| Medical Guidelines | Reason for Update |
|---|---|
| Biomarkers for Myocardial Infarction and Chronic Heart Failure AHS - G2150 | Reviewed by Avalon 3rd Quarter 2025 CAB. Description, Policy Guidelines and References updated. No change to policy statement. Medical Director review 7/2025. |
| Cardiovascular Disease Risk Assessment AHS – G2050 | Reviewed by Avalon 3rd Quarter 2025 CAB. Policy Guidelines and References updated. Updates to the When Covered section: Coverage criteria 3 now reads "3) Reimbursement is allowed for measurement of lipoprotein a (Lp(a)) once per lifetime (with measurement occurring when the individual is 18 years of age or older).", coverage criteria 4 subcriteria now reads "a) One test for initial screening. b) If the initial screen was abnormal, confirmatory testing no sooner than two weeks after the initial test. c) Annual screening for those with elevated hs-CRP that has been confirmed." Updates to Not Covered section: bullet point 1 updated and now reads "Hs-CRP testing for all other cardiovascular disease risk assessments not described above.", added new bullet point 2 "Conventional CRP testing for cardiovascular disease risk assessment." Note 2 edited for clarity. Medical Director review 7/2025. |
| Children's Mobility and Positioning Equipment | Added under Description section: Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician. References updated. Specialty Matched Consultant Advisory Panel review 9/2025. Medical Director review 9/2025. |
| Chiropractic Services | Removed related policy “Paraspinal Surface Electromyography (SEMG)” as policy has been archived. References updated. Specialty Matched Consultant Advisory Panel 9/2025. Medical Director review 9/2025. |
| Chromosomal Microarray and Low-pass Whole Genome Sequencing AHS - M2033 | Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Related Policies, Policy Guidelines, and References updated. Added 0209U to Billing/Coding section. No change to policy statement. Medical Director review 7/2025. |
| Coronavirus Testing in the Outpatient Setting AHS - G2174 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, Policy Guidelines, and References sections. Updated When Covered section to remove “Reimbursement for individuals with signs and symptoms of a respiratory tract infection (see Note 4), antigen panel testing of up to 5 antigens is allowed” and Note 4. Updated When Not Covered section to remove “Reimbursement is not allowed for antigen panel testing of 6 or more antigens.” Updated Billing/Coding section to remove 86318 and 87428. Medical Director review 7/2025. |
| Dermatologic Applications of Photodynamic Therapy | Description, Policy Guidelines, and References updated. Specialty Matched Consultant Advisory Panel review 9/2025. Medical Director review 9/2025. No change to policy statement. |
| Dry Needling of Myofascial Trigger Points | Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 09/2025. Medical Director review 09/2025. |
| Durable Medical Equipment (DME) | References updated. Specialty Matched Consultant Advisory Panel 9/2025. Medical Director review 9/2025. |
| Folate Testing AHS - G2154 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, references, and policy guidelines. Updated coverage criteria to allow serum folic acid testing for all types of anemia and for those who will or who have already undergone bariatric procedures. Medical Director review 7/2025. |
| Functional Capacity Assessment and Work Hardening | References updated. Specialty Matched Consultant Advisory Panel 9/2025. Medical Director review 9/2025. |
| Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 | Reviewed by Avalon 3rd Quarter 2025 CAB. Medical Director review 9/2025. Updated policy guidelines, guidelines and recommendations, and references. Added the following CPT codes to Billing/Coding section: 0591U, 0534U, 0550U, 0572U, 84153, 84154, 86316; deleted CPT codes: 0053U, 0558U, 0559U. Deleted Oncotype Dx throughout the policy. New name is (GPS) Genomic Prostate Score. Notes 3 & 4: edited and added new conditions and contraindications for prostate biopsy; Note 7: new note added. Under “When Covered” section: edited and clarified statements and added #6 coverage for use with Prostate Health index. |
