Look up medical policies

Search, view, and print our current medical coverage and payment policies. Please note this is not a complete listing. We update policies on a regular basis and they are subject to change.

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Please note: Policies are subject to change. If you can't find a policy for a specific service, please always refer to the following two policies:

The policies below exclude Federal Employee Program® (FEP) products. For FEP policies, please call (401) 272-5670.

Draft Medical Policies
Allergy Testing - Effective 3/1/2019
Cryosurgical Ablation of Miscellaneous Solid Tumors other than Renal, Liver and Prostate DRAFT
Laboratory Tests for Heart and Kidney Transplant Rejection DRAFT
Transanal Radiofrequency Treatment of Fecal Incontinence DRAFT
Vitamin D Testing
Devices & Equipment
Breast Pump - Hospital Grade PREAUTH
Compression Garments/stockings
Cranial Orthoses (Adjustable) for Positional Plagiocephaly and Craniosynostoses
Durable Medical Equipment (DME)
Electrical Stimulation for Treatment of Arthritis
Functional Neuromuscular Electrical Stimulation PREAUTH
Glucose Monitoring - Continuous
Hearing Aid Mandate
Home Prothrombin Time Monitoring
Home Spirometry
Home Uterine Activity Monitoring
Non-Wearable Automatic External Defibrillator PREAUTH
Oral Appliances for Sleep Apnea
Patient-Controlled End of Range Motion Stretching Devices
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Phototherapy for Seasonsal Affective Disorder
Prior Authorization via Web-Based Tool for Durable Medical Equipment (DME)
Therapeutic Eyeglasses and Contact Lenses
Therapeutic Shoes for Diabetics Mandate
Thoracic Lumbo Sacral Orthosis with Pneumatics
Transcutaneous Electrical Nerve Stimulation
Benlysta (Belimumab) PREAUTH
Benlysta (Belimumab) PREAUTH Effective 6/1/2018
Botulinun Toxin PREAUTH Effective 6/1/2018
Brineura (Cerliponase Alfa) - PREAUTH
Brineura (Cerliponase alfa) PREAUTH Effective 6/1/2018
Buprenorphine Implant for Treatment of Opioid Dependence
Cellular Immunotherapy for Prostate Cancer
Claim Filing Requirements for Drugs
Discarded Drugs/Biologicals
Drugs and Biologicals
Erythropoiesis-stimulating agents for End Stage Renal Disease
Exondys (Eteplirsen) for Duchenne Muscular Dystrophy
Exondys (Eteplirsen) for Duchenne Muscular Dystrophy Effective 6/1/2018
Infused Multiple Sclerosis Drugs - Lemtrada (Alemtuzumab) and Octrevus (Ocrelizumab) PREAUTH
Infused Multiple Sclerosis Drugs - Lemtrada (Alemtuzumab) and Octrevus (Ocrelizumab) PREAUTH Effective 6/01/2018
Injectable Agents for Asthma and Chronic Idiopathic Urticaria - Cinqair, Fasenra, Nucala, Xolair - PREAUTH
Injectable Fillers
Intravenous Anesthetics for the Treatment of Chronic Pain
Krystexxa (Pegloticase) PREAUTH
Krystexxa (Pegloticase) PREAUTH Effective 6/1/2018
Kymriah (Tisagenlecleucel) PREAUTH
Kymriah (Tisgenlecleucel) PREAUTH Effective 6/1/2018
Lutathera (lutetium Lu 177 dotatate) PREAUTH
Lutathera (lutetium Lu 177 dotatate) PREAUTH Effective 7/1/2018
Luxturna (voretigene neparvovec-rzyl) - PREAUTH
Luxturna (voretigene neparvovec-rzyl) PREAUTH Effective 7/1/2018
Mepsevii - PREAUTH
Off-Label Use of Prescription Drugs Mandate
Oral Antiemetic Drugs
Parsabiv (etelcalcetide) - PREAUTH
Parsabiv (etelcalcetide) - PREAUTH Effective 7/1/2018
Pharmacy Prescription Early Refill
Prior Authorization of Drugs New
Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies PREAUTH
Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies PREAUTH Effective 6/1/2018
Prolia and Xgeva (Denosumab) - PREAUTH
Radicava (Edaravone ) - PREAUTH
Radicava (Edaravone) PREAUTH Effective 6/1/2018
Soliris (Eculizumab)
Soliris (Eculizumab) PREAUTH Effective 6/1/2018
Spinraza (Nusineren) PREAUTH Effective 6/1/2018
Spinraza (Nusinersen)
