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
08.00.62i
Abatacept (Orencia®) for Injection for Intravenous Use
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12.00.01f
Acupuncture (Independence)
12.04.04
Acute Care Facility Inpatient Transfers
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08.01.11d
Ado-Trastuzumab Emtansine (Kadcyla®)
08.00.69a
Agalsidase beta (Fabrazyme®)
12.04.03c
Air Ambulance Services
08.01.22c
Alemtuzumab (Lemtrada®)
08.00.72g
Alglucosidase alfa (e.g., Lumizyme®)
07.00.21i
Allergy Immunotherapy
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)
08.00.91c
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
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00.01.52g
Always Bundled Procedure Codes
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
01.00.02b
Anesthesia Services for a Cancelled or Discontinued Procedure
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05.00.39o
Ankle-Foot/Knee-Ankle-Foot Orthoses
06.03.04n
Apheresis Therapy
11.08.05g
Application and Removal of Tattoos
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08.01.41c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
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11.05.16g
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.14.19l
Artificial Intervertebral Disc Insertion
08.01.35a
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
06.02.27l
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)
07.10.06f
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
06.03.05e
Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
11.14.06i
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
07.03.23b
Autonomic Nervous System Testing
11.16.06h
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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11.03.02r
Bariatric Surgery
08.01.03c
Belatacept (Nulojix®)
08.00.99b
Belimumab (Benlysta®) for Intravenous Use
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08.00.66k
Bevacizumab (Avastin®) and related biosimilars
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00.10.39j
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
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00.10.38
Billing Requirements for Multiple Births for Professional Providers
07.00.01h
Biofeedback Therapy
07.06.03b
Bioimpedance for the Detection of Lymphedema
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11.05.02i
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
08.01.21c
Blinatumomab (Blincyto®)
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11.01.06d
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
09.00.04i
Bone Mineral Density (BMD) Testing
08.00.73l
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.26u
Botulinum Toxin Agents
09.00.10y
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)
05.00.76b
Breast Pumps
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08.01.13c
Brentuximab Vedotin (Adcetris®)
11.16.07b
Bronchial Thermoplasty
08.01.49a
Burosumab-twza (Crysvita®)
08.00.96d
Cabazitaxel (Jevtana®)
08.01.51
Canakinumab (Ilaris®)
Show details for
10.01.01n
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
00.01.59e
Care Management and Care Planning Services
08.01.05e
Carfilzomib (Kyprolis™)
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00.10.15c
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
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11.01.07d
Cataract Surgery
11.02.06l
Catheter Ablation of Cardiac Arrhythmias
08.01.39b
Cerliponase alfa (Brineura™)
05.00.61f
Cervical Traction Devices for In-home Use
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08.00.67k
Cetuximab (Erbitux®)
11.08.08g
Chemical Peels
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08.01.43d
Chimeric Antigen Receptor (CAR) Therapy
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10.02.02i
Chiropractic Spinal and Extraspinal Manipulation Therapy
08.00.92y
Coagulation Factors
11.01.02n
Cochlear Implant
11.03.12q
Colorectal Cancer Screening
12.00.03f
Complementary and Integrative Health Services
07.06.01b
Complete Decongestive Therapy (CDT)
11.14.30
Composite Tissue Allotransplantation of the Hand(s) and Face
05.00.37f
Compression Garments
09.00.42c
Computer-Aided Detection (CAD) System for Use with Chest Radiographs
11.14.17d
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
06.00.01e
Computer Analysis and Generation of Automated Data in Conjunction with Diagnostic Studies
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07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
01.00.09c
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
05.00.08e
Continuous Passive Motion (CPM) Devices in the Home Setting
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07.13.07j
Corneal Pachymetry Using Ultrasound
12.01.03
Cosmetic Procedures
08.01.08c
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
05.00.25h
Cranial Remolding Orthoses (Helmets)
00.10.03i
Criteria for Reimbursement of Emergency Room Services
11.11.03d
Cryosurgical Ablation of the Prostate Gland
08.01.29d
Daratumumab (Darzalex™)
10.00.02b
Day Rehabilitation
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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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08.00.94k
Denosumab (Prolia®, Xgeva®)
04.00.03a
Dental Extractions Prior to Cardiac Surgery, Radiation Therapy, or Transplant Surgery
08.01.24
Deoxycholic Acid (Kybella™)
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00.03.02y
Diagnostic Radiology Services Included in Capitation
00.09.01e
Direct Access Obstetrics/Gynecology (OB/GYN)
08.00.49d
Dofetilide (Tikosyn®) Use in the Inpatient Setting
07.05.07c
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
08.01.37
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Probuphine Implant, Vivitrol Injection)
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05.00.21t
Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.48j
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
09.00.11c
Echocardiography Contrast Agents
08.00.84d
Eculizumab (Soliris®)
08.01.42a
Edaravone (Radicava™)
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11.06.02i
Elective Abortion
05.00.09h
Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
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07.07.07f
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
03.02.12c
Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
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07.03.09o
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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07.03.21j
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
09.00.02e
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
08.01.54
Emapalumab-lzsg (Gamifant®)
11.06.05e
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
08.00.51i
Enzyme Replacement for the Treatment of Gaucher's Disease
08.00.70d
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase™, Vimizim™, Naglazyme®, Mepsevii™, etc.)
