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
08.00.62j
Abatacept (Orencia®) for Injection for Intravenous Use
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12.00.01f
Acupuncture (Independence)
12.04.04a
Acute Care Facility Inpatient Transfers
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08.01.11e
Ado-Trastuzumab Emtansine (Kadcyla®)
08.00.69b
Agalsidase beta (Fabrazyme®)
12.04.03c
Air Ambulance Services
08.01.22d
Alemtuzumab (Lemtrada®)
08.00.72h
Alglucosidase alfa (e.g., Lumizyme®)
07.00.21i
Allergy Immunotherapy
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)
08.00.91d
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
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00.01.52i
Always Bundled Procedure Codes
07.02.09g
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21e
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
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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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11.05.16h
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.14.19o
Artificial Intervertebral Disc Insertion
08.01.35b
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
06.02.27l
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)
07.10.06h
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
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)
07.03.23c
Autonomic Nervous System Testing
11.16.06j
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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11.03.02s
Bariatric Surgery
08.00.99c
Belimumab (Benlysta®) for Intravenous Use
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08.00.66n
Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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00.10.39l
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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00.10.38a
Billing Requirements for Multiple Births for Professional Providers
07.00.01i
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®)
11.01.06e
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
09.00.04k
Bone Mineral Density (BMD) Testing
08.00.73l
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.26w
Botulinum Toxin Agents
09.00.10z
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)
05.00.76c
Breast Pumps
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08.01.13d
Brentuximab Vedotin (Adcetris®)
11.16.07b
Bronchial Thermoplasty
08.01.49a
Burosumab-twza (Crysvita®)
08.00.96e
Cabazitaxel (Jevtana®)
08.01.51
Canakinumab (Ilaris®)
Show details for
10.01.01n
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
00.01.59f
Care Management and Care Planning Services
08.01.05f
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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11.01.07e
Cataract Surgery
11.02.06m
Catheter Ablation of Cardiac Arrhythmias
08.01.39c
Cerliponase alfa (Brineura®)
05.00.61f
Cervical Traction Devices for In-home Use
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08.00.67l
Cetuximab (Erbitux®)
11.08.08g
Chemical Peels
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08.01.43e
Chimeric Antigen Receptor (CAR) Therapy
10.02.02j
Chiropractic Spinal and Extraspinal Manipulation Therapy
08.00.92ab
Coagulation Factors
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06.02.54
Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
11.01.02o
Cochlear Implant
11.03.12s
Colorectal Cancer Screening
12.00.03g
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 Procedures
00.01.69
Consultation Services
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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
09.00.11d
Contrast Agents Used in Conjunction with Echocardiography
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07.13.07j
Corneal Pachymetry Using Ultrasound
12.01.03
Cosmetic Procedures
05.00.04e
Coverage of Medical Devices
08.01.08d
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
05.00.80a
Cranial Electrotherapy Stimulation
05.00.25i
Cranial Remolding Orthoses (Helmets)
00.10.03j
Criteria for Reimbursement of Emergency Room Services
11.11.03d
Cryosurgical Ablation of the Prostate Gland
08.01.29e
Daratumumab (Darzalex™)
10.00.02c
Day Rehabilitation
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11.08.17i
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.15.20o
Deep Brain Stimulation (DBS)
11.15.09n
Denervation of the Spinal Nerves for Chronic Pain
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08.00.94m
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
08.01.24a
Deoxycholic Acid (Kybella™)
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00.03.02aa
Diagnostic Radiology Services Included in Capitation
00.09.01f
Direct Access to Obstetrics/Gynecology (OB/GYN) Services
08.00.49e
Dofetilide (Tikosyn®) Use in the Inpatient Setting
07.05.07d
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
08.01.37a
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)
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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
08.00.84g
Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®)
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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07.03.09p
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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07.03.21k