Stelara (Ustekinumab) Intravenous use for Crohn's Disease PREAUTH
Stelara (Ustekinumab) Intravenous use for Crohn's Disease PREAUTH Effective 6/1/2018
Xiaflex (Clostrial Collagenase) - PREAUTH Effective 6/1/2018
Xiaflex (Clostridial Collagenase) PREAUTH
Yescarta (axicabtagene)
Yescarta (axicabtagene) PREAUTH Effective 6/1/2018
2018 Corneal Collagen Cross-linking
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
Acupuncture Mandate
Adrenal-to-Brain Transplantation
Allergy Testing
Ambulance: Ground Transport
Ambulatory Blood Pressure Monitoring
Amniotic Membrane and Amniotic Fluid
Anastomosis of Extracranial-Intracranial Arteries - PREAUTH
Aqueous Shunts and Stents for Glaucoma
Artificial Intervertebral Disc Insertion Lumbar Spine
Artificial Pancreas Device System PREAUTH
Auditory Brain Stem Implant
Autologous Chondrocyte Implantation - PREAUTH
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
Balloon Dilation of the Eustachian Tube
Balloon Ostial Dialtion for Treatment of Chronic Rhinosinusitis
Benign Skin Lesion and Viral Infectious Lesion Removal
Biofeedback - PREAUTH
Bioimpedance Devices for Detection and Management of Lymphedema
Botulinum Toxin Injection - PREAUTH
Bronchial Thermoplasty
Bronchial Valves
Cardiac Hemodynamic Monitoring - PREAUTH
Cardiac Rehabilitation
Chelation Therapy for Off-Label Uses
Chromoendoscopy as an Adjunct to Colonoscopy
Chronic Intermittent Intravenous Insulin Therapy
Clinical Trials Mandate Commercial
Cochlear Implants
Cone Beam Computed Tomography
Confocal Laser Endomicroscopy
Constraint-Induced Movement Therapy
Cooling Devices Used in the Home and Outpatient Setting
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
Cosmetic Services/Procedures
Coverage of Complications Following a Non-covered Service
Daily Management of Epidurals
Dental Providers Filing Evaluation and Management for Medical Reasons
Dental Services for Accidental Injury
Dental Services Rendered in the Outpatient Setting - PREAUTH
Dermatological Applications of Photodynamic Therapy
Diabetes Self-Management Education Mandate
Dry Needling of Myofascial Trigger Points
Dynamic Posturography
EKG Services during Preventive Visit
Electrical Stimulation and Electromagnetic Therapy for Wound Treatment
Electromagnetic Navigation Bronchoscopy
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Emergency Department Services/Waiver of Copayment
Endometrial Ablation
Enhanced External Counterpulsation
Enteral/Parenteral Nutrition Therapy
Epidural Injections for Pain Management - PREAUTH
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
Fecal Calprotectin Testing
Fetal Surgery for Prenatally Diagnosed Malformations
Focal Treatments for Prostate Cancer
Fracture Care
High-tech Radiology Imaging
High-tech radiology Imaging Services - PREAUTH
Hyperthermia for Cancer Therapy
Implantable Bone Conduction and Bone Anchored Hearing Aids
Intensity Modulated Radiotherapy of the Breast and Lung PREAUTH
Intensity Modulated Radiotherapy: Abdomen and Pelvis
Intensity-Modulated Radiotherapy of the Prostate PREAUTH
Intensity-Modulated Radiotherapy: Central Nervous System
Intensity-Modulated Radiotherapy: Head, Neck or Thyroid
Interferential Current Stimulation
Intra-Articular Hyaluronan Injection for Osteoarthritis
Intravitreal Corticosteroid Implants
Laparoscopic and Percutaneous Techniques for the Myolysis of Uternie Fibroids
Low-Level Laser Therapy
Manipulation Under Anesthesia
Medicare Diabetes Prevention Program (MDPP)
Microwave Tumor Ablation
Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures Effective 7/1/2018
Neural Therapy
New Technology (Formerly CPT Category III Codes)
Newborn Metabolic, Endocrine, and Hemoglobinopathy, and the Newborn Hearing Loss Screening Programs Mandate
Non-Contact Ultrasound Treatment for Wounds