| General Inflammation Testing AHS - G2155 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, Policy Guidelines, Related Policies, and Reference sections. Updated when covered section for clarity. Added the following statement to Note 1 under when covered section: “If CRP and ESR are ordered at the same time for a condition where CRP or ESR are allowed, only CRP will be approved.” Medical Director review 7/2025. |
| Genetic Markers for Assessing Risk of Cardiovascular Disease AHS - M2180 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Policy Guidelines, and References. No change to policy statement. Medical Director review 7/2025. |
| Genetic Testing for Alpha- and Beta- Thalassemia AHS - M2131 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, Policy Guidelines, and References. No changes to policy statement. Medical Director review 7/2025. |
| Genetic Testing for Cystic Fibrosis AHS – M2017 | Reviewed by Avalon 3rd Quarter 2025 CAB. Policy Guidelines and References updated. Updates to the When Covered and Not Covered sections: CC1, 2, 3, and 5, changed “comprehensive gene sequencing for mutations in the CFTR gene” to “comprehensive analysis of the CFTR gene (i.e., full gene sequencing, deletion/duplication analysis)”, CC2, changed “mutations” to “pathogenic/likely pathogenic” to align with updated nomenclature for inherited variants. Combined CC2b and CC2c into single CC2b; now reads: “b. When one or more familial P/LP variants are known; testing must include the familial P/LP variants.” CC4, CC5, and Not Covered criteria changed “mutation” to “variant”, new CC6: “6. For the family members of individuals with CFTR-related metabolic disorder/cystic fibrosis screen positive, inconclusive diagnosis (CRMS/CFSPID), comprehensive analysis of the CFTR gene (i.e., full gene sequencing, deletion/duplication analysis) is covered in any of the following situations: a. For parents of the individual: When phasing of the CFTR variants would inform the diagnostic status of the individuals by confirming the inheritance pattern. b. For siblings of the individual.” Codes 96040 and S0265 removed from the Billing/Coding section. Medical Director review 7/2025. |
| Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies AHS – M2072 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Policy Guidelines and References. The following edits were made to the When Covered section for clarity: replaced mutation with “pathogenic or likely pathogenic (P/LP) variants” in coverage criteria 1, 2, 4, 5, Note 1 edited to write out “first”, “second”, and “third” for consistency, Note 2 edited to change “2” to “two”. No change to policy statement. Medical Director review 7/2025. |
| Genetic Testing for Familial Alzheimer’s Disease AHS – M2038 | Reviewed by Avalon 3rd Quarter 2025 CAB. Policy Guidelines updated without change to policy intent. References updated. Medical Director review 7/2025. |
| Genetic Testing for Familial Hypercholesterolemia AHS – M2137 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Policy Guidelines and References. Updates to When Covered section: CC1 rewritten to clearly define what clinical suspicions warrant genetic testing for FH. Now reads: “1) For individuals without an apparent secondary cause of hypercholesterolemia (Note 1), genetic testing for pathogenic or likely pathogenic (P/LP) variants for familial hypercholesterolemia (FH) (see Note 2) is considered medically necessary when one of the following conditions is met: a. For individuals who are less than 18 years of age and who had had two or more measurements of LDL-C levels ≥190 mg/dl. b For individuals who are 18 years of age or older and who had had two or more measurements of LDL-C levels ≥250 mg/dl c. For individuals who are less than 18 years of age and who have had two or more measurements of LDL-C levels ≥160 mg/dl and who have at least one of the following: i. A first-degree relative (see Note 3) who is similarly affected. ii. A first-degree relative (see Note 3) who has been diagnosed with premature CAD (see Note 4). iii. An unavailable family history (e.g., adoption). d. For individuals who are 18 years of age or older and who have had two or more measurements of LDL-C levels ≥190 mg/dl and who have at least one of the following: i. A first-degree relative (see Note 3) who is similarly affected. ii. A first-degree relative (see Note 3) who has been diagnosed with premature CAD (see Note 4). iii. An unavailable family history (e.g., adoption).” New CC2: “2. For individuals with suspected FH who have already tested