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Blue Cross NC Home Providers Policies, guidelines and codes Medical policies and guidelines
Providers Medical policies and guidelines

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Clinical Trial Services Investigational (Experimental) Services Medical Necessity Professional Pathology Billing Requirements AHS – R2169
Adaptive Behavioral Treatment for Autism Spectrum Disorders Medically Monitored Inpatient Withdrawal Management Psychiatric Intensive Outpatient Programs Psychiatric Partial Hospitalization Programs Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder Residential Treatment Substance Use Disorder Intensive Outpatient Programs Substance Use Disorder Partial Hospitalization Programs Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs)
Artificial Pancreas Device Systems Children's Mobility and Positioning Equipment Continuous Monitoring of Glucose in the Interstitial Fluid Continuous Passive Motion in the Home Setting Durable Medical Equipment (DME) Electrical Stimulation for the Treatment of Arthritis Infusion Therapy in the Home Interferential Stimulation Microprocessor-Controlled Prostheses for the Lower Limb Myoelectric Prosthetic Components for the Upper Limb Neurostimulation, Electrical Noninvasive Respiratory Assist Devices Oscillatory Devices for the Treatment of Respiratory Conditions Patient Lifts Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities Pressure Reducing Support Surfaces Private Duty Nursing Services Skilled Nursing Services Topical Negative Pressure Therapy for Wounds Ultrasound Accelerated Fracture Healing Device Wearable Cardioverter Defibrillators Wheelchairs (Manual and Power Operated)
Allergen Testing AHS – G2031 Beta-Hemolytic Streptococcus Testing AHS – G2159 Biochemical Markers of Alzheimer Disease and Dementia AHS – G2048 Biomarker Testing for Autoimmune Rheumatic Disease AHS - G2022 Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases AHS – G2123 Biomarkers for Myocardial Infarction and Chronic Heart Failure AHS - G2150 Bone Turnover Markers Testing AHS - G2051 Cardiovascular Disease Risk Assessment AHS – G2050 Celiac Disease Testing AHS - G2043 Cervical Cancer Screening AHS - G2002 Chromosomal Microarray and Low-pass Whole Genome Sequencing AHS - M2033 Colorectal Cancer Screening AHS - B0001 Coronavirus Testing in the Outpatient Setting AHS - G2174 Diabetes Mellitus Testing - AHS G2006 Diagnosis of Idiopathic Environmental Intolerance AHS - G2056 Diagnosis of Vaginitis AHS - M2057 Diagnostic Testing of Influenza AHS - G2119 Diagnostic Testing of Iron Homeostasis and Metabolism AHS - G2011 Diagnostic Testing of Sexually Transmitted Infections AHS – G2157 Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS - G2059 Esophageal Pathology Testing AHS - M2171 Evaluation of Dry Eyes AHS - G2138 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing AHS - G2060 Fecal Calprotectin Testing in Adults AHS - G2061 Fibromyalgia Testing AHS - M2177 Flow Cytometry AHS - F2019 Folate Testing AHS - G2154 Gamma-glutamyl Transferase Testing in Adults AHS-G2173 Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 General Genetic Testing, Germline Disorders AHS - M2145 General Genetic Testing, Somatic Disorders AHS - M2146 General Inflammation Testing AHS - G2155 Genetic Markers for Assessing Risk of Cardiovascular Disease AHS - M2180 Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma AHS - M2071 Genetic Testing for Alpha- and Beta- Thalassemia AHS - M2131 Genetic Testing for Breast, Ovarian, Pancreatic and Prostate Cancers (BRCA) AHS - M2003 Genetic Testing for CHARGE Syndrome AHS - M2070 Genetic Testing for Connective Tissue Disorders AHS - M2144 Genetic Testing for Cystic Fibrosis AHS – M2017 Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies AHS – M2072 Genetic Testing for Epilepsy AHS – M2075 Genetic Testing for Familial Alzheimer’s Disease AHS – M2038 Genetic Testing for Familial Hypercholesterolemia AHS – M2137 Genetic Testing for Fanconi