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Blue Cross NC Home Providers Policies, guidelines and codes Commercial Medical Policy Update June 10, 2026 Commercial Medical Policy Update June 10, 2026

 

Medical Guidelines	Reason for Update
Automated Percutaneous and Endoscopic Discectomy	Archived medical policies have been removed from the Related Policies section.  References updated.  Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Beta Amyloid Imaging with Positron Emission Tomography for Alzheimer’s Disease	Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026. Policy archived.
BioZorb®	References updated. Specialty Matched Consultant Panel review 5/2026. Medical Director review 5/2026.
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer	Description, Policy Guidelines and References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Chemoembolization of the Hepatic Artery, Transcatheter Approach	Description and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026. No change to policy statement.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation	Policy Guidelines update without change of policy intent. Regulatory Status and References updated.  Specialty Matched Consultant Advisory Panel review 5/2026.  Medical Director review 5/2026.
Electronic Brachytherapy for Nonmelanoma Skin Cancer	Description, Policy Guidelines and References updated. Code 0394T removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Endovascular Procedures for Intracranial Arterial Disease	Formatting changes made to the “When Covered” section without change to policy intent. References updated.  Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis	References updated.  Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System	References updated. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities	References updated. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis	Description, Policy Guidelines and References updated. Updates to When Covered section: changed “Patients” to “Individuals”, added coverage criteria o. Seminoma. Removed testicular cancer from the statement in the Not Covered section which now reads “Intensity-modulated radiation therapy (IMRT) is considered not medically necessary for all other uses in the abdomen and pelvis.” Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck	Description section edited for clarity, References updated. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Intensity Modulated Radiation Therapy (IMRT) of the Chest	Description section edited for clarity, References updated. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Intensity Modulated Radiation Therapy (IMRT) of the Prostate	Description, Policy Guidelines and References updated. When Covered section edited to replace “patient” with “individual” throughout. No change to policy statement. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026. (tm)
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)	Description section revised.  References updated.  Medical Director review 5/2026.  Specialty Matched Consultant Advisory Panel review 5/2026.
Interspinous Fixation (Fusion) Devices	Policy Guidelines updated without change to policy intent.  Added CPT code 22899 to the Billing/Coding section.  References updated.  Medical Director review 5/2026.  Specialty Matched Consultant Advisory Panel review 5/2026.
Intraoperative Neurophysiologic Monitoring	Policy Guidelines updated without change to policy intent.  References updated.  Medical Director review 5/2026.  Specialty Matched Consultant Advisory Panel review 5/2026.
Magnetic Resonance Spectroscopy	Description updated. References added. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director Review 5/2026.  No change to policy statement.
MRI-Guided Focused Ultrasound (MRgFUS)	Description, Regulatory Status, and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026. No change to policy statement.
Myocardial Sympathetic Innervation Imaging	References added. Description updated.  Specialty Matched Consultant Advisory Panel review 5/2026.  Medical Director review 5/2026. No change to policy statement.
Occipital Nerve Stimulation	References updated.  Medical Director review 5/2026.  Specialty Matched Consultant Advisory Panel review 5/2026.
Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy	Updated Description to remove “This policy does not address isolated treatment of male gonadal veins or varicose veins of the lower extremities. Refer to policy titled “Varicose Veins of the Lower Extremities, Treatment for.”
Percutaneous Electrical Nerve Stimulation (PENS), Percutaneous Neuromodulation Therapy, Restorative Neurostimulation Therapy, and Percutaneous Electrical Nerve Field Stimulation (PENFS)	Policy title changed to “Percutaneous Electrical Nerve Stimulation (PENS), Percutaneous Neuromodulation Therapy, Restorative Neurostimulation Therapy, and Percutaneous Electrical Nerve Field Stimulation (PENFS).” Added the following policy statement: “Restorative neurostimulation therapy (ReActiv8) is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures.” Description, regulatory status, and policy guidelines updated. References added. Billing/Coding section updated to add 64555, 64585, 64596, 64597, 95970, 95971, 95972, C1767, and C9807, and to remove “Providers may submit claims for these services using the unlisted code 64999. Providers should not be using 64553-64565, or 64590 to bill this service as these codes are not appropriate.” Medical Director review 6/2026. No change to policy statement.
Perirectal Spacer Use During Radiotherapy for Prostate Cancer	Description, Policy Guidelines and References updated. Specialty Matched Consultant Panel review 5/2026. Medical Director review 5/2026.
Positional Magnetic Resonance Imaging (MRI)	References added. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026. No change in policy statement.
Proton Beam Therapy	Coverage criteria b. under the When Covered section edited to replace “patients” with “individuals”. Added new coverage criteria i. under When Covered section which reads “Localized tumors associated with genetic syndromes (i.e., Neurofibromatosis type 1, [NF-1], Li-Fraumeni, Ataxia Telangiectasia [with deleterious ATM mutations], Hereditary Retinoblastoma, Lynch syndrome, or Hereditary Breast or Ovarian Cancer [with BRCA1/2 mutations]).” References updated. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Radioembolization for Primary and Metastatic Tumors of the Liver	Description, Policy Guidelines and References updated. When Covered section edited to replace “patients” with “individuals” for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Radiosurgery, Stereotactic Approach	Description and References updated. Minor editing to the When Covered and Policy Guidelines sections for clarity. No change to policy statement, Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026.
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA)	Description updated. References added. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026. No change to policy statement.
Surgical Deactivation of Headache Trigger Sites	References updated. Medical Director review 5/2026.  Specialty Matched Consultant Advisory Panel review 5/2026.
Therapeutic Radiopharmaceuticals in Oncology	References added. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026. No change to policy statement.
Vagus Nerve Stimulation	Regulatory Status and Policy Guidelines sections updated. No change to intent of policy.  Added the following HCPCS code to the Billing/Coding section: C1827. References updated.   Medical Director review 5/2026.  Specialty Matched Consultant Advisory Panel review 5/2026.
Varicose Veins of the Lower Extremities, Treatment for	Updated note in Description section to remove the word “Gonadal.”  Updated Related Policies to correct title from “Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation and Sclerotherapy” to “Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy.”
Whole Body Computed Tomography Scan as a Screening Test	References added. Specialty Matched Consultant Advisory Panel review 5/2026. Medical Director review 5/2026. No change to policy statement.