negative for P/LP variants in LDLR, APOB, and PCSK9 using a limited three gene panel, testing for P/LP variants in LDLRAP1is considered medically necessary.” Former CC2, now CC3, changed “known familial mutation” to “known familial P/LP variant” for clarity. Added new Notes 1,2, and 4: “Note 1: Apparent secondary causes of hypercholesterolemia include hypothyroidism, diabetes, renal disease, nephrotic syndrome, liver disease, and medications. Note 2: “Genetic testing for patients with suspected FH should, at a minimum, include analysis of LDLR, APOB, and PCSK9. This analysis should include for LDLR and PCSK9 sequencing of all exons and exon/intron boundaries, as well as LDLR deletion/duplication analysis, and for APOB the exons encoding the LDLR ligand-binding region.” When larger, more inclusive lipid disorder panels are ordered, “they should include the following genes: LDLR, APOB, PCSK9, LDLRAP1, LIPA, ABCG5, ABCG8, and APOE.” Note 4: Development of CAD is considered premature when it develops in male subjects who are less than 56 years of age and when it develops in female subjects who are less than 66 years of age.” Former Note 1, now Note 3, changed “1st”, “2nd”, and “3rd” degree to “first”, “second”, and “third” degree for consistency. New Note 6: “Note 6: If LDL-C values are unavailable, the following total cholesterol values could be used: • Total cholesterol levels of ≥320 mg/dL, corresponding to LDL-C levels ≥250 mg/dL. • Total cholesterol levels of ≥260 mg/dL, corresponding to LDL-C levels ≥190 mg/dL. • Total cholesterol levels of ≥230 mg/dL, corresponding to LDL-C levels ≥160 mg/dL.” Medical Director review 7/2025. |
| Genetic Testing for Hereditary Hearing Loss AHS – G2148 | Reviewed by Avalon 3rd Quarter 2025 CAB. Description, Policy Guidelines and References updated. Not Covered section edited for clarity: added “repeat” to first criteria which now reads “Repeat genetic testing for hereditary hearing loss-related mutations more than once per lifetime is considered not medically necessary.” Changes to Billing/Coding section: Note edited to change “2 to “two”, codes 81403 and 81479 added, codes 81252, 81254, and S3844 removed. Medical Director review 7/2025. |
| Genetic Testing for Hereditary Pancreatitis AHS – M2079 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, Policy Guidelines and References. Minor edits made to the When Covered section for clarity, no change to policy statement. Medical Director review 7/2025. |
| Genetic Testing for Lactase Insufficiency AHS – M2080 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, Policy Guidelines, and References. No changes to policy statement. Medical Director review 7/2025. |
| Genetic Testing for Li-Fraumeni Syndrome AHS – M2081 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, Policy Guidelines, and References. When Covered section under number 2 ii a changed “age 46 years” to “46 years of age”. No changes to coverage criteria. Added CPT code 81479 to Billing/Coding section. Medical Director review 7/2025. |
| Genetic Testing for Neurofibromatosis and Related Disorders AHS – M2134 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, Policy Guidelines, and References. Under when covered section #8 changed from “For individuals 25 years and younger who have at least two hyperpigmented skin patches” to “For individuals who have at least two hyperpigmented skin patches”. Medical Director review 7/2025. |
| Genetic Testing for Ophthalmologic Conditions AHS-M2083 | Reviewed by Avalon Q3 2025 CAB. Medical Director review 9/2025. Updated policy guidelines, guidelines and recommendations, and references. Under Billing/Coding section: added CPT codes 81415, 81416, 81417, 81425, 81426 and deleted CPT 81599. |
| Genetic Testing for PTEN Hamartoma Tumor Syndrome AHS – M2087 | Reviewed by Avalon 3rd Quarter 2025 CAB. Description, Policy Guidelines and References sections updated. Updated Note 1 “Major Testing Criteria” to align with major criteria as defined by the NCCN. Updated “Minor Testing Criteria” to replace “≥3” with “three or more” for consistency across policies. Medical Director review 7/2025. |