Anemia AHS – M2077 Genetic Testing for FMR1 Mutations AHS – M2028 Genetic Testing for Germline Variants of the RET Proto-Oncogene AHS - M2078 Genetic Testing for Hereditary Hearing Loss AHS – G2148 Genetic Testing for Hereditary Hemochromatosis AHS – M2012 Genetic Testing for Hereditary Pancreatitis AHS – M2079 Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS – M2025 Genetic Testing for Lactase Insufficiency AHS – M2080 Genetic Testing for Li-Fraumeni Syndrome AHS – M2081 Genetic Testing for Lipoprotein A Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment AHS – M2082 Genetic Testing for Muscular Dystrophies AHS – M2074 Genetic Testing for Neurodegenerative Disorders AHS – M2167 Genetic Testing for Neurofibromatosis and Related Disorders AHS – M2134 Genetic Testing for Ophthalmologic Conditions AHS-M2083 Genetic Testing for Polyposis Syndromes AHS-M2024 Genetic Testing for PTEN Hamartoma Tumor Syndrome AHS – M2087 Genetic Testing for Rett Syndrome AHS – M2088 Genetic Testing of CADASIL Syndrome AHS – M2069 Genetic Testing of Mitochondrial Disorders AHS – M2085 Genomic Testing for Hematopoietic Neoplasms AHS- M2182 Helicobacter Pylori Testing AHS – G2044 Hepatitis Testing AHS – G2036 Human Immunodeficiency Virus AHS – M2116 Identification of Microorganisms using Nucleic Acid Probes AHS – M2097 Immune Cell Function Assay for Organ Transplant Rejection AHS-G2098 Immunohistochemistry AHS – P2018 Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105 In Vitro Chemoresistance and Chemosensitivity Assays AHS- G2100 Intracellular Micronutrient Analysis AHS – G2099 Laboratory Procedures Medical Policy AHS - R2162 Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS – G2121 Liquid Biopsy AHS - G2054 Lyme Disease Testing AHS – G2143 Lynch Syndrome AHS - M2004 Metabolite Markers of Thiopurines AHS – G2115 Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification AHS-B0002 Microsatellite Instability and Tumor Mutational Burden Testing AHS - M2178 Minimal Residual Disease (MRD) AHS - M2175 Molecular Analysis for Gliomas AHS - M2139 Molecular Diagnostics for Breast Cancer Prognosis AHS - M2020 Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 Molecular Profiling for Cancers of Unknown Primary Origin AHS- M2065 Molecular Testing for Cutaneous Melanoma AHS - M2029 Molecular Testing for Pulmonary Disease AHS - M2160 Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 Nerve Fiber Density Testing AHS - M2112 Onychomycosis Testing AHS - M2172 Oral Cancer Screening and Testing AHS - G2113 Pancreatic Cancer Risk Testing Using Pancreatic Cyst Fluid AHS - M2114 Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153 Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS - G2164 Pathogen Panel Testing AHS – G2149 Pharmacogenetics Testing AHS - M2021 Pre-Implantation Genetic Testing AHS - M2039 Prenatal Screening (Genetic) AHS - M2179 Prenatal Screening (Nongenetic) AHS - G2035 Prenatal Testing for Fetal Aneuploidy AHS - G2055 Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS - T2015 Prostate Biopsy Specimen Analysis AHS – G2007 Prostate Specific Antigen (PSA) Testing AHS - G2008 Proteogenomic Testing of Individuals with Cancer AHS - M2168 Red Blood Cell Molecular Testing AHS - M2170 Salivary Hormone Testing AHS - G2120 Serum Testing for Evidence of Mild Traumatic Brain Injury AHS - G2151 Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS - G2110 Serum Tumor Markers for Malignancies AHS - G2124 Testing for 5-Fluorouracil Use in Cancer Patients AHS - M2067 Testing for Alpha-1 Antitrypsin Deficiency AHS - M2068 Testing for Colorectal Cancer Management AHS - M2026 Testing for Developmental Delay AHS - M2176 Testing for Diagnosis of Active or Latent Tuberculosis AHS - G2063 Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030 Testing for Vector-Borne Infections AHS – G2158 Testing of Homocysteine Metabolism Related Conditions AHS - M2141 Testosterone AHS – G2013 Thyroid Disease Testing AHS – G2045 Transplant Rejection Testing AHS - M2091 Urinary Tumor Markers for Bladder Cancer AHS - G2125 Urine Culture Testing for Bacteria AHS - G2156 Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer AHS - M2126 Venous and Arterial Thrombosis Risk Testing AHS - M2041 Vitamin B12 and Methylmalonic Acid Testing AHS - G2014 Vitamin D Testing AHS - G2005 Whole Genome and Whole Exome Sequencing AHS – M2032
