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
05.00.39o
Ankle-Foot/Knee-Ankle-Foot Orthoses
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.76c
Breast Pumps
05.00.61f
Cervical Traction Devices for In-home Use
05.00.37f
Compression Garments
05.00.08e
Continuous Passive Motion (CPM) Devices in the Home Setting
05.00.04e
Coverage of Medical Devices
05.00.80a
Cranial Electrotherapy Stimulation
05.00.25i
Cranial Remolding Orthoses (Helmets)
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05.00.21u
Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.48j
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
05.00.09h
Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
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05.00.05l
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
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05.00.35f
Foot Orthotics and Other Podiatric Appliances
05.00.14j
High-Frequency Chest Wall Oscillation Devices
05.00.69b
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
05.00.58l
Home Oxygen Therapy
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05.00.26i
Home Prothrombin Time Monitoring
05.00.56i
Hospital Beds and Accessories
05.00.62h
Injectable Dermal Fillers
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05.00.79b
Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
05.00.47n
Knee Orthoses
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05.00.59j
Lower Limb Prostheses
05.00.12g
Manual Wheelchairs
05.00.70b
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
05.00.15q
Nebulizers and Inhalation Solutions
05.00.38j
Negative-Pressure Wound Therapy (NPWT) Systems
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05.00.73c
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
05.00.30m
Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (Independence Administrators)
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05.00.50k
Ostomy Supplies
05.00.42g
Patient Lifts
05.00.75
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
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05.00.01m
Pneumatic Compression Therapy Devices
05.00.54g
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
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05.00.60h
Pressure-Reducing Support Surfaces
05.00.31e
Pulse Oximetry Devices in the Home Setting
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05.00.44k
Repair and Replacement of Durable Medical Equipment (DME)
05.00.45k
Repair or Replacement of an External Prosthetic Device
05.00.43f
Seat Lift Mechanisms
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05.00.24q
Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
05.00.32j
Speech and Non-Speech Generating Devices
05.00.71c
Standing Frames
05.00.77a
Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating Life-threatening Ventricular Tachyarrhythmia
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05.00.11i
Therapeutic Shoes and Orthopedic Shoes
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05.00.74d
Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
05.00.78
Transtympanic Micropressure Device as a Treatment of Meniere's Disease
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05.00.72f
Upper Limb Prostheses
05.00.55i
Wheelchair Cushions and Seating
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05.00.67p
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.