Medical Policies

The policies contained in the FEP Medical Policy Manual are developed to assist in administering contractual benefits and do not constitute medical advice. They are not intended to replace or substitute for the independent medical judgment of a practitioner or other health care professional in the treatment of an individual member. The Blue Cross and Blue Shield Association does not intend by the FEP Medical Policy Manual, or by any particular medical policy, to recommend, advocate, encourage or discourage any particular medical technologies. Medical decisions relative to medical technologies are to be made strictly by members/patients in consultation with their health care providers. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that the Blue Cross and Blue Shield Service Benefit Plan covers (or pays for) this service or supply for a particular member.

1.01.05 Low Intensity Pulsed Ultrasound Fracture Healing Device
1.01.09 Transcutaneous Electrical Nerve Stimulation
1.01.15 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
1.01.17 Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
1.01.18 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
1.01.24 Interferential Current Stimulation
1.01.26 Cooling Devices Used in the Outpatient Setting
1.01.27 Electrical and Electromagnetic Stimulation for the Treatment of Arthritis
1.01.28 Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
1.01.29 Tumor Treating Fields Therapy
1.01.30 Artificial Pancreas Device Systems
1.01.35 Digital Health Therapies for Substance Use Disorders
1.03.04 Powered Exoskeleton for Ambulation in Patients with Lower-Limb Disabilities
1.04.04 Myoelectric Prosthetic and Orthotic Components for the Upper Limb
1.04.05 Microprocessor-Controlled Prostheses for the Lower Limb
2.01.04 Hyperbaric Oxygen Therapy
2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome
2.01.21 Temporomandibular Joint Disorder
2.01.26 Prolotherapy
2.01.39 Quantitative Sensory Testing
2.01.40 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
2.01.50 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
2.01.54 Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
2.01.56 Low Level Laser Therapy
2.01.68 Laboratory Tests Post Transplant and for Heart Failure
2.01.73 Actigraphy
2.01.84 Chromoendoscopy as an Adjunct to Colonoscopy
2.01.87 Confocal Laser Endomicroscopy
2.01.89 Laser Treatment of Onychomycosis
2.01.91 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis
2.01.98 Orthopedic Applications of Platelet-Rich Plasma
2.01.99 Polysomnography for Non-Respiratory Sleep Disorders
2.01.100 Dry Needling of Trigger Points for Myofascial Pain
2.01.105 Dry Hydrotherapy for chronic pain conditions
2.02.08 Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
2.02.10 Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
2.02.30 Transcatheter Mitral Valve Repair or Replacement
2.02.31 Myocardial Strain Imaging
2.02.32 Leadless Cardiac Pacemakers
2.04.02 Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
2.04.07 Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance
2.04.08 Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
2.04.10 Identification of Microorganisms Using Nucleic Acid Probes
2.04.13 Genetic Testing for Alzheimer Disease
2.04.14 Evaluation of Biomarkers for Alzheimer Disease
2.04.15 Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover
2.04.19 Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines
2.04.23 Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disorders
2.04.26 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
2.04.29 Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening