Look up medical and payment 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
Acupuncture Services
Aliqopa (copanlisib)
Aquoeous Shunts and Stents for Glaucoma
Crysvita (burosumab-twza)
Dermatologic Applications of Photodynamic Therapy
Diagnosis and Treatment of Sacroiliac Joint Pain
Electrical Stimulation for Treatment of Arthritis
Enteral and Parentneral Therapy DRAFT
Fecal Calprotectin Testing
Libtayo (cemiplimab-rwlc)
New Technology
Onpattro (patisiran)
Poteligeo (mogamulizumab-kpkc)
ST2 Assay for Chronic Heart Failure and Heart Transplant Rejection
Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia
Medical
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
Aqueous Shunts and Stents for Glaucoma
Artificial Intervertebral Disc Insertion Lumbar Spine
Auditory Brain Stem Implant
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 Dilation for Treatment of Chronic Rhinosinusitis
Benign Skin Lesion and Viral Infectious Lesion Removal
Bioimpedance Devices for Detection and Management of Lymphedema
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
Cardiointegram
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 BlueCHiP for Medicare
Clinical Trials Mandate Commercial
Cochlear Implants
Colorectal Screening Mandate
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 Primary or Metastatic Liver Tumors
Daily Management of Epidurals
Dental Services for Accidental Injury
Dermatological Applications of Photodynamic Therapy
Diabetes Self-Management Education Mandate
Dry Needling of Myofascial Trigger Points
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
Electrogastrography (EGG)
Electromagnetic Navigation Bronchoscopy
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Endometrial Ablation
Enhanced External Counterpulsation
Esophageal pH Monitoring
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 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
Injectable Fillers
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
Intravitreal 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 Effective 1/1/2019
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
Medical Necessity
Meniscal Allograft Transplantation and Collagen Meniscus Implants
Mental Illness and Substance Use Disorders Mandate
Microvolt T-Wave Alternans Testing
Microwave Tumor Ablation
Minimally Invasive Coronary Artery Bypass Graft Surgery
Minimally Invasive Intradiscal and Annular Procedures for Back Pain
Mobile Cardiac Outpatient Telemetry (MCOT)
Molecular Testing in the Management of Pulmonary Nodules
Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
Multimarker Serum Testing Related to Ovarian Cancer
Nerve Graft With Radical Prostatectomy
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
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
Orthotic and Prosthetic Services Mandate
Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
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
Phototherapy for the Treatment of Seasonal Affective Disorder
Phototherapy in the Home for the Treatment of Dermatological Conditions
Post Payment Audits
Post-partum Hospital Stays Mandate
Preventive Services for BlueCHiP for Medicare 2019
Preventive Services for Commercial Members
Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
Prophylactic Mastectomy
Prostate Specific Antigen (PSA) Screening/Testing Mandate
Prostatic Urethral Lift
Pulsed Radiofrequency for the Treatment of Chronic Pain
Reflectance Confocal Microscopy for Evaluating Skin Lesions for Suspected Malignancy
Retinal Telescreening for Diabetic Retinopathy
Rhinomanometry and Acoustic Optical Rhinometry
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
Smoking Cessation Mandate
Speech Therapy
Sphenopalatine Ganglion Block for Headache
Steroid-Eluting Sinus Stents
Surgery for Groin Pain in Athletes
Surgical Deactivation of Migraine Headache Trigger Sites
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Surgical Treatments for Breast Cancer-Related Lymphedema
Surgical Ventricular Restoration
Sympathetic Therapy for the Treatment of Pain
Synthetic Cartilage Implants for Joint Pain
Temporary Prostatic Stent
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
Payment
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
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
Cardiac Rehabilitation
Care Plan Oversight
Chiropractic Services
Chromoendoscopy as an Adjunct to Colonoscopy
Claim Filing Requirements for Drugs
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
Date of Service for Laboratory Specimens
Dental Providers Filing Evaluation and Management for Medical Reasons
