Medical Policies - Excellus Providers


Page Title for page template

Medical Policies

Nested Applications

Medical Policies - Main Content

Use the link below to access policies for Other BlueCross members

In accessing our Medical Policies you signify your agreement to our Terms of Use.

Learn more about how Medical Policies are developedOpen a PDFand about Experimental & Investigational Procedures.

Medical Policies - Right Column Box

Make a Comment

We invite practitioners to review & comment on our policies

Asset Search Filter and Browse

Showing 1– 25 of 291 Results
Title Last Updated Category
Wireless Capsule Endoscopy/Imaging for Examination of the Gastrointestinal (GI) Tract: AGILE Patency Capsule, Given® Capsule Camera, PillCam SB, PillCam ESO Open a PDF 6.01.27 2019-07-18 Digestive System (Gastroenterology)
Whole Exome and Whole Genome Sequencing for the Diagnosis of Genetic Disorders Open a PDF 2.02.46 2019-07-18 Genetic Disease (Inherited Disease)
Wheelchairs and Power Operated Vehicles (POVs) (e.g., Scooters) Open a PDF 1.01.16 2019-08-09 Durable Medical Equipment & Supplies
Vitrectomy Chair/ Face-Down Positioning System Open a PDF 1.01.52 2019-06-03 Durable Medical Equipment & Supplies
Vision/Eye Therapy: Optometric Phototherapy, Occlusion Therapy, Orthoptics, Pleoptics Open a PDF 9.01.04 2019-01-17 Eyes (Ophthalmology)
Ventricular Assist Devices (VAD, LVAD) Open a PDF 7.01.07 2019-09-19 Heart & Blood Vessels (Cardiovascular)
Varicosities/Varicose Veins, Treatment Alternatives to Vein Stripping and Ligation (e.g., Ambulatory, Stab or Transilluminated Powered Phlebectomy, ClariVein®, Endoluminal Radiofrequency Ablation, Endovenous Laser Ablation, Mechanochemical Endovenous Ablation, MOCA, Sclerotherapy, Varithena™, Venaseal™,VNUS) Open a PDF 7.01.47 2019-10-16 Cosmetic / Reconstructive Surgery
Vagus Nerve Stimulation Open a PDF 7.01.05 2019-08-22 Nervous Systems (Neurology)
Uterine Artery Occlusion in the Treatment of Uterine Fibroids: Uterine Artery/Fibroid Embolization (UAE/UFE), Uterine Artery Coagulation Open a PDF 4.01.04 2019-03-22 Women's Health (Obstetrics & Gynecology)
Urine Drug Testing, immunoassay, presumptive testing, confirmatory testing Open a PDF 2.02.50 2019-02-06 Lab Tests (pathology)
Urinary Tumor Markers for Bladder Cancer: AccuDx, BTA Stat™, Fibrin/Fibrinogen Degradation Products (FDP), ImmunoCyt, Nuclear Matrix Protein (NMP-22), Urinary Bladder Cancer Antigen (UBC Rapid Test) Open a PDF 2.02.12 2019-08-22 Lab Tests (pathology)
Tumor-Treatment Field Therapy for Glioblastoma: Electrical Field Therapy, NovoTTF-100™ Open a PDF 6.01.45 2019-04-29 Cancer Treatment (Oncology)
Treatment of Tinnitus: Habituation Therapy, Jastreboff Method, Masking, Retraining Therapy Open a PDF 8.01.07 2019-03-22 Ear, Nose & Throat (Otorhinolaryngology)
Treatment of Hirsutism/Hypertrichosis (Hair Removal) (e.g., Electrolysis, Epilation) Open a PDF 2.01.38 2019-01-17 Cosmetic / Reconstructive Surgery
Treatment of Gambling Disorder and Other Repetitive Behaviors Open a PDF 3.01.19 2019-04-29 Behavioral Health (Psychology)
Transurethral Microwave Thermotherapy (e.g., Prostatron, Targis, Urowave System, CoreTherm, Prolieve, TMx-2000, TUMT) Open a PDF 7.01.28 2019-01-17 Urinary System (Genitourinary)
Transpupillary Thermotherapy (TTT) Open a PDF 9.01.05 2019-09-19 Eyes (Ophthalmology)
Transmyocardial Revascularization (TMR), Percutaneous Transmyocardial Revascularization (PTMR) Open a PDF 7.01.12 2019-03-22 Heart & Blood Vessels (Cardiovascular)
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD): ELF, EndoCinch, Endoluminal Fundoplication, Endoluminal Gastroplication, Enteryx, EsophyX, Gatekeeper, Plexiglas Microspheres, NDO Plicator System, Radiofrequency Esophageal Treatment, Stretta) Open a PDF 7.01.45 2019-06-14 Digestive System (Gastroenterology)
Transcranial Magnetic Stimulation: Deep TMS device, MagVita TMS, NeuroStar TMS device, rTMS, TMS Open a PDF 3.01.09 2019-01-17 Behavioral Health (Psychology)
Transcranial Doppler Ultrasound Open a PDF 6.01.18 2019-01-17 Radiology (x-rays) & Imaging
Transcatheter Closure Devices for Cardiac Defects: Amplatzer Septal Occluder, Angel Wing Device, Atrial Septal Detect Occluding System (ASDOS), CardioSEAL, HELEX, Sideris Buttoned Device Open a PDF 7.01.34 2019-09-19 Heart & Blood Vessels (Cardiovascular)
Total Parenteral Nutrition (TPN), Intradialytic Parenteral Nutrition (IDPN), Intraperitoneal Nutrition (IPN), or Hyperalimentation Open a PDF 11.01.04 2019-04-29 Food (Nutrition)
Total Hip Resurfacing, Metal-on-Metal Open a PDF 7.01.74 2019-07-18 Bone & Joints (Orthopedic)
Temporomandibular Joint (TMJ) Disease Open a PDF 11.01.17 2019-01-17 Bone & Joints (Orthopedic)
Showing 1– 25 of 291 Results

Blue Router - Pre-Service Review for Nationwide BCBS Members Modal

Modal for Medical Policy and Preauthorization Information for Members of Other BlueCross Plans

GLO-PRV-Medical Policies - Terms of Use Modal

Modal for Medical Policy Terms of Use