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
07.00.21i
Allergy Immunotherapy
07.02.09e
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21c
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
07.10.06g
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
07.03.23b
Autonomic Nervous System Testing
07.00.01h
Biofeedback Therapy
07.06.03b
Bioimpedance for the Detection of Lymphedema
07.06.01b
Complete Decongestive Therapy (CDT)
Show details for
07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
Show details for
07.13.07j
Corneal Pachymetry Using Ultrasound
07.05.07c
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
Show details for
07.07.07f
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
Show details for
07.03.09o
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Show details for
07.03.21j
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.02.22
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.07r
Evaluation and Management of Autism Spectrum Disorders (ASD)
07.03.15d
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
07.02.05j
External Counterpulsation (ECP)
07.05.08a
Fecal Microbiota Transplantation (FMT)
Show details for
07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.00.05g
In Vivo Allergy Sensitivity Testing
07.13.12d
Instrument-Based Vision Screening
07.03.14n
Intraoperative Neurophysiological Monitoring (INM)
Show details for
07.00.02i
Intravenous Chelation Therapy
07.03.24
Laboratory-Based Vestibular Function Testing
07.00.14f
Low-level Laser Therapy (LLLT)
07.03.10e
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
07.11.02f
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
07.08.03d
Medical and Surgical Treatment of Temporomandibular Joint Disorder
07.03.03g
Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
Show details for
07.03.18n
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
Show details for
07.03.08i
Neuropsychological Testing for Neurologically Based Conditions
07.08.01f
Non-Surgical Spinal Decompression Therapy
07.10.05l
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
07.03.25
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
07.13.01g
Orthoptic/Pleoptic Training
07.10.04c
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor
Show details for
07.13.08e
Partial Coherence Interferometry
07.12.01e
Pelvic Floor Stimulation as a Treatment of Incontinence
Show details for
07.07.03m
Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
07.00.10i
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
07.13.05k
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
07.07.05b
Photography, Including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
Show details for
07.13.13c
Prescription Lenses and Visual Devices
07.00.15l
Reimbursement for the Administration of Immunizations
07.00.20f
Routine Costs Associated with Qualifying Clinical Trials
Show details for
07.07.01n
Routine Foot Care for Certain Medical Conditions
07.13.06k
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
07.03.05v
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (Independence)
07.11.01c
Smell and Taste Dysfunction Testing
07.07.09f
Stem-Cell Therapy for Orthopedic Applications and Autologous Platelet-Derived Growth Factors (PDGFs)/Platelet-Rich Plasmas (PRPs) for Acute or Chronic Wound Healing and Other Miscellaneous Conditions
07.00.09d
Topical Oxygenation
07.05.06f
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
07.03.22c
Transcranial Magnetic Stimulation (TMS)
07.03.26
Tumor Treating Fields
Show details for
07.07.02j
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
Show details for
07.05.02n
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon

Connect with Us        


© 2017 Independence Blue Cross.
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.