treatment for Wounds
Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Nutrient Panel Testing
Occipital Nerve Stimulation Insertion
Ocriplasmin for Symptomatic Vitreomacular Adhesion
Ophthalmologic Techniques that Evaluate the Posterior Segment for Glaucoma
Optical Coherence Tomography of the Anterior Eye Segment
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy
Oral Appliances for Sleep Apnea
Orally Administered Anticancer Medication Mandate
Orthopedic Applications of Platelet-Rich Plasma
Orthotic and Prosthetic Services Mandate
Outpatient Pulmonary Rehabilitation
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain
Patient-Controlled End of Range Motion Stretching Devices
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy
Peripheral Artery Disease (PAD) Rehabilitation
Peripheral Subcutaneous Field Stimulation
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
Phototherapy for the Treatment of Seasonal Affective Disorder
Post-partum Hospital Stays Mandate
Powered Exoskeleton for Ambulation in Patients with Lower-Limb Disabilities
Prescription Digital Therapeutics for Substance Abuse
Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
Prostate Specific Antigen (PSA) Screening/Testing Mandate
Prostate Specific Antigen (PSA) Screening/Testing Mandate - Effective 1.1.2022
Prostatic Stent - Temporary
Prostatic Urethral Lift
Pulsed Radiofrequency for the Treatment of Chronic Pain
Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions
Reflectance Confocal Microscopy for Evaluating Skin Lesions for Suspected Malignancy
Retinal Telescreening for Diabetic Retinopathy
Rhinomanometry and Acoustic Optical Rhinometry
Risk Reducing Mastectomy (Formally Prophylactic Mastectomy)
Routine Foot Care and Nail Debridement
Salivary Estriol as Risk Predictor for Preterm Labor and Management of Menopause and/or Aging
Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer
Scintimammography and Gamma Imaging of the Breast and Axilla
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Sensory Integration Therapy and Auditory Integration Therapy
Serum Biomarker Human Epididymis Protein 4
Serum Tumor Markers for Breast and Gastrointestinal Malignancies
Signal-Averaged Electrocardiography (SAECG)
Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions
Sphenopalatine Ganglion Block for Headache
Steroid-Eluting Sinus Stents
Surgery for Groin Pain in Athletes
Surgical Deactivation of Migraine Headache Trigger Sites
Surgical Ventricular Restoration
Sympathetic Therapy for the Treatment of Pain
Synthetic Cartilage Implants for Joint Pain
Therapeutic Shoes for Diabetics Mandate
Thermal Capsulorrhaphy as a Treatment of Joint Instability
Thoracic Lumbo Sacral Orthosis with Pneumatics
Topographic Brain Mapping
Transanal Radiofrequency Treatment for Fecal Incontinence
Transcutaneous Electrical Nerve Stimulation
Transesophageal Endoscopic Treatments for Gastroesophageal Reflux
Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease
Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
Ultrasonographic Measurement of Carotid intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Urinary Biomarkers Markers for Cancer Screening, Diagnosis, and Surveillance
Venipuncture for State Mandated Lead Screening
Vertebral Axial Decompression
Vertebral Fracture Assessment
Vestibular Function Test
Viscocanalostomy and Canaloplasty
Vitamin D Testing
Whole Gland Cryoablation of Prostate Cancer
Acupuncture and Dry Needling for BlueChip for Medicare Effective 01/01/21
Acupuncture Services for Commercial Products Effective 01/01/2021
Advance Notice of Noncoverage
Advance Practice Providers
Advanced Care Planning
After Hours: Special Services, Procedures, and Reports
Allergy Immunotherapy Injections
Anesthesia Services
Asthma Management Services
Automated Testing Devices
BCBSRI Provider Transparency
BCBSRI use of Provider Performance Data for Healthcare Operations
Behavioral Health Integration Services including the Collaborative Care Model
Behavioral Health Outpatient Professional Services
Behavioral Health Outpatient Professional Services - Effective 1/01/2022
Behavioral Health Services Inpatient and Intermediate Levels of Care
Behavioral Health Supervisory Protocol for Licensed Clinical Social Workers and Post Doctorate Clinicians
Behavioral Health Supervisory Protocol for Licensed Clinical Social Workers and Post Doctorate Clinicians - Effective 1/01/2022
Cardiac Rehabilitation
Care Plan Oversight
Chimeric Antigen Receptor (CAR) T-cell Therapy for Cancers