Digital Breast Tomosynthesis
Digital Electroencephalography (EEG)
Discarded Drugs/Biologicals
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 Interpretation
Emergency Room Reimbursement
Enteral/Parenteral Nutrition Therapy
Evaluation of Hearing Impairment/Loss
Fluoroscopy Without Films
Fracture Care
Health and Behavior Assessment
High Risk Pregnancy Services and the Maternity Global Reimbursement
Hospital Audit Process
Hospital Duplicate Services
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 Record Audit
Medical Records Standards
Medical Supply Wastage
Medicare Diabetes Prevention Program (MDPP)
Mid-level Practitioners
Modifier 22 Guidelines
Modifier 59, XE, XP, XS, XU Guidelines
New Provider Credentialing Process
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 Antiemetic Drugs
Oral Surgeons Filing Anesthesia Services
Ordering Provider NPI Number Requirement
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
Pharmacy Prescription Early Refill
Phototherapeutic Keratectomy
Physical and Occupational Therapy
Physical and Occupational Therapy Payment Cap
Physician Concierge Services
Preventive Medicine and Other Evaluation and Management Office/Outpatient Services
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
Psychological and Neuropsychological Testing
Rabies Treatment: Pre and Post Exposure
Radiopharmaceuticals
Self-Treatment or Treatment of Immediate Family Members
Specimen Provenance Error Testing
Structured Screening and Brief Intervention Services
Telemedicine Services
Termination of Pregnancy
Therapeutic Eyeglasses and Contact Lenses
Timely Filing Limit
Transitional Care, Chronic Care and Complex Chronic Care Management Effective 5/1/2019
Transitional, Chronic 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)
Ambulance Air and Water Transport
Anastomosis of Extracranial-Intracranial Arteries
Artificial Pancreas Device System
Autism Spectrum Disorders Mandate
Autologous Chondrocyte Implantation
Bariatric Surgery
Benlysta (belimumab)
Botulinum Toxin Injection
Breast Pump - Hospital Grade
Brineura (cerliponase alfa)
Corneal Collagen Cross-linking
Cryosurgical Ablation of Miscellaneous Solid Tumors other than Renal, Liver and Prostate
Dental Services Rendered in the Outpatient Setting
Elzonris (tagraxofusp-erzs)
Epidural Injections for Pain Management
Evenity (romosozumab-aqqg)
Exondys (Eteplirsen) for Duchenne Muscular Dystrophy
Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
Functional Neuromuscular Electrical Stimulation
Gamifant (emapalumab-lzsg)
Gender Reassignment Surgery
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 Services
Glucose Monitoring - Home
Home Health Care Services - Non Skilled - Effective 1/1/2019 NEW
Home Health Care Services - Skilled
Implantation of Intrastromal Corneal Ring Segments
Infertility Services
Infused Multiple Sclerosis Drugs - Lemtrada (Alemtuzumab) and Octrevus (Ocrelizumab)
Injectable Agents for Asthma and Chronic Idiopathic Urticaria - Cinqair, Fasenra, Nucala, Xolair
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
Krystexxa (Pegloticase)
Kymriah (Tisagenlecleucel)
Kyphoplasty and Vertebroplasty
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
Lutathera (lutetium Lu 177 dotatate)
Luxturna (voretigene neparvovec-rzyl)
Mepsevii (vestronidase alfa-vjbk)
Molecular Markers in Fine Needle Aspirates of the Thyroid
Non-Wearable Automatic External Defibrillator
Oral Nutrition Mandate
Orthognathic Surgery
Out of Network Services
Outpatient Pulmonary Rehabilitation
Parsabiv (etelcalcetide)
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
Polivy (polatuzumab vedotin-piiq)
Prior Authorization - Cardiology Services Effective 10/1/2019
Prior Authorization High-Tech Radiology Imaging Eff 10_1_2019
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
Prolia and Xgeva (Denosumab)
Proprietary Laboratory Analyses (PLA)
Proteogenomic Testing for Patients with Cancer
Provenge (Sipuleucel-T)
Radicava (Edaravone)
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Radium-223, Xofigo for Treatment of Metastatic Castration-Resistant Prostate Cancer
Removal of Non-Covered Implantable Devices
Skilled Nursing Facilities:Admission and Concurrent Review
Soliris (Eculizumab)
Spinraza (Nusinersen)
Spravato (esketamine)
Stelara (Ustekinumab) Intravenous Use for Crohns Disease
Stereotactic Body Radiation Therapy
Total Joint Arthroplasty – Hip and Knee
Transcatheter Mitral Valve Repair
Transcranial Magnetic Stimulation
Tumor Treating Fields Therapy
Varicose Vein Treatment
Xiaflex (Clostridial Collagenase)
Yescarta (axicabtagene ciloleucel)
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