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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Draft Medical and Payment Policies
Biomarker Testing Mandate
Coding and Payment Guidelines Modifiers Effective 11-1-2023
E-Consults/Interprofessional Consults/Electronic Consults
Hospital Based Clinics Effective 10-1-2023
Mammogram and Pap Smears Mandate effective 01/01/2024
Non Reimbursable Health Service Codes Effective 1-1-24
Non Reimbursable Health Service Codes Effective 10-1-23
Non Reimbursable Health Service Codes Effective 11-1-23
Preventive Services for Commercial Members effective 1-1-24
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 Brainstem Implant
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Automated Point of Care Nerve Conduction Tests
Autonomic Nervous System Testing Using Portable Automated Devices
Axial Lumbosacral Interbody Fusion
Bariatric Surgery
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
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
Confocal Laser Endomicroscopy
Constraint-Induced Movement Therapy
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
Cranial Electrotherapy Stimulation and Auricular Electrostimulation
Cranial Orthoses (Adjustable) for Positional Plagiocephaly and Craniosynostoses
Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis
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
Digital Health Technologies - Therapeutic Applications
Digital Health Technologies for Attention Deficit/Hyperactivity Disorder - Effective 01/12/2023
Digital Health Technologies: Diagnostic Applications
Digital Health Therapies for Attention Deficit/Hyperactivity Disorder
Digital Health Therapies for Substance Use Disorders
Disposable Negative Pressure Wound Therapy (Former Title: Non-Powered Negative Pressure Wound Therapy)
Dry Hydrotherapy for Chronic Pain Conditions
Dry Needling of Trigger Point for Myofascial Pain
Dynamic Posturography
Dynamic Spinal Visualization and Vertebral Motion Analysis
Early Intervention Services Mandate
Electrical and Electromagnetic Stimulation for the Treatment of Arthritis
Electrical Bone Growth Stimulation of the Appendicular Skeletal-Implantable and Semi-Implantable and Semi Invasive
Electrical Stimulation and Electromagnetic Therapy for Wound Treatments
Electrogastrography (EGG)
Electromagnetic Navigational Bronchoscopy
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Endometrial Ablation
Enhanced External Counterpulsation
Esophageal pH Monitoring
Evaluation of Biomarkers for Alzheimer's Disease
Evaluation of Hearing Impairment/Loss
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
Functional Neuromuscular Electrical Stimulation
Gait Analysis
Gastric Electrical Stimulation - Insertion
Glucose Monitoring - Continuous
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery
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)
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 Devices for the Treatment of Constipation
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
Intraocular Radiotherapy for Age-Related Macular Degeneration
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Conditions
Intravitreal and Punctum Corticosteroid Implants
Intravitreal and Punctum Corticosteroid Implants - Effective 01/11/2023
Islet Transplantation
Laser Interstitial Thermal Therapy for Neurological Conditions
Laser Treatment of Onychomycosis
Local or Whole Body Hyperthermia
Low-Level Laser Therapy
Lyme Disease Diagnosis and Treatment Mandate
Lyme Disease Diagnosis and Treatment Mandate, Effective 01/12/2023
Lysis of Epidural Adhesions
Magnetic Capsule Endoscopy
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease
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 Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
Measurement of Ocular Blood Flow for Glaucoma
Measurement of Serum Antibodies to Selected Biologic Agents
Medical Necessity
Meniscal Allografts and Other Meniscal Implants
Mental Illness and Substance Use Disorders Mandate
Microvolt T-Wave Alternans Testing
Minimally Invasive Coronary Artery Bypass Graft Surgery
Minimally Invasive Procedures for Back Pain Related to Disc Disease
Mobile Cardiac Outpatient Telemetry (MCOT)
Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
Multimarker Serum Testing Related to Ovarian Cancer
Myoelectric Controlled Upper-Limb Orthoses
Navigated Transcranial Magnetic Stimulation
Nerve Graft with Radical Prostatectomy
Neural Therapy
New Technology and Miscellaneous Services
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/Nutritional Panel Testing
Occipital Nerve Stimulation Insertion
Ocriplasmin for Symptomatic Vitreomacular Adhesion
Optical Coherence Tomography of the Anterior Eye Segment
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy
Oral Appliances and Medical Management 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 Subcutaneous Field Stimulation
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
Phototherapeutic Keratectomy
