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2.0

Medicine

2.01 Medicine Introduction 

Medically
Necessary
and
Investigational

For Blue Cross of Idaho`s definition of medically necessary and investigational, please click here. 
2.01.01 Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., Clinical Ecology) 
2.01.02 Dynamic Posturography 
2.01.04 Hyperbaric Oxygen Pressurization (HBO)  
2.01.06 Hypnosis
2.01.07 Psoralens with Ultraviolet A (PUVA) in Psoriasis 
2.01.08 Rhinomanometry and Acoustic Rhinometry 
2.01.10 Topographic Brain Mapping 
2.01.12 Vitamin B12 Injection 
2.01.16 Recombinant and Autologous Platelet-derived Growth Factors as a Primary Treatment of Wound Healing and Other Miscellaneous Conditions 
2.01.17 Sublingual Immunotherapy as a Technique of Allergen Specific Therapy 
2.01.18 Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome 
2.01.20 Esophageal pH Monitoring 
2.01.21 Temporomandibular Joint Dysfunction 
2.01.26 Prolotherapy
2.01.27 Biofeedback as a Treatment of Urinary Incontinence in Adults 
2.01.28 Neurofeedback
2.01.29 Biofeedback as a Treatment of Headache 
2.01.30 Biofeedback as a Treatment of Chronic Pain 
2.01.31 Intra-articular Hyaluronan Injections for Osteoarthritis 
2.01.34 Cutaneous Electrogastrography (EGG) 
2.01.35 Paraspinal Surface Electromyography (SEMG) 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 
2.01.41 Noncontact Radiant Heat Bandage for the Treatment of Wounds 
2.01.42 Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy
2.01.43 Chronic Intermittent Intravenous Insulin Therapy (CIIIT) 
2.01.44 Dermatologic Applications of Photodynamic Therapy 
2.01.47 Light Therapy for Psoriasis 
2.01.50 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders 
2.01.53 Biofeedback for Miscellaneous Indications 
2.01.54 Endovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) 
2.01.56 Low-Level Laser Therapy
2.01.57 Electrostimulation and Electromagnetic Therapy for the Treating Wounds 
2.01.58 Transanal Radiofrequency Treatment of Fecal Incontinence 
2.01.61 Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders 
2.01.64 Biofeedback as a Treatment of Fecal Incontinence or Constipation  
2.01.65 Aerosolized Antibiotics as a Treatment of Chronic Sinusitis 
2.01.68 Laboratory Tests for Heart Transplant Rejection 
2.01.71  Non-Pharmacologic Treatment of Rosacea 
2.01.72 Insulin Potentiation Therapy 
2.01.73 Actigraphy
2.01.77 Automated Point-of-Care Nerve Conduction Tests 
2.01.79 Non-Contact Ultrasound Treatment for Wounds
2.01.80 Endoscopic Radiofrequency Ablation or Cryoablation for Barrett`s Esophagus
2.01.81  Ingestible pH and Pressure Capsule 
2.01.82  Bioimpedance Devices for Detection of Lymphedema 
2.01.83  Interventions for Progressive Scoliosis 
2.01.84 Chromoendoscopy as an Adjunct to Colonoscopy
2.01.85 Neural Therapy
2.01.86 Light Therapy for Vitiligo
2.01.87 Confocal Laser Endomicroscopy
2.01.198 Mesenchymal Stem Cell Therapy for Orthopedic Indications
2.01.199  Immunizations 
2.02 Cardiology Introduction 
2.02.01 Catheter Ablation for Cardiac Arrhythmias 
2.02.06 Enhanced External Counterpulsation (EECP) 
2.02.08 Ambulatory Event Monitors and Moblie Outpatient Cardiac 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 
2.02.11 Intra-arterial Brachytherapy for Prevention and Management of Restenosis after Percutaneous Transluminal Angioplasty (PTA) 
2.02.12 Noninvasive Measurements of Cardiac Hemodynamics in the Ambulatory Care-Outpatient Setting 
2.02.13 T-Wave Alternans 
2.02.15 Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement
2.02.16 Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis 
2.02.17 End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema 
2.02.18 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia 
2.02.19 Catheter Ablation of Pulmonary Veins 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 
2.02.27  Acoustic Cardiography 
2.02.28 Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
2.02.29 Optical Coherence Tomography in Coronary Artery Imaging
2.02.99  Acoustic Heart Sound Recording and Computer Analysis 
2.03 Oncology Introduction 
2.03.01 In Vitro Chemoresistance and Chemosensitivity Assays
2.03.03 Donor Leukocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Stem-cell Transplant
2.03.04 Melanoma Vaccines
2.03.05 Uses of Monoclonal Antibodies for the Treatment of Non-Hodgkin Lymphoma including Chronic Myeloid Leukemia, and Acute Myeloid Leukemia in the Non-Hematopoietic stem-cell Transplant Setting
2.03.07 Cytoreductive Surgery and Periioperative Intraperitoneal Chemotherapy for the Treatment of Pseudomyxoma Peritonei, Peritoneal Carcinomatosis of Fastrointestinal Origin, and Peritoneal Mesothelioma
2.03.10 Real-Time Intra-Fraction Target Tracking during Radiation Therapy
2.04 Pathology/Laboratory Introduction 
2.04.02 Genetic Testing for Hereditary Breast and/or Ovarian Cancer 
2.04.03 Fetal Fibronectin Enzyme Immunoassay
2.04.04 Cervicography
2.04.05 Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary Carcinoma of the Thyroid
2.04.07 Urinary Tumor Markers for Bladder Cancer
2.04.08 Genetic Testing for Lynch Syndrome and Inherited Intestinal Polyposis Syndromes
2.04.10 Identification of Microorganisms Using Nucleic Acid Probes
2.04.13 Genetic Testing for Familial Alzheimer’s Disease
2.04.14 Biochemical Markers of Alzheimer’s Disease
2.04.15 Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover
2.04.19 Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines 
2.04.20 Apolipoprotein B in the Risk Assessment and Management of Cardiovascular Disease
2.04.21 Lipoprotein(a) Enzyme Immunoassay in the Management of Cardiovascular Disease
2.04.22 High-Sensitivity C-Reactive Protein
2.04.23 Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease
2.04.24 High-Density Lipoprotein Subclass Testing in the Diagnosis and Management of Cardiovascular Disease
2.04.25 Apolipoprotein E Genotype or Phenotype in the Management of Cardiovascular Disease 
2.04.26  Fecal Analysis in the Diagnosis of Intestinal Dysbiosis 
2.04.27 CA-125
2.04.29 Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening
2.04.30 Serologic Diagnosis of Celiac Disease
2.04.31 Measurement of Serum Intermediate Density Lipoproteins (Remnant-like Particles)
2.04.32 Measurement of Lipoprotein-associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk
2.04.33 Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer
2.04.36 Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer
2.04.37 Detection of Circulating Tumor Cells in the Management of Patients with Cancer
2.04.38 Cytochrome p450 Genotyping
2.04.41 Multianalyte Assays with Algorithmic Analysis for the Evaluation and Monitoring of Patients with Chronic Liver Disease
2.04.42 Leukocyte Histamine Release Test
2.04.43 Genetic Testing for the Congenital Long QT Syndrome
2.04.44 Genetic Testing for Familial Cutaneous Malignant Melanoma
2.04.45 Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC)
2.04.46 Alpha-Fetoprotein for Detection of Hepatocellular (Liver) Cancer
2.04.48 Genetic Testing for Warfarin Dose
2.04.49 Laboratory Testing for HIV Tropism 
2.04.50 Genetic Testing for Helicobactor Pylori Treatment 
2.04.51 Genetic Testing for Tamoxifen Treatment 
2.04.52  PathFinder® Molecular Testing 
2.04.53  KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer 
2.04.54 Microarray-based Gene Expression Testing for Cancers of Unknown Primary
2.04.55 KRAS Mutation Analysis in Non-Small Cell Lung Cancer (NSCLC)
2.04.56  Immune Cell Function Assay
2.04.57  Non-BRCA Breast Cancer Risk Assessment (OncoVue) 
2.04.58  Nerve Fiber Density Testing
2.04.59  Array Comparative Genomic Hybridization (aCSH) for the Genetic Evaluation of Patients with Developmental Delay/Mental Retardation or Autism Spectrum Disorder 
2.04.60  JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms 
2.04.61  Multigene Expression Assay for Predicting Recurrence in Colon Cancer 
2.04.62  Protemics-based Testing for the Evaluation of Ovarian (Adnexal) Masses 
2.04.63  Use of Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer 
2.04.64  Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer
2.04.65  Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease 
2.04.66  Serum Biomarker Human Epididymis Protein 4 (HE4) 
2.04.67  KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy 
2.04.68  Laboratory Testing to Allow Area Under the Curve (AUC) - Targeted 5-Flourouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer 
2.04.69  Fecal Calprotectin Testing 
2.04.70  Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment  
2.04.71  Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm 
2.04.72  Gene Expression Testing to Predict Coronary Artery Disease 
2.04.73  Intracellular Micronutrient Analysis 
2.04.74  DNA-Based Testing for Adolescent Idiopathic Scoliosis 
2.04.75  NOTCH 3 Genotyping for Diagnosis of CADASIL 
2.04.76  Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers 
2.04.77  BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy 
2.04.78 Mutation Analysis in Fine Needle Aspirates of the Thyroid
2.04.79 Genetic Testing for Alpha-1 Antitrypsin Deficiency
2.04.80 Genetic Testing for Hereditary Hemochromatosis
2.04.81 Genetic Testing for Rett Syndrome
2.04.82 Genetic Testing for Inherited Thrombophilia
2.04.83 Genetic Testing for FMR 1 Muations (including Fragile X Syndrome)
2.04.84 Measurement of Serum Antibodies to Infliximab
2.04.85 BCR-ABL1 Testing for Diagnosis, Monitoring and Drug Resistance Mutation Detection in Chronic Myelogenous Leukemia
2.04.86 Genetic Testing for Duchenne and Becker Muscular Dystrophy
2.04.87 Genetic Testing for Nonsyndrominc Hearing Loss
2.04.88 Genetic Testing for PTEN Hamartoma Tumor Syndrome
2.04.89 Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies
2.04.90 Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes
2.04.91 General Approach to Genetic Testing
2.04.93 Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
2.04.95  Salivary Hormone Testing 
2.04.96  Genetic Testing for Statin-Induced Myopathy 
2.04.97  Microarry-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification
2.04.99 Genetic Testing for Hereditary Pancreatitis
2.04.102 Whole Exome Sequencing
2.04.103 Genetic Testing for Macular Degeneration
2.04.104 Genetic Testing for Alpha Thalassemia
2.04.105 Genetic Testing for Facioscapulohumeral Muscular Dystrophy
2.04.106 Genetic Testing for CHARGE Syndrome
2.04.107 Carrier Testing for Genetic Diseases
2.04.108 Fetal RDH Genotyping Using Maternal Plasma
2.04.109 Genetic Testing for Epilepsy
2.04.110 Genecept Assay
2.04.111 Microarray-Based Gene Expression Analysis for Prostate Cancer Management
2.04.113 Analysis of MGMT Promoter Methylation in Malignant Gliomas
2.04.114 Genetic Testing for Dilated Cardiomyopathy
2.04.200 Drug Screen Testing
2.04.300 Unproven and Inappropriate Diagnostic Tests for Allergic and Immune Deficiency Diseases
   