Non-Powered Negative Pressure Wound Therapy (Former Title: Mechanical Wound Suction)
Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Occipital Nerve Stimulation Insertion
Ocriplasmin for Symptomatic Vitreomacular Adhesion
Ophthalmologic Techniques that Evaluate the Posterior Segment for Glaucoma
Ophthalmology Examinations and Routine Eye Exams
Optical Coherence Tomography of the Anterior Eye Segment
Oral Nutrition Mandate - PREAUTH
Oral Surgeons Filing Anesthesia Services
Orally Administered Anticancer Medication Mandate
Out of Network Services - PREAUTH
Outpatient Pulmonary Rehabilitation - PREAUTH
Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain
Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation PREAUTH
Percutaneous Tibial Nerve Stimulation - PREAUTH
Peripheral Artery Disease (PAD) Rehabilitation
Peripheral Subcutaneous Field Stimulation
Phototherapy in the Home for the Treatment of Dermatological Conditions
Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
Pulsed Radiofrequency for the Treatment of Chronic Pain
Rabies Treatment: Pre and Post Exposure
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors PREAUTH
Radiology Interpretation- Emergency Room
Radium-223, Xofigo:for treatment of metastatic, castration-resistant prostate cancer_PREAUTH
Reflectance Confocal Microscopy for Evaluating Skin Lesions for Suspected Malignancy
Removal of Non-Covered Implantable Devices PREAUTH
Respiratory Syncytial Virus Immunoglobulin - PREAUTH
Routine Foot Care and Nail Debridement
Scintimammography and Gamma Imaging of the Breast and Axilla
Self-Treatment or Treatment of Immediate Family Members
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Sensory Integration Therapy and Auditory Integration Therapy
Skilled Nursing Facilities: Admission and Concurrent Review-PREAUTH
Speech Therapy - Effective 1/1/2018 NEW
Structured Screening and Brief Intervention Services
Surgery for Groin Pain in Athletes
Telemedicine Services Effective 1/1/2018 NEW
Transcatheter Mitral Valve Repair
Transcranial Magnetic Stimulation
Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease
Treatment of Hyperhidrosis
Tumor Treating Fields Therapy - PREAUTH
Ultrasonographic Measurement of Carotid intima-medial (or intimal-media) thickness (CIMT)
Vertebral Axial Decompression
Wireless Pressure Sensors in Endovascular Aneurysm Repair
Bariatric Surgery - PREAUTH
Breast Ductal Lavage for Detection of Breast Cancer
Carotid Angioplasty/Stenting Without Embolic Protection
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Electrical Bone Growth Stimulation of the Appendicular Skeleton- Implantable and Semi Invasive
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus
Endovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
Gastric Electrical Stimulation - Insertion
Gender Reassignment Surgery - PREAUTH
Image_Guided Minimally Invasive Decompression for Spinal Stenosis
Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease
Implantation of Intrastromal Corneal Ring Segments - PREAUTH
Infertility Treatment - PREAUTH
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
Intraocular Lens (IOL) Implant
Islet Cell Transplant
Laser Treatment for Proliferative Vascular Lesions PREAUTH
Laser Treatment of Onychomycosis
Lysis of Epidural Adhesions
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease GERD
Meniscal Allograft Transplantation and Collagen Meniscus Implants
Minimally Invasive Coronary Artery Bypass Graft Surgery
Minimally Invasive Intradiscal and Annular Procedures for Back Pain
Nerve Graft With Radical Prostatectomy
Orthognathic Surgery PREAUTH
Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation - PREAUTH - Effective 2/1/19
Phototherapeutic Keratectomy - NEW- Effective 10/1/2018
Prior Authorization via Web-Based Tool for Procedures
Prophylactic Mastectomy
Prostatic Urethral Lift
Radioembolization for Primary and Metastatic Tumors of the Liver PREAUTH
Sphenopalatine Ganglion Block for Headache
Stereotactic Body Radiation Therapy PREAUTH
Surgical Deactivation of Migraine Headache Trigger Sites
Surgical Treatment of Snoring and Obstructive Sleep Apnea
Termination of Pregnancy
Thermal Capsulorrhaphy as a Treatment of Joint Instability
Total Joint Arthroplasty – Hip and Knee PREAUTH
Transcatheter Mitral Valve Repair - Effective 11/1/2018
Transesophageal Endoscopic Treatments for Gastroesophageal Reflux
Varicose Vein Treatment - PREAUTH
Viscocanalostomy and Canaloplasty
Whole Gland Cryoablation of Prostate Cancer
Bone Mineral Density Studies
Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
Clean Claim Criteria
Contraceptive Drugs and Devices Mandate
Cranial Electrotherapy Stimulation and Auricular Electrostimulation
Date of Service for Laboratory Specimens
Detection of Circulating Tumor Cells in the Management of Patients with Cancer Effective 10/01/2015
Digital Breast Tomosynthesis
Digital Electroencephalography (EEG)
Dynamic Spinal Visualization and Vertebral Motion Analysis
Esophageal pH Monitoring
Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies - PREAUTH
First -Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment
Gait Analysis
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management PREAUTH
Gene Expression Profiling for Cutaneous Melanoma - Effective 10/1/2018
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer PREAUTH
Genetic Testing for Diagnosis and Management of Mental Health Conditions PREAUTH
Genetic Testing Services PREAUTH
Glucose Monitoring - Home PREAUTH
Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease New Policy
Immune Cell Function Assay
In Vitro Chemoresistance and Chemosensitivity Assays
Ingestible pH and Pressure Capsule
Intracellular Micronutrient Analysis
Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer
Mammograms and Pap Smears Mandate
Measurement of Cerebrospinal Fluid and Urinary Biomarkers of Alzheimer Disease
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
Measurement of Serum Antibodies to Infliximab and Adalimumab
Measurement of Small Low Density Lipoprotein Particles
Microvolt T-Wave Alternans Testing
Mobile Cardiac Outpatient Telemetry (MCOT)
Molecular Markers in Fine Needle Aspirates of the Thyroid PREAUTH
Molecular Testing in the Management of Pulmonary Nodules
Multimarker Serum Testing Related to Ovarian Cancer
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
PathFinderTG® Molecular Testing - PREAUTH
Proprietary Laboratory Analyses (PLA) - Effective 10/1/2018
Prostate Specific Antigen (PSA) Screening/Testing Mandate
Proteogenomic Testing for Patients with Cancer
Psychological and Neuropsychological Testing
Retinal Telescreening for Diabetic Retinopathy
Rhinomanometry and Acoustic Optical Rhinometry
Salivary Estriol as Risk Predictor for Preterm Labor and Management of Menopause and/or Aging
Serum Biomarker Human Epididymis Protein 4
Serum Tumor Markers for Breast and Gastrointestinal Malignancies
Signal-Averaged Electrocardiography (SAECG)
Surgical Ventricular Restoration
Topographic Brain Mapping
Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
Urinary Biomarkers Markers for Cancer Screening, Diagnosis, and Surveillance
Venipuncture for State Mandated Lead Screening
Vertebral Fracture Assessment
Vestibular Function Test
Visual Screening for Children Aged 0-5 Years
External Ocular Photography
2018 PCP Quality Incentive Program Booklet FINAL
Autism Spectrum Disorders Mandate
Behavioral Health Services
Care Plan Oversight
Chiropractic Services
Clinical Trials BlueCHiP for Medicare
Coding and Payment Guidelines
