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.

2.01.85 Neural Therapy
2.01.86 Light Therapy for Vitiligo
2.01.87 Confocal Laser Endomicroscopy
2.01.89 Laser Treatment of Onychomycosis
2.01.90 Navigated Transcranial Magnetic Stimulation
2.01.91 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis
2.01.92 Fecal Microbiota Transplantation
2.01.93 Antigen Leukocyte Antibody Test
2.01.94 Epidural Steroid Injections for Back Pain
2.01.96 Autonomic Nervous System Testing
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
2.01.101 Multispectral Digital Skin Lesion Analysis
2.01.105 Dry Hydrotherapy for chronic pain conditions
2.02.01 Catheter Ablation for Cardiac Arrhythmias
2.02.06 Enhanced External Counterpulsation (EECP)
2.02.08 Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
2.02.09 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
2.02.10 Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
2.02.15 Wearable Cardioverter Defibrillators
2.02.16 Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
2.02.18 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
2.02.19 Catheter Ablation as Treatment for Atrial Fibrillation
2.02.22 Ultrafiltration in Decompensated Heart Failure
2.02.23 Electrocardiographic Body Surface Mapping
2.02.24 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
2.02.25 Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease
2.02.26 Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
2.02.29 Optical Coherence Tomography for Imaging of Coronary Arteries
2.02.30 Transcatheter Mitral Valve Repair or Replacement
2.02.31 Myocardial Strain Imaging
2.02.32 Leadless Cardiac Pacemakers
2.03.01 In Vitro Chemoresistance and Chemosensitivity Assays
2.03.04 Melanoma Vaccines
2.03.07 Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
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 or RNA in Stool Samples as a Technique for Colorectal Cancer Screening
2.04.32 Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
2.04.33 Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
2.04.36 Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer