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
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08.00.62i
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
11.05.16h
Attachment A (ICD-10 codes ) to 11.05.16h Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.14.19n
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)
07.03.23b
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
08.00.99b
Belimumab (Benlysta®) for Intravenous Use

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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.