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse Allergy Immunotherapy (Desensitization) Allergy Skin and Challenge Testing Ambulance and Medical Transport Services Ambulatory Event Monitors and Outpatient Cardiac Telemetry Amniotic Membrane and Amniotic Fluid Injections for Ophthalmic Indications Anesthesia Services Aqueous Shunts and Devices for Glaucoma Autonomic Nervous System Testing Baroreflex Stimulation Devices Bioimpedance Devices for Detection of Lymphedema Bone Mineral Density Studies Capsule Endoscopy, Wireless Cardiac Monitoring Devices in the Outpatient Setting Carotid Intimal-Medial Thickness Chelation Therapy Chemoembolization of the Hepatic Artery, Transcatheter Approach Complementary and Alternative Medicine Computerized Corneal Topography Convection-Enhanced Delivery of Therapeutic Agents to the Brain Corneal Collagen Cross-linking Diagnosis and Treatment of Sacroiliac Joint Pain Dynamic Posturography Electrodiagnostic Studies Electrogastrography, Cutaneous Electromagnetic Navigation Bronchoscopy Electrostimulation and Electromagnetic Therapy for Wounds Enhanced External Counterpulsation (EECP) Enteral Nutrition Epidural Steroid Injections for Back Pain Epiretinal Radiation Therapy for Age-Related Macular Degeneration Esophageal pH Monitoring Extracorporeal Photopheresis Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Fundus Photography Glaucoma, Evaluation by Ophthalmologic Techniques Growth Factors in Wound Healing Hemodialysis Treatment for ESRD Hyperbaric Oxygen Therapy Inpatient Interfacility Transfers Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) Intradialytic Parenteral Nutrition Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders Intravenous Antibiotic Therapy for Lyme Disease Keratoprosthesis Maternal and Fetal Diagnostics Non-Contact Ultrasound Treatment for Wounds Non-Pharmacologic Treatment of Rosacea Observation Room Services Optical Coherence Tomography (OCT) Anterior Segment of the Eye Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence Polysomnography for Non‒Respiratory Sleep Disorders Quantitative Sensory Testing Remote Electrical Neuromodulation for Migraines Remote Therapeutic and Physiologic Monitoring Signal-Averaged ECG Skilled Nursing Facility Care Sleep Apnea: Diagnosis and Medical Management Stem-cell Therapy for Peripheral Arterial Disease Synthetic Cartilage Implants for Joint Pain TENS (Transcutaneous Electrical Nerve Stimulator) Tinnitus Treatment Tumor Treatment Fields Therapy Vestibular Function Testing
Ablative Techniques for the Myolysis of Uterine Fibroids Hormone Pellet Implantation for Treatment of Menopause Related Symptoms Infertility Diagnosis and Treatment – B0006 Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy
Chiropractic Services Dry Needling of Myofascial Trigger Points Focal Treatments for Prostate Cancer Functional Capacity Assessment and Work Hardening Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus Orthopedic Applications of Stem Cell Therapy Orthotics Sensory Integration Therapy and Auditory Integration Therapy Skin and Soft Tissue Substitutes Spinal Manipulation Under Anesthesia Vertebral Axial Decompression (VAD-X)