Chiropractic Services
Chromoendoscopy as an Adjunct to Colonoscopy
Claim Filing Requirements for Drugs
Claim Timely Filing - Inpatient Level of Care Appeals and Observation
Coding and Payment Guidelines
Compression Garments/stockings
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
Cooling Devices Used in the Home and Outpatient Setting
Coordination of Benefits
Cosmetic Services/Procedures
Coverage of Complications Following a Non-covered Service
COVID-19 Diagnostic Testing, Vaccine and Antibody Treatment Administration Reimbursement
COVID-19 Monoclonal Antibody Treatment
COVID-19 Vaccinations
Date of Service for Laboratory Specimens
Dental Providers Filing Evaluation and Management for Medical Reasons
Dental Services for Accidental Injury
Digital Breast Tomosynthesis
Digital Electroencephalography (EEG)
Discarded Drugs/Biologicals
Draft Doula Maternity Services
Drugs and Biologicals
Durable Medical Equipment (DME)
EKG Services during Preventive Visit
Electronic Funds Transfer/Direct Deposit for Participating Providers
Emergency Department Services/Waiver of Copayment
Emergency Room - Radiology Imaging Interpretation Services
Emergency Room Reimbursement
Enteral/Parenteral Nutrition Therapy
Evaluation of Hearing Impairment/Loss
Fee-for-Time Compensation Arrangements (Former Title: Locum Tenens)
Fluoroscopy Without Films
Fracture Care
Health and Behavior Assessment
High Risk Pregnancy Services
Hospital Audit Process
Hospital Duplicate Services
Hospital Laboratory Pass Through Billing - Effective 2.1.2020
Hospital Readmission
Hospital Utilization Review
Hospital-based Clinic
Immunizations Adult and Pediatric
Inactive Provider Termination
Inpatient Admission
Intensive Behavioral Therapy (IBT) for Obesity
Interim Billing
Intraocular Lens (IOL) Implant
Lactation Consultations
Medical Records Standards
Medical Supply Wastage
Medicare Advantage Plans Laboratory Network Hospital Outpatient Allowable Test Listing Effec. 6/1/2021
Medicare Advantage Plans Laboratory Network Hospital/Physician/Urgent Care Allowable Test Listing
Medicare Advantage Plans National and Local Coverage Determinations
Medicare Diabetes Prevention Program (MDPP)
Modifier 22 Guidelines
Modifier 59, XE, XP, XS, XU Guidelines
Multi-Function Home Ventilators
Non Reimbursable Health Service Codes
Nutritional Counseling/Medical Nutritional Therapy (MNT)
Off-Label Use of Prescription Drugs Mandate
Ophthalmology Examinations and Routine Eye Exams
Oral Surgeons Filing Anesthesia Services
Ordering Provider NPI Number Requirement
Outpatient Observation Services
Payment Adjustments for Serious Reportable Events (also known as SRE or Never Events) and Hospital Acquired Conditions
Payments for Outpatient Service Performed when a Member is Admitted as an Inpatient to a Different Hospital
Pharmacy Prescription Early Refill
Phototherapeutic Keratectomy
Phototherapy in the Home for the Treatment of Dermatological Conditions
Physical and Occupational Therapy
Physical and Occupational Therapy Payment Cap
Physician Concierge Services
Post Payment Audits
Preventive Medicine and Other Evaluation and Management Office/Outpatient Services
Preventive Services for Commercial Members
Preventive Services for Medicare Advantage Plans 2021
Professional Reporting Requirements for Services Not Personally Performed (AKA Incident to Services)
Prolonged Physician Services
Provider Credentialing and Recredentialing Process
Provider Guidelines for Requesting Point of Service Payment and Maintaining Patient Credit Card Information
Provider Reimbursement for Care Plan Management
Psychological and Neuropsychological Testing
Rabies Treatment: Pre and Post Exposure
Self-Treatment or Treatment of Immediate Family Members
Smoking Cessation Mandate
Specimen Provenance Error Testing
Speech Therapy
Structured Screening and Brief Intervention Services
Telemedicine/Telephone Services for Commercial Products - Effective 1/1/2021
Telemedicine/Telephone Services for Medicare Advantage Plans during the Public Health Emergency (PHE) - Effective 1/1/2021
TEMPORARY Cost Share Waiver for Treatment of Confirmed Cases of COVID- 19 Effective 4/1/20
TEMPORARY COVID-19 Diagnostic Testing Effective 3/6/20
TEMPORARY COVID-19 Pediatric Vaccination Preventative Medicine Counseling Services for Commercial Members
TEMPORARY Encounter for Determination of Need for COVID-19 Diagnostic Testing Effective 3/18/20