11.15.23g
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
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05.00.05k
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.75m
Erythropoiesis-Stimulating Agents (ESAs)
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)
11.11.01i
Evaluation and Treatment of Erectile Dysfunction (ED)
03.02.13f
Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG)
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06.02.52l
eviCore Lab Management Program (Independence)
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12.01.01ar
Experimental/Investigational Services
07.02.05j
External Counterpulsation (ECP)
11.14.13g
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
04.00.05d
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
00.01.19d
Facility Reporting of Observation Services
07.05.08a
Fecal Microbiota Transplantation (FMT)
06.02.04d
Fetal Fibronectin Enzyme (fFN) Immunoassay
11.00.03j
Fetal Surgery
09.00.36k
First-Trimester Prenatal Screening for Fetal Aneuploidy Using Fetal Ultrasound Markers
05.00.04d
Food and Drug Administration (FDA) Approval of Medical Devices
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05.00.35e
Foot Orthotics and Other Podiatric Appliances
11.03.05c
Frenectomy or Frenotomy for Ankylogossia (Tongue-Tie)
09.00.24c
Full-Body Computerized Tomography (CT) Scan Screening
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07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
11.03.15h
Gastric Electrical Stimulation (Enterra™), Gastric Pacing
06.02.31f
Genetic Testing for Congenital Long QT Syndrome (Independence Administrators)
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06.02.06p
Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (Independence Administrators)
06.02.10q
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) (Independence Administrators)
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06.02.35t
Genetic Testing (Independence Administrators)
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08.01.15d
Golimumab (Simponi Aria®) Intravenous (IV) Injection
08.01.33a
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
06.02.50
GPS Cancer™ Testing by NantHealth
12.04.02h
Ground Ambulance Transport Services (Emergency and Nonemergency)
00.05.01e
Guidelines for Well Mother/Well Baby Visits Under the Mother's Option Program
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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)
05.00.14j
High-Frequency Chest Wall Oscillation Devices
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09.00.46v
High-Technology Radiology Services (Independence)
09.00.13c
High Osmolar Contrast Agents
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08.00.97h
Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)
05.00.69b
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
02.01.01d
Home Health Care Services
05.00.58l
Home Oxygen Therapy
Show details for
05.00.26g
Home Prothrombin Time Monitoring
05.00.65e
Home Uterine Activity Monitoring (HUAM) Devices
02.02.01g
Hospice Care
05.00.56i
Hospital Beds and Accessories
06.02.09g
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping (Independence Administrators)
00.10.37b
Humanitarian Use Devices (HUD) and the Humanitarian Device Exemption (HDE) Process
08.01.00g
Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies
11.00.13g
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies
08.01.46a
Ibalizumab-uiyk (Trogarzo™)
06.02.37a
Immune Cell Function Assay
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08.00.13t
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.22m
Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
08.01.04t
Immunizations
11.16.08b
Implantable Steroid-Eluting Sinus Stents
11.05.11c
Implantation of Intrastromal Corneal Ring Segments (ICRS)
06.02.26d
In Vitro Allergy Testing
06.02.14h
In Vitro Chemosensitivity and Chemoresistance Assays
07.00.05g
In Vivo Allergy Sensitivity Testing
Show details for
08.00.34l
Infliximab and Related Biosimilars
05.00.62h
Injectable Dermal Fillers
00.01.47c
Inpatient Hospital Readmission
11.15.03j
Insertion of Implantable Infusion Pumps
03.12.04c
Insertion or Application of Urinary Catheters and the Associated Supplies Provided in the Office Setting
07.13.12d
Instrument-Based Vision Screening
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05.00.79a
Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
09.00.17o
Intensity-Modulated Radiation Therapy (IMRT) (Independence Administrators)
08.01.23e
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra™)
11.14.07t
Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
07.03.14n
Intraoperative Neurophysiological Monitoring (INM)
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07.00.02i
Intravenous Chelation Therapy
00.01.45
Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances
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08.00.74l
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®], and related biosimilars)
Show details for
08.01.01h
Ipilimumab (Yervoy®)
11.04.01c
Islet Cell Transplantation
05.00.47n
Knee Orthoses
11.06.09d
Labiaplasty
07.03.24
Laboratory-Based Vestibular Function Testing
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00.03.07v
Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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08.01.40a
Lanreotide (Somatuline® Depot)
11.08.03j
Lipectomy and Liposuction
07.00.14f
Low-level Laser Therapy (LLLT)
09.00.31d
Low Osmolar Contrast Agents
Show details for
05.00.59i
Lower Limb Prostheses
06.02.01i
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
11.15.13d
Lysis of Epidural Adhesions

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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.