Beta Amyloid Imaging with Positron Emission Tomography for Alzheimer’s Disease BioZorb® Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer Computed Tomography to Detect Coronary Artery Calcification Electronic Brachytherapy for Nonmelanoma Skin Cancer Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Intensity Modulated Radiation Therapy (IMRT) of the Chest Intensity Modulated Radiation Therapy (IMRT) of the Prostate Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System Magnetic Resonance Spectroscopy Monoclonal Antibody Imaging for Prostate Cancer MRI-Guided Focused Ultrasound (MRgFUS) Myocardial Sympathetic Innervation Imaging Perirectal Spacer Use During Radiotherapy for Prostate Cancer Positional Magnetic Resonance Imaging (MRI) Proton Beam Therapy Radioembolization for Primary and Metastatic Tumors of the Liver Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) Therapeutic Radiopharmaceuticals in Oncology Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous
Add-On Codes Advanced Illness / Advance Directives Ambulance Reimbursement Policy Ambulatory Surgical Center (ASC) Reimbursement Anesthesia Services, Professional And Facility Bundling Guidelines Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant At-Surgery Guidelines Consistency Guidelines Developmental Delay Screening and Testing Guidelines Diagnosis Validity & Code Guidelines Documentation Requirements for Treatment of End Stage Renal Disease Drug and Biologicals ECG Reimbursement Evaluation and Management Services Facility Behavioral Health Facility Billing Guidelines Facility Emergency Department E&M Services Genetic and Molecular Testing Global Surgery Group Visit (Shared Medical Appointment) Guidelines Guidelines for Global Maternity Reimbursement Immunization Guidelines Inpatient Readmissions Interfacility Transfer Maximum Units of Service Modifier Guidelines Multiple and Bilateral Surgery Multiple Endoscopy Services Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures Multiple Therapy Services NCCI Editing NDC Requirements Nonpayment for Serious Adverse Events Observation, Facility Once In a Lifetime Opioid Treatment Program Reimbursement Outpatient Code Editor (OCE) Edits Overuse Place of Service Preadmission and Preoperative Services Pricing and Adjudication Principles Radiation Therapy Services Radiology Reductions for Technology Type Radiology Services Reimbursement Policy Reduced and Discontinued Services Removal of Impacted Cerumen Revenue Codes Requiring Procedure Codes, Facility Services Bundled into Inpatient / Outpatient Stays Split Surgical Package Status Codes Supply and Equipment Telehealth Unplanned Return to Surgery
Abdominoplasty and Panniculectomy Ablation and Neural Therapy Procedures for Headache and Pain Management Artificial Intervertebral Disc Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions Autologous Chondrocyte Implantation Automated Percutaneous and Endoscopic Discectomy Balloon Dilation of the Eustachian Tube Balloon Ostial Dilation (Balloon Sinuplasty) Bariatric Surgery Bone Morphogenetic Protein Breast Surgeries Bronchial Thermoplasty Cardiac (Heart) Transplantation Carotid Artery Angioplasty/Stenting (CAS) Cervical Spine Procedures Chromoendoscopy as an Adjunct to Colonoscopy Cochlear Implant Composite Allotransplantation of the Hand and Face Computer Assisted Surgical Navigational Orthopedic Procedures Confocal Laser Endomicroscopy Congenital Heart Defect, Repair Devices Cord Blood as a Source of Stem Cells Cosmetic and Reconstructive Surgery Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Cryosurgical Ablation of Primary or Metastatic Liver Tumors Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services Dental Reconstructive Services Electrical Bone Growth Stimulation Endobronchial Valves Endovascular Procedures for Intracranial Arterial Disease Facet Joint Denervation Gastric Electrical Stimulation Gastroesophageal Reflux Disease, Transendoscopic Therapies Gender Affirmation Surgery Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery Heart-Lung Transplantation Hematopoietic Cell Transplantation Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis Implantable Bone Conduction Hearing Aids Implantable Cardioverter Defibrillator Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence Injection Therapy for Headache (Migraine and Other) and Non-Spine Management Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Interspinous Fixation (Fusion) Devices Intraoperative Neurophysiologic