TEMPORARY Telemedicine/Telehealth and Telephone Preventive Medicine Evaluation and Management Visits and Annual Wellness Visits During the COVID-19 Crisis Effective 3/18/20
TEMPORARY Telemedicine/Telehealth and Telephone Services During the COVID-19 Crisis – Effective 3/18/20 - 12/31/20
TEMPORARY Telemedicine/Telehealth and Telephone Services During the COVID-19 Crisis – Effective 3/5/2020 – 3/17/2020
TEMPORARY Timely Filing Limit Extension Policy – Additional 180 Days During the COVID-19 Crisis Effective 3/18/20 - 3/31/21
Termination of Pregnancy
Therapeutic Eyeglasses and Contact Lenses
Timely Filing Limit
Transitional Care, Chronic Care and Complex Chronic Care Management
Transplants- Travel and Accommodations for Blue CHiP for Medicare
Unlisted Procedures
Visual Screening for Children Aged 0-5 Years
Prior Authorization
Acute Inpatient Rehabilitation Level of Care
Adult Child and Family Intensive Services (AIS CFIT)
Adult Child and Family Intensive Services (AIS CFIT) - Effective 1/01/2022
Ambulance Air and Water Transport
Anastomosis of Extracranial-Intracranial Arteries
Artificial Pancreas Device System
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Autism Spectrum Disorders Mandate
Autism Spectrum Disorders Mandate - Effective 1/01/2022
Autologous Chondrocyte Implantation
Balloon Dilation of the Eustachian Tube
Bariatric Surgery
Breast Pump - Hospital Grade
Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies (Former Title: Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies)
Corneal Collagen Cross-linking
Cryosurgical Ablation of Miscellaneous Solid Tumors other than Renal, Liver and Prostate
Dental Services Rendered in the Outpatient Setting
Diagnosis and Treatment of Sacroiliac Joint Pain
Envisia for Idiopathic Pulmonary Fibrosis
Epidural Injections for Pain Management
Exondys (eteplirsen) and Vyondys (golodirsen) for Duchenne Muscular Dystrophy
Functional Neuromuscular Electrical Stimulation
Gender Reassignment Surgery Effective 1/1/21
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
Gene Expression Profiling for Cutaneous Melanoma
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Genetic Testing for Diagnosis and Management of Mental Health Conditions
Genetic Testing for Diagnosis and Management of Mental Health Conditions Effective 4.1.2022
Genetic Testing Services
Genetic Testing Services Effective 3/1/2022
Glucose Monitoring - Home - Non-One Touch Brand
Home Health Care Services - Skilled
Implantation of Intrastromal Corneal Ring Segments
Infertility Services
Intensity Modulated Radiotherapy of the Abdomen and Pelvis
Intensity Modulated Radiotherapy of the Breast and Lung
Intensity Modulated Radiotherapy of the Central Nervous System
Intensity Modulated Radiotherapy of the Head, Neck and Thyroid
Intensity Modulated Radiotherapy of the Prostate
Kyphoplasty and Vertebroplasty
Laboratory Tests Post Transplant and for Heart Failure - Effective 6/1/2021 (Former Title: Laboratory Tests for Heart and Kidney Transplant Rejection)
Laser Treatment for Proliferative Vascular Lesions
Long Term Acute Care Hospital (LTACH) Admission and Transition of Care Criteria
Magnetic Resonance Imaging-Guided Focused Ultrasound
Microwave Tumor Ablation
Molecular Markers in Fine Needle Aspiration of the Thyroid
Molecular Testing in the Management of Pulmonary Nodules
Non-Wearable Automatic External Defibrillator
Oral Nutrition Mandate
Orthognathic Surgery
Out of Network Services
PathFinderTG® Molecular Testing
Pediatric Dental Services Essential Health Benefit -Dental Review
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Percutaneous Tibial Nerve Stimulation
Prior Authorization of Cardiology and Radiology Services
Prior Authorization of Drugs
Prior Authorization via Web-Based Tool for Durable Medical Equipment (DME)
Prior Authorization via Web-Based Tool for Procedures
Private Duty Nursing
Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies
Proprietary Laboratory Analyses (PLA)
Proteogenomic Testing for Patients with Cancer
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Removal of Implantable Devices
Skilled Nursing Facilities: Admission and Concurrent Review
Stereotactic Body Radiation Therapy
Surgical and Debulking Treatments for Lymphedema - Effective 10/1/2021
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Transcatheter Mitral Valve Repair
Transcranial Magnetic Stimulation
Transcranial Magnetic Stimulation - Effective 1/01/2022
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia
Tumor Treating Fields Therapy
Varicose Vein Treatment