Colorectal Screening Mandate
Concurrent Care
Consultation Codes
Coordination of Benefits
Covered Health Services
CPT Category III Codes_final_1
Early Intervention Services Mandate
Electronic Funds Transfer/Direct Deposit for Participating Providers
Emergency Room Reimbursement
Evaluation of Hearing Impairment/Loss
Fluoroscopy Without Films
Genetic Counseling
Health and Behavior Assessment/Intervention
Health Insurance Claim Forms CMS-1500 & UB-04
High Risk Pregnancy Services and the Maternity Global Reimbursement
Home Health Care Services - Non Skilled PREAUTH Effective 1/1/2019 NEW
Home Health Care Services - Skilled- Effective 07/01/2018 PREAUTH
Hospital Audit Process
Hospital Duplicate Services
Hospital Readmission
Hospital Utilization Review
Hospital-based Clinic
Human Leukocyte Antigen (HLA) Testing Mandate
Hyperbaric Oxygen Therapy (HBO) - PREAUTH
Immunizations Adult and Pediatric
Inactive Provider Termination
Inpatient Admission
Intensive Behavioral Therapy (IBT) for Obesity
Interim Billing
Kidney Disease Education
Lactation Consultations
Long Term Acute Care Hospital (LTACH) Admission and Transition of Care Criteria- PREAUTH
Lyme Disease Diagnosis and Treatment Mandate
Mastectomy Treatment, Breast Reconstruction and Hospital Stays Mandates Effective 1/1/2019
Medical Necessity
Medical Record Audit
Medical Records Standards
Medical Supply Wastage
Mental Illness and Substance Use Disorders Mandate
Mid-level Practitioners
Modifier 22 Guidelines -NEW
Modifier 59, XE, XP, XS, XU Guidelines NEW Effective 8/15/2018
New Provider Credentialing Process
Nutritional Counseling/Medical Nutritional Therapy (MNT)
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy
Orthotic and Prosthetic Services Mandate
Outpatient Observation Services
Payment Adjustments for Error and Hospital Acquired Conditions
Payments for Outpatient Service Performed when a Member is Admitted as an Inpatient to a Different Hospital
Pediatric Dental Services Essential Health Benefit -Dental Review
Physical and Occupational Therapy
Physical Therapy Occupational Payment Cap
Physician Certification/Recertification of Care Plans
Physician Concierge Services
Post Payment Audits
Post-partum Hospital Stays Mandate
Preventive Medicine and Other Evaluation and Management Office/Outpatient Services
Preventive Services BlueCHiP for Medicare 2019
Preventive Services for BlueCHiP for Medicare 2018
Preventive Services for Commercial Members
Private Duty Nursing - PREAUTH
Professional Reporting Requirements for Services Not Personally Performed (AKA "Incident to Services")
Prolonged Physician Services
Provider Guidelines for Requesting Point of Service Payment and Maintaining Patient Credit Card Information
Provider Reimbursement for Care Plan Management
Smoking Cessation Mandate
Specimen Provenance Error Testing
Speech Therapy - Effective 1/1/2017 PREAUTH
Sympathetic Therapy for the Treatment of Pain
Temporary Prostatic Stent
Timely Filing Limit
Transitional, Chronic and Complex Chronic Care Management
Transplants- Travel and Accommodations for Blue Chip for Medicare
Unlisted Procedures
Advance Notice of Noncoverage
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
Behavioral Health Services Effective 01/01/2019
Behavioral Health Services Inpatient and Intermediate Levels of Care
BlueCHiP for Medicare Laboratory Network Hospital/Physician/Urgent Care Allowable Test Listing
BlueCHiP for Medicare National and Local Coverage Determinations
Electrogastrography (EGG)
Non Reimbursable Health Service Codes
Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer
Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions
Prior Authorization
Acute Inpatient Rehabilitation Level of Care
Adult Child and Family Intensive Services (AIS CFIT)
Ambulance Air and Water Transport