Phototherapy for the Treatment of Seasonal Affective Disorder
Phototherapy in the Home for the Treatment of Dermatological Conditions
Phrenic Nerve Stimulation for Central Sleep Apnea
Plugs for Anal Fistula Repair
Post-Partum Hospital Stays Mandate
Powered Exoskeleton for Ambulation in Patients with Lower-Limb Disabilities
Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
Prostatic Stent - Temporary
Pulsed Radiofrequency for the Treatment of Chronic Pain
Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions
Reflectance Confocal Microscopy for Evaluating Skin Lesions for Suspected Malignancy
Remote Electrical Neuromodulation for Migraines
Retinal Prosthesis
Retinal Telescreening for Diabetic Retinopathy
Rhinomanometry and Acoustic Optical Rhinomanometry
Risk Reducing Mastectomy
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
Scanning Computerized Ophthalmic Diagnostic Imaging
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
Serologic Genetic and Molecular Screening for Colorectal Cancer
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
Speech Therapy
Sphenopalatine Ganglion Block for Headache
Stationary Ultrasonic Diathermy Device
Steroid-Eluting Sinus Stents and Implants
Subtalar Arthroereisis
Surgery for Groin Pain in Athletes
Surgical Deactivation of Migraine Headache Trigger Sites
Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation
Surgical Ventricular Restoration
Sympathetic Therapy for the Treatment of Pain
Synthetic Cartilage Implants for Joint Pain
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
Therapeutic Shoes for Diabetics Mandate
Thermal Capsulorrhaphy as a Treatment of Joint Instability
Thoracic Lumbosacral Orthosis with Pneumatics
Topographic Brain Mapping
Transanal Radiofrequency Treatment of Fecal Incontinence
Transcranial Magnetic Stimulation (TMS)
Transcutaneous Electrical Nerve Stimulation
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
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
Treatment for Duchenne Dystrophy
Tumor-Informed Circulating Tumor DNA Testing for Cancer Management
Ultrasonographic Measurement of Carotid intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Urinary Biomarkers Markers for Cancer Screening, Diagnosis, and Surveillance
Uterus Transplantation for Absolute Uterine Factor Infertility
Vertebral Axial Decompression
Vertebral Fracture Assessment
Vestibular Function Tests
Viscocanalostomy and Canaloplasty
Vitamin D Testing
Whole Gland Cryoablation of Prostate Cancer
Acupuncture and Dry Needling for Medicare Advantage Plans
Acupuncture Services for Commercial Products
Advance Care Planning
Advance Notice of Noncoverage
Advanced Practice Providers
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 Services Inpatient and Intermediate Levels of Care
Behavioral Health Supervisory Protocol for Licensed Clinical Social Workers, Postdoctoral Clinicians, Mental Health Counselor Associates, and Marriage and Family Therapist Associates
Benign Skin Lesions and Viral Infectious Lesion Removal
Breast Pump - Hospital Grade
Cardiac Rehabilitation
Care Plan Oversight
Chimeric Antigen Receptor (CAR) T-cell Therapy for Cancers
Chiropractic Services
Chromoendoscopy as an Adjunct to Colonoscopy
Claim Timely Filing - Inpatient Level of Care Appeals and Observation
Coding and Claim Filing Requirements for Drugs
Coding and Payment Guidelines / Modifiers
Colorectal Screening Mandate
Compression Garments/stockings
Contraceptive Drugs and Devices Mandate
Convalescent Plasma
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 After PHE End Date
COVID-19 Diagnostic Testing, Vaccine and Antibody Treatment Administration Reimbursement
COVID-19 Monoclonal Antibody Treatment and Antiviral IV Medications
COVID-19 Vaccinations
Date of Service for Laboratory Specimens
Dental Providers Filing Evaluation and Management for Medical Reasons
Dental Services for Accidental Injury
Digital Electroencephalography (EEG)
Discarded Drugs/Biologicals
Doula Maternity Services
Drugs and Biologicals
Durable Medical Equipment (DME)
EKG Services during Preventive Visit
Emergency Department Services/Waiver of Copayment
Emergency Room - Radiology Imaging Interpretation Services
Emergency Room Reimbursement
Enteral/Parenteral Nutrition Therapy
Fee-for-Time Compensation Arrangements (Former Title: Locum Tenens)
Foot Care and Nail Debridement
Fracture Care
Health and Behavior Assessment
High Risk Pregnancy Services
Hospital Audit Process
Hospital Laboratory Pass Through Billing
Hospital Readmission
Hospital Utilization Review
Hospital-based Clinic
Immunizations Adult and Pediatric
Inactive Provider Termination
Intensive Behavioral Therapy (IBT) for Obesity
Intraocular Lens (IOL) Implant
Lactation Consultations
Maximum Units
Medical Records Standards
Medical Supply Wastage
Medicare Advantage Plans Laboratory Network Hospital Outpatient 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
Physical and Occupational Therapy
Physical and Occupational Therapy Payment Cap
