| Medical Guidelines | Reason for Update |
|---|---|
| Adaptive Behavioral Treatment for Autism Spectrum Disorders | Specialty Matched Consultant Advisory Panel Review 6/2025. References added. No change to policy statement. Medical Director review 6/2025. |
| Ambulatory Event Monitors and Outpatient Cardiac Telemetry | References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Amniotic Membrane and Amniotic Fluid Injections for Ophthalmic Indications | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. References added. Edited related policy title “Meniscal Allograft and Collagen Meniscus Implants” to reflect title change from “collagen” to “other” meniscus implants. No change to policy statement. |
| Aqueous Shunts and Devices for Glaucoma | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. Reference added. No change to policy statement. |
| Artificial Pancreas Device Systems | Description and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions | Policy Guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Autologous Chondrocyte Implantation | Policy guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Cardiac (Heart) Transplantation | Description, Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Carotid Artery Angioplasty/Stenting (CAS) | References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Computer Assisted Surgical Navigational Orthopedic Procedures | References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Computerized Corneal Topography | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. Reference added. No change to policy statement. |
| Congenital Heart Defect, Repair Devices | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Continuous Monitoring of Glucose in the Interstitial Fluid | Description, policy guidelines, and references updated. Updated When Covered section to remove the requirement for “multiple daily doses of insulin.” Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Continuous Passive Motion in the Home Setting | References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Corneal Collagen Cross-linking | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. References added. No change to policy statement. |
| Electrical Bone Growth Stimulation | References updated. Minor wording edits. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Epiretinal Radiation Therapy for Age-Related Macular Degeneration | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. References added. No change to policy statement. |
| Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing | Policy Guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director Review 6/2025. |
| Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. References added. No change to policy statement. |
| Fundus Photography | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. No change to policy statement. |
| Glaucoma, Evaluation by Ophthalmologic Techniques | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. References added. No change to policy statement. |
| Implantable Cardioverter Defibrillator | Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) | References added. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. No changes to policy statement or intent. |
| Islet Cell Transplantation | Description, policy guidelines, and references updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. No changes to policy statement or intent. |
| Keratoprosthesis | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. No change to policy statement. |
| Medically Monitored Inpatient Withdrawal Management | Specialty Matched Consultant Advisory Panel Review 6/2025. References added. No change to policy statement. Medical Director review 6/2025. |
| Meniscal Allografts and Other Meniscal Implants | Regulatory status updated to include information regarding RejuvaKnee™. References updated. Specialty Matched Consultant Advisory Panel review 06/2025. Medical Director review 6/2025. |
| Myoelectric Prosthetic Components for the Upper Limb | Updated Regulatory Status. References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Optical Coherence Tomography (OCT) Anterior Segment of the Eye | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. Reference added. No change to policy statement. |
| Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty | Updated Regulatory Status to include UNIKO PointCloud Knee Instruments. References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Psychiatric Intensive Outpatient Programs | References added. Updated Billing/Coding section for clarity and alignment with reimbursement policy. No changes to policy statement. Specialty Matched Consultant Advisory Panel Review 6/2025. Medical Director review 6/2025. |
| Psychiatric Partial Hospitalization Programs | References added. Updated Billing/Coding section for clarity and alignment with reimbursement policy. No changes to policy statement. Specialty Matched Consultant Advisory Panel Review 6/2025. Medical Director review 6/2025. |
| Refractive Surgery | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. Updated policy guidelines and removed reference to CMP “Phototherapeutic Keratoplasty” as that policy was archived. Reference added. No change to policy statement. |
| Remote Electrical Neuromodulation for Migraines | New policy developed. Remote Electrical Neuromodulation for Migraines is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures. Specialty Matched Consultant Review 5/2025. Medical Director Review 5/2025. Notification given 5/14/2025 for effective date 7/16/2025. |
| Renal Denervation as a Treatment of Hypertension | Title changed to Renal Denervation as a Treatment of Hypertension. Policy statement updated and now reads: “Radiofrequency ablation and ultrasound ablation of the renal sympathetic nerves are considered investigational. BCBSNC does not provide coverage for investigational services or procedures.” Description and Policy Guidelines sections updated to include information regarding ultrasound renal denervation. Regulatory and References sections updated. Not Covered section updated and now reads “Radiofrequency ablation and ultrasound ablation of the renal sympathetic nerves are considered investigational for the treatment of uncontrolled hypertension.” Specialty Matched Advisory Panel review 4/2025. Medical Director review 4/2025. Notification given 5/14/25 for effective date 7/16/25. |
| Residential Treatment | Updated Related Policies. Added the following note to When Covered section: “Note: Treatment plan includes urine drug testing, if applicable.” References added. No change to policy statement. Specialty Matched Consultant Advisory Panel Review 6/2025. Medical Director review 6/2025. |
| Retinal Prosthesis | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. Reference added. No change to policy statement. |
| Sensory Integration Therapy and Auditory Integration Therapy | Description and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. No change to policy statement. |
| Substance Use Disorder Intensive Outpatient Programs | References added. Updated Billing/Coding section for clarity and alignment with reimbursement policy. Specialty Matched Consultant Advisory Panel Review 6/2025. Medical Director review 6/2025. No change to policy statement. |
| Substance Use Disorder Partial Hospitalization Programs | References added. Updated Billing/Coding section for clarity and alignment with reimbursement policy. Specialty Matched Consultant Advisory Panel Review 6/2025. Medical Director review 6/2025. No change to policy statement. |
| Surgery for Femoroacetabular Impingement | References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Surgery for Groin Pain in Athletes | References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Surgical Management of Transcatheter Heart Valves | Description, Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Surgical Ventricular Restoration | Description and References sections updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Topical Negative Pressure Therapy for Wounds | Description section updated and statement “The focus of this document is on use of NPWT in the outpatient setting.” updated to read “The focus of this document is on use of NPWT in the outpatient setting. It is recognized that individuals may begin using the device in the inpatient setting as they transition to the outpatient setting.” When covered section updated to indicate Chronic Wounds > 30 days this was previously > 90 days. Additional clarity added for Traumatic/Large wounds to indicate Traumatic or large surgical wounds (eg.laparotomy wounds) where with failure of immediate closure is not practical due to size of wound, contamination and/or location (ie perineum) or delayed primary closure; AND there is exposed bone, cartilage, tendon, fascia, or foreign material within the wound; AND no contraindications to negative pressure wound therapy. Contraindications moved from policy guidelines to When covered, exposed organ removed as contraindication. When Topical Negative Pressure Therapy for Wounds is not covered section updated to include “Incisional Negative Pressure Wound Therapy (iNPWT) devices (e.g., PICO Single Use Negative Pressure Wound Therapy System; Prevena Incision Management System) are considered not medically necessary when used over closed surgical wounds.” Policy guidelines updated to include the evidence on portable single-use NPWT of PICO device and Prevena Incision Management System. References updated. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. Notification given 05/14/25 for effective date 07/16/25. |
| Transcatheter Closure of Ventricular Septal Defects | When Covered section edited for clarity, no change to policy statement. References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | Regulatory status and policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. No change to policy statement. |
| Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs) | References added. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. No change to policy statement. |
| Vertebral Axial Decompression (VAD-X) | References updated. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. |
| Viscocanalostomy and Canaloplasty | Specialty Matched Consultant Advisory Panel review 6/18/2025. Medical Director review 6/2025. References added. No change to policy statement. |
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