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
11.08.05g
Application and Removal of Tattoos
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11.05.16h
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.14.19l
Artificial Intervertebral Disc Insertion
11.14.06i
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
11.16.06i
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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11.03.02r
Bariatric Surgery
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11.05.02i
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
11.01.06e
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
11.16.07b
Bronchial Thermoplasty
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11.01.07d
Cataract Surgery
11.02.06l
Catheter Ablation of Cardiac Arrhythmias
11.08.08g
Chemical Peels
11.01.02n
Cochlear Implant
11.03.12q
Colorectal Cancer Screening
11.14.30
Composite Tissue Allotransplantation of the Hand(s) and Face
11.14.17d
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures
11.11.03d
Cryosurgical Ablation of the Prostate Gland
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11.08.17h
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.15.20o
Deep Brain Stimulation (DBS)
11.15.09l
Denervation of the Spinal Nerves for Chronic Pain
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11.06.02i
Elective Abortion
11.06.05f
Endometrial Ablation
11.02.10m
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
11.02.17f
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
11.15.23g
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
11.11.01i
Evaluation and Treatment of Erectile Dysfunction (ED)
11.14.13g
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
11.00.03j
Fetal Surgery
11.03.05d
Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)
11.03.15h
Gastric Electrical Stimulation (Enterra™), Gastric Pacing
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11.08.01f
Hair Transplants and Cranial Prostheses (Wigs)
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11.07.01s
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
11.00.13g
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies
11.16.08b
Implantable Steroid-Eluting Sinus Stents
11.05.11c
Implantation of Intrastromal Corneal Ring Segments (ICRS)
11.15.03j
Insertion of Implantable Infusion Pumps
11.14.07t
Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
11.04.01c
Islet Cell Transplantation
11.06.09d
Labiaplasty
11.08.03j
Lipectomy and Liposuction
11.15.13d
Lysis of Epidural Adhesions
11.06.06e
Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation
11.14.24b
Manipulation Under Anesthesia
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11.14.03f
Meniscal Allograft Transplantation
11.14.01g
Mentoplasty or Genioplasty
11.14.21g
Microprocessor-Controlled Prostheses for Lower-Extremity Amputees
11.15.24a
Migraine Deactivation Surgery
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11.08.23j
Mohs' Micrographic Surgery
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11.00.10u
Multiple Surgical Reduction Guidelines (Independence)
11.15.19e
Nucleoplasty
11.14.08d
Orthognathic Surgery
11.14.12e
Osteochondral Allograft Transplantation
11.14.09g
Osteochondral Autograft Transplantation (OAT) Procedure
11.01.01j
Otoplasty or Non-Surgical External Ear Molding
11.06.07d
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
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11.08.06j
Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
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11.02.27b
Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (Independence)
11.15.15g
Percutaneous Discectomy
11.15.22d
Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis
11.14.14e
Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
11.02.26a
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
11.02.12i
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery
11.14.10q
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
11.05.08d
Photocoagulation of Macular Drusen
11.08.29e
Procedures for the Treatment of Acne
11.03.11n
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
11.08.19m
Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
11.00.16g
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
11.08.15v
Reconstructive Breast Surgery
11.08.02h
Reduction Mammoplasty
11.05.01f
Refractive Keratoplasty
11.05.10b
Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens
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11.08.14j
Removal of Breast Implants
11.03.01e
Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate
11.00.01e
Revision of a Previous Cosmetic Procedure
11.08.13g
Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
11.00.18
Robotic-Assisted Surgery
11.17.04s
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
11.11.06h
Saturation Needle Biopsy of the Prostate
11.08.25m
Scar Revision
11.08.04h
Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
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11.07.02j
Sentinel Lymph Node Biopsy and Mapping
11.16.01h
Septoplasty, Rhinoplasty, and Septorhinoplasty
11.00.09f
Solid Organ Transplantation and Procurement Cost of Organs and Tissues
11.15.01u
Spinal Cord and Dorsal Root Ganglion Stimulation
11.14.22d
Spinal Decompression with Interspinous and Interlaminar Devices
11.14.29c
Spinal Discectomy
11.14.27c
Spinal Fusion
11.14.28b
Spinal Laminectomy
11.08.12h
Surgery for Gynecomastia
11.17.06l
Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
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11.05.07d
Surgical Correction of Strabismus
11.14.23c
Surgical Treatment of Femoroacetabular Impingement
11.14.26a
Surgical Treatments of Athletic Pubalgia
11.02.19f
Total Artificial Hearts (TAHs)
11.02.25f
Transcatheter Cardiac Valve Procedures
11.02.11g
Transcatheter Closure of Cardiac Septal Defects
11.09.02g
Treatment of Gender Dysphoria
11.00.02f
Treatment of Medical and Surgical Complications
11.00.06j
Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring
11.00.14f
Treatment of Twin-Twin Transfusion Syndrome (TTTS)
11.02.01r
Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence
11.14.02n
Trigger Point Injections
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11.00.11k
Use of an Operating Microscope During a Surgical Procedure
11.06.04k
Uterine Artery Embolization
11.15.16n
Vagus Nerve Stimulation (VNS)
11.02.16r
Ventricular Assist Devices (VADs)
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11.08.20t
Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds

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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.