Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   

Policy #
Policy Bulletin Title
Show details for
MA05.010d
Ankle-Foot/Knee-Ankle-Foot Orthoses
Show details for
MA05.005c
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
MA05.052b
Canes and Crutches
MA05.009
Cervical Traction Devices for In-home Use
MA05.035b
Cold Therapy Devices
MA05.036b
Commode Chairs
MA05.045a
Compression Garments
MA05.019a
Continuous Passive Motion (CPM) Devices in the Home Setting
MA05.040b
Coverage of Medical Devices
MA05.066a
Cranial Electrotherapy Stimulation
MA05.028d
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
Show details for
MA05.044g
Durable Medical Equipment (DME)
MA05.059
Electrical Continence Aid
MA05.033b
External Breast Prosthesis
MA05.050a
Eye Prostheses and Scleral Cover Shell
MA05.029b
Heating Pads and Heat Lamps
MA05.001c
High-Frequency Chest Wall Oscillation Devices
MA05.022
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
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MA05.015c
Home Blood Glucose Monitors and Supplies
MA05.017b
Home Oxygen Therapy
Show details for
MA05.016f
Home Prothrombin Time Monitoring
MA05.061
Home Use of Interferential and Sequential Stimulation Devices
MA05.002c
Hospital Beds and Accessories
MA05.053g
Implantable and External Infusion Pumps
MA05.021a
Injectable Dermal Fillers
MA05.013c
Knee Orthoses
MA05.067b
Leadless Pacemakers
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MA05.024c
Lower Limb Prostheses
Show details for
MA05.026a
Manual Wheelchairs
MA05.043a
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
MA05.007c
Nebulizers and Inhalation Solutions
MA05.008a
Negative Pressure Wound Therapy (NPWT) Systems
MA05.058a
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
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MA05.012a
Orthopedic Footwear
MA05.018a
Osteogenic Stimulators (i.e., Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System)
Show details for
MA05.014a
Ostomy Supplies
MA05.031a
Patient Lifts
MA05.064
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
Show details for
MA05.004c
Pneumatic Compression Therapy Devices
MA05.032
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
Show details for
MA05.025c
Pressure-Reducing Support Surfaces
MA05.042a
Pulse Oximeters in the Home Setting
Show details for
MA05.062d
Repair and Replacement of Durable Medical Equipment (DME)
Show details for
MA05.063c
Repair or Replacement of an External Prosthetic Device
MA05.011a
Seat Lift Mechanisms
MA05.003c
Speech and Non-Speech Generating Devices
MA05.030c
Spinal Orthoses
MA05.055
Standing Frames
MA05.027
Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating Life-threatening Ventricular Tachyarrhythmia
Show details for
MA05.020f
Therapeutic Shoes
MA05.034
Tracheostomy Care Supplies
Show details for
MA05.006d
Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
MA05.065
Transtympanic Micropressure Device as a Treatment of Meniere Disease
MA05.047d
Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring in Adults
Show details for
MA05.057c
Upper Limb Prostheses
MA05.054d
Urological Supplies
MA05.037
Walkers
MA05.023a
Wheelchair Cushions and Seating
Show details for
MA05.046e
Wheelchair Options and Accessories









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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.