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
09.00.02e
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
08.01.54b
Emapalumab-lzsg (Gamifant®)
11.06.05f
Endometrial Ablation
11.02.10n
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
08.00.43a
Enfortumab vedotin-ejfv (Padcev™)
08.00.51j
Enzyme Replacement for the Treatment of Gaucher's Disease
08.01.26c
Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., elapegademase-lvlr [Revcovi™)
08.00.70e
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
11.15.23i
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
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08.00.45a
Eptinezumab-jjmr (VYEPTI™)
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05.00.05l
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.75n
Erythropoiesis-Stimulating Agents (ESAs)
07.02.22a
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.07t
Evaluation and Management of Autism Spectrum Disorder (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)
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06.02.52q
eviCore Lab Management Program (Independence)
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12.01.01av
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
08.00.12a
Fam-trastuzumab deruxtecan-nxki (Enhertu®)
07.05.08a
Fecal Microbiota Transplantation (FMT)
06.02.04d
Fetal Fibronectin Enzyme (fFN) Immunoassay
11.00.03j
Fetal Surgery
09.00.36l
First-Trimester Prenatal Screening for Fetal Aneuploidy Using Fetal Ultrasound Markers
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05.00.35f
Foot Orthotics and Other Podiatric Appliances
11.03.05d
Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (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)
Show details for
06.02.06q
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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06.02.35y
Genetic Testing (Independence Administrators)
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08.01.15d
Golimumab (Simponi Aria®) Intravenous (IV) Injection
08.01.33b
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
06.02.50
GPS Cancer™ Testing by NantHealth
12.04.02i
Ground Ambulance Services (Emergency and Nonemergency) (Independence)
00.05.01f
Guidelines for Home Care Visits Following Inpatient Maternity Stay
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11.08.01g
Hair Transplants and Cranial Prostheses (Wigs)
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11.07.01t
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
05.00.14j
High-Frequency Chest Wall Oscillation Devices
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09.00.46ab
High-Technology Radiology Services (Independence)
09.00.13c
High Osmolar Contrast Agents
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
05.00.26i
Home Prothrombin Time Monitoring
02.02.01g
Hospice Care
05.00.56i
Hospital Beds and Accessories
06.02.09g
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping (Independence Administrators)
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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08.00.13w
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.22m
Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
08.01.04v
Immunizations
11.15.03k
Implantable Infusion Pumps
11.16.08d
Implantable Steroid-Eluting Sinus Stents
11.05.11c
Implantation of Intrastromal Corneal Ring Segments (ICRS)
06.02.26d
In Vitro Allergy Testing
06.02.14i
In Vitro Chemosensitivity and Chemoresistance Assays
07.00.05g
In Vivo Allergy Sensitivity Testing
00.10.40d
Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
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08.00.34n
Infliximab and Related Biosimilars
05.00.62h
Injectable Dermal Fillers
00.01.47c
Inpatient Hospital Readmission
07.13.12d
Instrument-Based Vision Screening
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05.00.79b
Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
09.00.17o
Intensity-Modulated Radiation Therapy (IMRT) (Independence Administrators)
08.01.23f
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)
11.14.07v
Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
07.03.14o
Intraoperative Neurophysiological Monitoring (INM)
Show details for
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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08.00.74n
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
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08.01.01i
Ipilimumab (Yervoy®)
08.00.46
Isatuximab-irfc (Sarclisa®)
11.04.01d
Islet Cell Transplantation
05.00.47n
Knee Orthoses
11.06.09d
Labiaplasty
07.03.24a
Laboratory-Based Vestibular Function Testing
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00.03.07y
Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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08.01.40b
Lanreotide (Somatuline® Depot)
11.08.03j
Lipectomy and Liposuction
07.00.14g
Low-level Laser Therapy (LLLT)
09.00.31d
Low Osmolar Contrast Agents
Show details for
05.00.59j
Lower Limb Prostheses
08.00.10b
Luspatercept–aamt (Reblozyl®)
08.01.57
Lutathera® (Lutetium Lu 177 Dotatate) (Independence Administrators)
06.02.01j
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
11.15.13d
Lysis of Epidural Adhesions
11.06.06e
Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation

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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.