Medical Policy Disclaimer

Blue Cross Blue Shield medical policy documents are designed for informational purposes only and is not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

Individual consideration

All our medical policies are written for the majority of people with a given condition. Each policy is based on medical science. For many of our medical policies, each individual's unique clinical circumstances may be considered in light of current scientific literature. For consideration of an individual patient, physicians may send relevant clinical information to:

For services already billed:

Blue Cross Blue Shield of Massachusetts
Provider Services
P.O. Box 986075
Boston, MA 02298

Prior to performance of service:

Blue Cross Blue Shield of Massachusetts
Appeals Unit
One Enterprise Drive
Quincy, MA 02171
Tel: 1-800-327-6716
Fax: 1-888-641-5330


You can find a medical policy in any of the following ways:

  1. Find a keyword topic alphabetically.
    If you prefer an alphabetical listing of medical policy topics - just click on the letter below.

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  1. Use the Directory of Documents list by category.
    Click here to bring up the directory of all medical policies and other documents, listed by category.


Note: Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.





003 TENS and PENS-PNT

008 Laboratory Testing for HIV Tropism

016 Homocysteine Testing

042 Wearable Cardioverter Defibrillators

046 Total Hip Resurfacing

048 Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy

050 Corneal Endothelial Microscopy

053 Ophthalmologic Techniques to Evaluate the Retinal Nerve Fiber Layer

054 Corneal Pachymetry

055 Assays of Genetic Expression in Tumor Tissue

057 Pregabalin (Lyrica)

058 Bisphosphonate, Oral

061 Bisphosphonates, Infusion-Injection

062 Natalizumab (Tysabri)

063 Oncology, Oral

065 Screening for Diabetic Retinopathy

066 Hysterectomy Using Various Laparoscopic Approaches

067 Genetic Testing for Tamoxifen Treatment

069 Esophageal pH Monitoring

070 Implantable Cardioverter Defibrillator

081 Extracorporeal Shock Wave Treatment

083 Spinal, Vagal, Deep Brain, Cerebellar Stimulation

084 Anterior Eye Segment Optical Imaging

085 Image Guided Radiation Therapy for Prostate Cancer

090 Intensity Modulated Radiation Therapy of the Prostate

812 Managed Care, Indemnity and PPO Guidelines Processing Information

999 Policy Updates





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