| Genome and Exome Sequencing AHS – M2032 | Reviewed by Avalon 3rd Quarter 2025 CAB. Policy title changed to Genome and Exome Sequencing. Removed “whole” from policy statement which now reads “BCBSNC will provide coverage for genome sequencing and exome sequencing when it is determined the medical criteria or reimbursement guidelines below are met.” Changed “whole genome sequencing/WGS” to “genome sequencing/GS” and “whole exome sequencing/WES” to “exome sequencing/ES” in all coverage criteria where references to either were found. Description, Policy Guidelines and References updated. Billing/Coding section updated to remove code 0209U. Medical Director review 7/2025. |
| Molecular Profiling for Cancers of Unknown Primary Origin AHS- M2065 | Reviewed by Avalon 3rd Quarter 2025 CAB. Medical Director review 9/2025. Updated description, policy guidelines, guidelines and recommendations and references. |
| Non-Pharmacologic Treatment of Rosacea | Description, Policy Guidelines, and references updated. Specialty Matched Consultant Advisory Panel review 9/2025. No change to policy statement. Medical Director review 9/2025. |
| Pathogen Panel Testing AHS – G2149 | Reviewed by Avalon 3rd Quarter 2025 CAB. Description, Policy Guidelines and References updated. Updates to the When Covered section: coverage criteria 2 edited to add antigen panel testing and moved respiratory infection signs/symptoms to new Note 1 and now reads "Reimbursement is allowed for panel testing of up to 5 respiratory pathogens (antigen panel testing or multiplex PCR-based panel testing) for individuals who are displaying signs and symptoms of a respiratory tract infection (see Note 1)." Updates to Not Covered section: coverage criteria 2 edited to add antigen panel testing and now reads "2. Reimbursement is not allowed for antigen panel testing or multiplex PCR-based panel testing of 6 or more respiratory pathogens." Updates to Billing/Coding section: added code 87428 and removed codes 0240U, 0241U, 0369U, 0370U, 0373U and 0374U. Added codes 0590U and 0593U, effective 10/1/25. Medical Director review 7/2025. |
| Patient Lifts | References updated. Specialty Matched Consultant Advisory Panel review 9/2025. Medical Director review 9/2025. |
| Prenatal Screening (Genetic) AHS - M2179 | Reviewed with Avalon Q3 CAB 2025. Updated description, related policies, policy guidelines, and references. Updated Billing/Coding section to add 81252, 81253, and S3844. Medical Director review 7/2025. |
| Pressure Reducing Support Surfaces | References updated. Specialty Matched Consultant Advisory Panel 9/2025. Medical Director review 9/2025. |
| Red Blood Cell Molecular Testing AHS - M2170 | Reviewed by Avalon 3rd Quarter 2025 CAB. Medical Director review 9/2025. Updated description, policy guidelines, guidelines and recommendations and references. |
| Rehabilitative Therapies | References updated. Specialty Matched Consultant Advisory Panel review 9/2025. Medical Director review 9/2025. |
| Serum Testing for Evidence of Mild Traumatic Brain Injury AHS - G2151 | Reviewed by Avalon 3rd Quarter 2025 CAB. When Not Covered Section updated for clarity as follows: “Panels designed to measure biomarkers of TBI (e.g., i-STAT TBI Plasma, Alinity® i TBI) are considered investigational” removed from the first criterion and is now a stand-alone criterion. Policy Guidelines updated without change to policy intent. Added PLA code 0570U to the Billing/Coding section. References updated. Medical Director review 7/2025. |
| Serum Tumor Markers for Malignancies AHS - G2124 | Reviewed by Avalon Q3 2025 CAB. Medical Director review 9/2025. Added code 0599U to Billing/Coding section for effective date 10/1/25. Under “when covered” section, added indications for testing of serum biomarkers, which include: uveal melanoma, occult primary workup for adenocarcinoma, chorionic gonadotropin beta polypeptide CGB3, human epididymis protein 4 HEA. Updated policy guidelines, guidelines and recommendations, added and updated references. |
| Speech Generating Devices | Specialty Matched Consultant Advisory Panel review 9/2025. Medical Director review 9/2025. |
| Testing for Colorectal Cancer Management AHS - M2026 | Reviewed by Avalon Q3 2025 CAB. Medical Director review 9/2025. Updated policy guidelines, guidelines and recommendations and references. |
| Wheelchairs (Manual and Power Operated) | Added Children’s Mobility and Positioning Equipment to Related Policies section. References updated. Specialty Matched Consultant Advisory Panel 9/2025. Medical Director review 9/2025. |
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語
© 2025 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.