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.

1.01.02 Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
1.01.05 Low Intensity Pulsed Ultrasound Fracture Healing Device
1.01.06 Home Cardiorespiratory Monitoring
1.01.09 Transcutaneous Electrical Nerve Stimulation and Transcutaneous Afferent Patterned Stimulation
1.01.15 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
1.01.16 Negative Pressure Wound Therapy in the Outpatient Setting
1.01.17 Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
1.01.18 Compression Pumps for Treatment of Lymphedema and Venous Ulcers
1.01.20 Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
1.01.23 Transtympanic Micropressure Applications as a Treatment of Meniere Disease
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
1.03.05 Patient-Controlled End of Range Motion Stretching Devices
1.04.04 Myoelectric Prosthetic and Orthotic Components for the Upper Limb
1.04.05 Microprocessor-Controlled Prostheses for the Lower Limb
2.01.02 Dynamic Posturography
2.01.04 Hyperbaric Oxygen Therapy
2.01.16 Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions
2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome
2.01.20 Esophageal pH Monitoring
2.01.21 Temporomandibular Joint Disorder
2.01.26 Prolotherapy
2.01.35 Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain
2.01.38 Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
2.01.39 Quantitative Sensory Testing
2.01.40 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
2.01.44 Dermatologic Applications of Photodynamic Therapy
2.01.47 Light Therapy for Psoriasis
2.01.49 Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy
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
2.01.57 Electrostimulation and Electromagnetic Therapy for Treating Wounds
2.01.58 Transanal Radiofrequency Treatment of Fecal Incontinence
2.01.68 Laboratory Tests Post Transplant and for Heart Failure
2.01.71 Nonpharmacologic Treatment of Rosacea
2.01.73 Actigraphy
2.01.77 Automated Point-of-Care Nerve Conduction Tests
2.01.79 Noncontact Ultrasound Treatment for Wounds
2.01.80 Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
2.01.81 Ingestible pH and Pressure Capsule
2.01.82 Bioimpedance Devices for Detection and Management of Lymphedema
2.01.83 Interventions for Progressive Scoliosis
2.01.84 Chromoendoscopy as an Adjunct to Colonoscopy