Medical Policies
Policies that are included in the FEP Medical Policy Manual.
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.
- 5.99.020 Zokinvy (lonafarnib)
- 5.99.021 Lupkynis (voclosporin)
- 5.99.023 Saphnelo (anifrolumab-fnia)
- 5.99.024 Zortress (everolimus)
- 5.99.025 Condoms
- 5.99.026 Vyvgart (efgartigimod alfa-fcab)
- 5.99.027 Weight Loss Medications
- 5.99.029 Zynteglo (betibeglogene autotemcel)
- 5.99.030 Saxenda Wegovy
- 6.01.01 Bone Mineral Density Studies
- 6.01.03 Computed Tomography to Detect Coronary Artery Calcification
- 6.01.06 Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography
- 6.01.10 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
- 6.01.12 Thermography
- 6.01.20 Cardiac Applications of Positron Emission Tomography Scanning
- 6.01.24 Magnetic Resonance Spectroscopy
- 6.01.25 Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine
- 6.01.26 Oncologic Applications of Positron Emission Tomography Scanning (Genitourinary)
- 6.01.29 Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer
- 6.01.32 Virtual Colonoscopy/Computed Tomography Colonography
- 6.01.33 Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
- 6.01.40 Whole Body Dual X-Ray Absorptiometry to Determine Body Composition
- 6.01.43 Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation
- 6.01.44 Vertebral Fracture Assessment with Densitometry or Biomechanical Computed Tomography
- 6.01.49 Computed Tomography Perfusion Imaging of the Brain
- 6.01.51 Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
- 6.01.55 Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease
- 6.01.56 Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure
- 6.01.59 Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve
- 6.01.61 Oncologic Applications of Positron Emission Tomography Scanning (Gastrointestinal and Pancreatic)
- 6.01.62 Oncologic Applications of Positron Emission Tomography Scanning (Breast and Gynecologic)
- 6.01.63 Oncologic Applications of Positron Emission Tomography Scanning (Bone and Sarcoma)
- 6.01.64 Oncologic Applications of Positron Emission Tomography Scanning (Hematologic)
- 6.01.65 Oncologic Applications of Positron Emission Tomography Scanning (Lung)
- 6.01.66 Oncologic Applications of Positron Emission Tomography Scanning (Thyroid, Neuroendocrine, Head and Neck)
- 6.01.67 Oncologic Applications of Positron Emission Tomography Scanning (Brain, Melanoma, Unknown Primary)
- 7.01.05 Cochlear Implant
- 7.01.07 Electrical Bone Growth Stimulation of the Appendicular Skeleton
- 7.01.13 Surgical Treatment of Bilateral Gynecomastia
- 7.01.15 Meniscal Allografts and Other Meniscal Implants
- 7.01.18 Automated Percutaneous and Percutaneous Endoscopic Discectomy
- 7.01.19 Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
- 7.01.21 Reduction Mammaplasty for Breast-Related Symptoms
- 7.01.29 Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy
- 7.01.44 Implantable Cardioverter Defibrillators
- 7.01.47 Bariatric Surgery
- 7.01.48 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
- 7.01.58 Intraoperative Neurophysiologic Monitoring
- 7.01.66 Allograft Injection for Degenerative Disc Disease
- 7.01.68 Extracranial Carotid Artery Stenting