Monitoring Islet Cell Transplantation Laser Treatment of Port Wine Stains Leadless Cardiac Pacemakers Liver Transplant and Combined Liver-Kidney Transplant Lumbar Spine Procedures Lung and Lobar Lung Transplantation Lung Volume Reduction Surgery Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD) Meniscal Allografts and Other Meniscal Implants MRI-guided Laser Interstitial Thermal Therapy for Neurological Indications Occipital Nerve Stimulation Orthodontics for Pediatric Patients Orthognathic Surgery Pancreas Transplant Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty Penile Prosthesis Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS) Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia Phrenic Nerve Stimulation for Central Sleep Apnea Plugs for Fistula Repair Prostatic Urethral Lift Radiosurgery, Stereotactic Approach Reconstructive Eyelid Surgery and Brow Lift Refractive Surgery Renal (Kidney) Transplantation Renal Denervation as a Treatment of Hypertension Retinal Prosthesis Rhinoplasty Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Sacroiliac Joint Fusion/Stabilization Semi-Implantable and Fully Implantable Middle Ear Hearing Aid Septoplasty Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Spinal Cord and Dorsal Root Ganglion Stimulation Subtalar Arthroereisis Surgery for Femoroacetabular Impingement Surgery for Groin Pain in Athletes Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Surgical Deactivation of Headache Trigger Sites Surgical Management of Transcatheter Heart Valves Surgical Treatment for Lipedema Surgical Treatment of Chest Wall Deformities (Congenital or Acquired) Surgical Treatment of Sinus Disease Surgical Treatments for Lymphedema Surgical Ventricular Restoration Temporomandibular Joint Dysfunction (TMJD) Three Dimensional Printed Orthopedic Implants Total Facet Arthroplasty Transanal Endoscopic Microsurgery (TEMS) Transcatheter Closure of Ventricular Septal Defects Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia Vagus Nerve Stimulation Varicose Veins of the Lower Extremities, Treatment for Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents Viscocanalostomy and Canaloplasty Whole Gland Ablative Treatments of Prostate Cancer
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Dermatologic Applications of Photodynamic Therapy Rehabilitative Therapies Speech Generating Devices Trigger Point and Tender Point Injections
Amvuttra (vutrisiran) (PDF) Medicare Part B Prior Authorization (PDF) Medicare Part B Step Therapy (PDF) Non-Formulary Exception Criteria (PDF) Onpattro (PDF) Oxlumo (PDF)
Power Enhanced, Robotic Assisted and/or Microprocessor Upper and Lower Extremity Rehabilitative Devices (MyoPro/IpSiHand/Motus) Upper Limb Prosthetics
Foresee Home AMD Monitoring Transportation and Lodging Related to Transplants
Add-On Codes Ambulance Reimbursement Policy Anesthesia, Professional and Facility Bundling Guidelines Co-Surgeon, Assistant Surgeon, Team Surgeon, and Assistant-at-Surgery Guidelines Consistency Guidelines Diagnosis Validity & Coding Guidelines Drug and Biologicals Evaluation and Management Services Facility Billing Guidelines Facility Emergency Department E&M Services Global Surgery Immunization Guidelines Inpatient Readmissions Maximum Units of Service Modifier Guidelines Multiple Procedure Payment Reduction Guidelines NCCI Editing NDC Requirements Nonpayment For Serious Adverse Events Observation, Facility Once in a Lifetime Opioid Treatment Program Reimbursement Outpatient Code Editor (OCE) Edits Partial Hospitalization and Intensive Outpatient Programs Place of Service Preadmission And Preoperative Services Pricing and Adjudication Principles Reduced and Discontinued Services Revenue Codes Requiring Procedure Codes, Facility Split Surgical Package Status Codes Supply and Equipment Reimbursement MA Telehealth Unplanned Return to Surgery
Orthognathic Surgery Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation Refractive Surgical Procedures Temporomandibular Joint Dysfunction Surgery