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Blue Advantage Final Medical Policies

WEBPolicies are written to cover a given condition for the majority of people. Each individual's unique clinical circumstances may be considered in light of current scientific literature. …

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Medical and Drug Policies

WEBPolicies are intended to be used for some or all of the following purposes in Blue Cross and Blue Shield's administration of plans: (i) adjudication of claims (including pre-admission …

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Policies & Guidelines

WEBMorbid obesity is defined as a body mass index (BMI) greater than 40 kg/m 2 or a BMI greater than 35 kg/m 2 with weight related complications. BMI is calculated by …

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Medical and Drug Policies

WEBDraft Provider-Administered Drug Policies. Radiation Therapy. Draft Policies. Chronic Condition Management. Genetic Testing. Draft Genetic Testing Policies. HealthSmartRx …

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Policies & Guidelines

WEBcapsule. For the treatment of the cardiomyopathy of wild type or hereditary transthyretin-mediated amyloidosis in adults to reduce cardiovascular mortality and cardiovascular …

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Medical and Drug Policies

WEBOnline. Go to your local Plan's provider portal to initiate pre-service review (Electronic Provider Access) for these services for out-of-area members. Contact your local Blue …

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Medical and Drug Policies

WEBProphylactic use in patients with solid tumors or non-myeloid malignancy † 1-12,20,22-28 Patient is undergoing myelosuppressive chemotherapy with an expected incidence of …

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Medical Policies

WEBPolicies are intended to be used for some or all of the following purposes in Blue Cross and Blue Shield's administration of plans: (i) adjudication of claims (including pre-admission …

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Medical and Drug Policies

WEBBehavioral health policies and guidelines can be found on the Lucet website. Lucet is our business associate and is an independent company that provides diagnostic testing, …

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Medical Policies

WEBTo view medical policies for advanced imaging services, click "Accept" below the policy type you wish to view. Cardiology. Radiology. For a copy of previous imaging policies, email …

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Medical and Drug Policies

WEBFax completed PEEHIP Prior Authorization Request Form for PEEHIP members only to 1-866-606-6021. Prescribers and Specialty Pharmacies should not use this form for …

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Medical and Drug Policies

WEBPolicy title change: Medical Foods and Specialized Formula for the Treatment of Inborn Errors of Metabolism. Medical Policy Group, March 2023 (6): Updates to Policy …

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Medical and Drug Policies

WEBThe American Diabetes Association (ADA) recommends the following guidelines: (9,10) Healthy lifestyle behaviors, diabetes self-management education and support, …

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Medical Policies

WEBMake sure your voice is heard by providing feedback directly to us: Complete our medical policy feedback form online , or. Send comments and supporting documentation by mail …

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Medical and Drug Policies

WEBAgent(s) FDA Indication(s) Notes. Ref# Adipex-P®, Lomaira™, Phentermine*~ Tablet Capsule. Short-term (a few weeks) adjunct in a regimen of weight reduction based on …

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Medical and Drug Policies

WEBBilling Code/Availability Information; HCPCS: J3490 – Unclassified drugs; S0013 – Esketamine, nasal spray, 1 mg: 1 billable unit = 1 mg *G2082 – Office or other outpatient …

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Name of Blue Advantage Policy Liposuction for Lymphedema

WEBDESCRIPTION OF PROCEDURE OR SERVICE: Lipedema is a disorder characterized by a large amount of subcutaneous fat in the extremities, typically the legs …

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Medical and Drug Policies

WEB95782. Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist. 95783. Polysomnography; younger …

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