  Genetic Testing/Counseling Introduction 
2.04.02 Genetic Testing for Inherited BRCA1 or BRCA2 Mutations
2.04.05 Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary Carcinoma of the Thyroid
2.04.08 Genetic Testing for Inherited Susceptibility to Colon Cancer: Including Microsatellite Instability Testing
2.04.13 Genetic Testing for Familial Alzheimer’s Disease
2.04.29 Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening/providers/medical_policies/Med/mp_20448.asp
2.04.33 Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer
2.04.36 Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients With Breast Cancer
2.04.38 Cytochrome p450 Genotyping
2.04.43 Genetic Testing for the Congenital Long QT Syndrome
2.04.44 Genetic Testing for Familial Cutaneous Malignant Melanoma
2.04.45 Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC)
2.04.47 Biomarker Genes for Detection of Lymph Nodes Metastases in Breast Cancer
2.04.48 Genetic Testing for Initial Warfarin Dose
2.04.50

Genetic Testing for Hleicobactor Pylori Treatment

2.04.51 Genetic Testing for Tamoxifen Treatment
2.04.52 PathFinderTG® Molecular Testing
2.04.54 Microarray-based Gene Expression Testing for Cancers of Unknown Primary
2.04.55 KRAS in Non-Small Cell Lung Cancer
2.04.59  Array Comparative Genomic Hybridization (aCSH) for the Genetic Evaluation of Patients with Developmental Delay/Mental Retardation or Autism Spectrum Disorder 
2.04.60  Tyrosine Kinase Mutations in Myeloproliferative Neoplasms 
2.04.62  Protemics-based Testing for the Evaluation of Ovarian (Adnexal) Masses 
2.04.63  Use of Commone Genetic Variants to Predict Risk of Non-familial Breast Cancer 
2.04.64  Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer 
2.04.70  Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin 
2.04.71  Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aeurysm 
2.04.74  DNA-Based Testing for Adolescnet Idiopathic Scoliosis 
2.04.75  NOTCH 3 Genotyping for Diagnosis of CADASIL 
2.04.77 BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy 
2.04.79 Genetic Testing for Alpha-1 Antitrypsin Deficiency
2.04.80 Genetic Testing for Hereditary Hemochromatosis
2.04.81 Genetic Testing for Rett Syndrome
2.04.82 Genetic Testing for Inherited Thrombophilia
2.04.103 Genetic Testing for Macular Degeneration
2.04.98 Genetic Testing
4.02.05 Preimplantation Genetic Diagnosis
4.02.10  Genetic Testing for Recurrent Pregnancy Loss