Physician Concierge Services
Place of Service (POS) 10 Telemedicine
Post Payment Audits
Preventive Medicine and Other Evaluation and Management Office/Outpatient Services
Preventive Services for Commercial Members
Preventive Services for Medicare Advantage Plans
Professional Reporting Requirements for Services Not Personally Performed (AKA Incident to Services)
Prolonged Physician Services
Prostate Specific Antigen (PSA) Screening/Testing Mandate
Provider Credentialing and Recredentialing Process
Provider Guidelines for Requesting Point of Service Payment and Maintaining Patient Credit Card Information
Psychological and Neuropsychological Testing
Rabies Treatment: Pre and Post Exposure
Self-Treatment or Treatment of Immediate Family Members
Smoking Cessation Mandate
Specialty Interdisciplinary Care Team Participation
Specimen Provenance Error Testing
Structured Screening and Brief Intervention Services
Telemedicine Services for Medicare Advantage Plans
Telemedicine/Telephone Services for Commercial Products - Effective 12/05/2023
Telemedicine/Telephone Services for Medicare Advantage Plans during the Public Health Emergency (PHE) - Effective 03/08/2022
TEMPORARY Cost Share Waiver for Treatment of Confirmed Cases of Covid-19
TEMPORARY COVID-19 Diagnostic Testing
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
Termination of Pregnancy
Therapeutic Eyeglasses and Contact Lenses
Timely Filing Limit
Transfers between DRG Facilities
Transitional Care, Chronic Care and Complex Chronic Care Management
Transplants- Travel and Accommodations for Medicare Advantage Plans
Unlisted Procedures
Venipuncture for State Mandated Lead Screening
Visual Screening for Children Aged 0-5 Years
Prior Authorization
Acute Inpatient Rehabilitation Level of Care
Adult Intensive Services (AIS) and Child and Family Intensive Services (CFIT)
Ambulance Air and Water Transport
Anastomosis of Extracranial-Intracranial Arteries
Arthrotomy for Temporomandibular Joint (TMJ) Disorder
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
Balloon Dilation of the Eustachian Tube
Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
Corneal Collagen Cross-linking
Cryosurgical Ablation of Miscellaneous Solid Tumors other than Renal, Liver and Prostate
Dental Procedures in the Outpatient Setting
Diagnosis and Treatment of Sacroiliac Joint Pain
Digestive Enzyme Cartridges
Envisia for Idiopathic Pulmonary Fibrosis
Epidural Injections for Pain Management
Exondys (eteplirsen) and Vyondys (golodirsen) for Duchenne Muscular Dystrophy
Gender Affirming Care (Former Title: 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 for Mental Health Conditions, Effective 01/10/2023
Genetic Testing for Mitochondrial Disorders
Genetic Testing Services
Genetic Testing Services - Effective 11.1.2023
Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases - Effective 8.1.2023
Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms - Effective 8.1.2023
Glucose Monitoring - Home - Non-One Touch Brand
Home Health Care Services - Skilled
Implantation of Intrastromal Corneal Ring Segments
Infertility Services
Intensity-Modulated Radiotherapy
Laboratory Tests Post Transplant and for Heart Failure
Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids & Hysterectomies
Laser Treatment for Proliferative Vascular Lesions
Long Term Acute Care Hospital (LTACH) Admission and Transition of Care Criteria
Lung Liquid Biopsy
Magnetic Resonance Imaging‐Guided Focused Ultrasound
Microprocessor-Controlled Prostheses for the Lower Limb
Microwave Tumor Ablation
Minimal Residual Disease Testing for Cancer
Minimal Residual Disease Testing for Cancer - Effective 11.1.2023
Miscellaneous Vascular Embolization Procedures
Molecular Markers in Fine Needle Aspiration of the Thyroid
Molecular Testing for the Management of Pancreatic Cysts, Barrett Esophagus, and Solid Pancreaticobiliary Lesions
Molecular Testing in the Management of Pulmonary Nodules
Oral Nutrition Mandate
Orthognathic Surgery
Out-of-Network Services Requests
Pediatric Dental Services Essential Health Benefit -Dental Review
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Percutaneous Tibial Nerve Stimulation
Peripheral Artery Disease (PAD) Rehabilitation
Prior Authorization of Cardiology and Radiology Services
Prior Authorization of Drugs
Prior Authorization of Spinal Procedures
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)
Prostatic Urethral Lift
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
Removal of Implantable Devices - Effective 01/03/2023
Skilled Nursing Facilities: Admission and Concurrent Review
Spinal Cord Stimulation
Stereotactic Body Radiation Therapy
Surgical and Debulking Treatments for Lymphedema
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Total Joint Arthroplasty – Hip and Knee
Transcatheter Mitral Valve Repair
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia
Varicose Vein Treatment
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