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Coverage Policy
(Specific to Discrete Procedures or Technologies)
The medical director of Arkansas Blue Cross and Blue Shield has established specific coverage policies addressing certain medical procedures or technologies.
The purpose of a Coverage Policy is to inform members and their physicians why certain medical procedures may or may not be covered under Arkansas Blue Cross and Blue Shield health plans. In addition to these specific Coverage Policies, all Arkansas Blue Cross and Blue Shield health plans or contracts also include more generally applicable coverage standards known or the Primary Coverage Criteria. The Primary Coverage Criteria apply to
ALL
benefits members may claim under their plan, no matter what types of health intervention may be involved or when or where members obtain the intervention. For more specifics on Primary Coverage Criteria, click on the Primary Coverage Criteria link below.
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Abarelix (Plenaxis™)
Abatacept (Orencia) for Rheumatoid Arthritis
Abdominoplasty
Acne, Laser Treatment
Acupuncture
Adoptive Immunotherapy
Advanced Nurse Practitioners
Air Fluidized Beds
Alglucerase
Allergy Immunotherapy
Allergy Testing
Alpha I Globulin Antitrypsin Replacement Therapy (Prolastin)
Alpha-Fetoprotein for Prediction of risk of Hepatocellular Cancer, Cholangi
Ambulatory Blood Pressure Monitoring
Amevive (Alefacept)
Anakinra (Kineret) for Systemic Onset Juvenile Rheumatoid Arthritis
Anesthesia, Monitored Care
Angioplasty, Intracranial Artery Atherosclerosis, Stenosis, Percutaneous
Angioplasty, Pulmonary Artery, Percutaneous
Angioplasty/Stenting, Abdominal Aortic & Lower Extremity Artery Stenosis, P
Angioplasty/Stenting, Percutaneous, Carotid Artery
Anterior Cruciate Ligament Reconstruction With Allograft Patellar Or Achill
Antigen Immunotherapy for Repeat Fetal Loss
Antioxidant Measurement, Non-invasive
Antiretroviral Drug Resistance Testing
Antithrombin III Replacement
Apheresis, Erythrocytes (Erythrocyte Pheresis)
Apheresis, Leukocytes (Leukocyte Pheresis)
Apheresis, Lowering LDL Cholesterol (Lipid Apheresis)
Apheresis, Platelets (Platelet Depletion)
Apheresis, Therapeutic (Plasma Exchange Transfusion)
Apolipoprotein E Genotype or Phenotype in the Management of Cardiovascular
Arthroereisis for Pes Planus (Flat Feet) (Subtalar stabilization)
Artificial Heart, Total
Artificial Intervertebral Disc: Cervical Spine
Artificial Vertebral Disc: Lumbar Spine
Assisted Reproductive Technologies
Atherectomy, Peripheral/Visceral Artery, Percutaneous
Attention Deficit/Hyperactivity Disorder (ADD)
Auditory Brain Stem Implant
Auditory Evoked Potential
Autologous Chondrocyte Implantation
Autologous Serum Tears
Autologus Cell Therapy for the Treatment of Damaged Myocardium
Back School
Baclofen Intrathecal Therapy
Balloon Sinuplasty
Biofeedback
Biophysical Fetal Profile
Biventricular Pacemakers for the Treatment of Congestive Heart Failure
Bladder Cancer, Urinary Tumor Markers
Blepharoplasty/Blepharoptosis
Blood-Derived Growth Factors for Wound Healing
Bone Growth Stimulation, Electrical
Bone Markers (Collagen Crosslinks as Biological Markers of Bone Turnover)
Bone Mineral Density Study
Boron Neutron Capture Therapy
Brachytherapy, Brain Tumors
Brachytherapy, Breast
Brachytherapy, Intracoronary
Brachytherapy, Prostate
Brachytherapy, Prostate, High-Dose Rate Temporary
Brachytherapy, Radioembolization of Primary & Metastatic Tumors of the Live
Brachytherapy, Uterine cancer
Breast Ductal Lavage for Detection of Malignancy
Canalith Repositioning as a Treatment of Benign Paroxysmal Positional Verti
Cardiac Event Recorder Insertable Loop Recorder
Cardiac Event Recorder, Mobile Telemetry
Cardiac Event Recorder, Presymptom Memory Loop
Cardiac Rehabilitation
Cardioverter Defibrillator, Implantable
Cardioverter Defibrillator, Wearable Cardiac Vest
Carotid Intimal-Medial Thickness, Ultrasound Measurement to Assess Subclini
Catheter Ablation for Cardiac Arrhythmias
Celiac Disease Antibody Testing
Cerebellar Stimulator/Pacemaker for Treatment of Neurological Disease
Certified Nurse Midwives
Cervicography
Chelation Therapy
Chemical Ecology (Environmental Illness, Multiple Chemical Sensitivities, E
Chemical Labyrinthectomy in the Treatment of Meniere's Syndrome
Chemodenervation (Botulinum Toxins)
Chemonucleolysis
Chemotherapy for Malignancy
Cholesterol, Skin Test for
Chronic Intermittent Intravenous Insulin Therapy (CIIIT)
Clinical Nurse Specialist
Closure Devices for Patent Foramen Ovale and Atrial or Ventricular Septal D
Cochlear Implant
Cold Therapy
Computed Tomography (CT) Scanning for Lung Cancer Screening
Computed Tomography, Cardiac and Coronary Artery
Computed Tomography, Coronary Artery Quantitative Calcium Scoring
Computer-aided Detection in Conjunction with Digitized Screen-Film Mammogra
Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedur
Constraint-Induced Movement Therapy
Continuous Passive Motion Device
Cord Blood as a Source of Stem Cells for Treatment of Identified (Diagnosed
Cord Blood as a Source of Stem Cells for Unspecified Future Use
Corneal Topography
Correlated Audioelectric Cardiography
Cryoablation of Prostate Cancer
Cryoablation of Renal Tumors
Cryosurgical Ablation of Breast Tumors, Benign and Malignant
Cryosurgical Ablation of Pancreatic Cancer
Current Perception Threshold Test
Cystatin C
Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy
Dermatomal Somatosensory Evoked Potentials
Dermatoscopy
Detection of Circulating Tumor Cells in the Management of Patients with Can
Digital Motion X-ray (Cineradiography/Videoradiography) for Musculoskeletal
Digitization: Computer Enhanced X– Ray Analysis for Spinal Evaluation
Disc Biacuplasty
Donor Leukocyte Infusion
Dry Hydrotherapy (Hydro massage)
Dynamic Cardiomyoplasty
Dynamic Orthotic Cranioplasty as a Treatment of Plagiocephaly
EKG, Signal Averaged
Electrical Impedance Scanning of the Breast
Electrical Stimulation, Deep Brain (e.g. Parkinsonism, dystonia, multiple s
Electrical Stimulation, H-wave
Electrical Stimulation, Pelvic Floor Stimulation (Electrical)-Adult Urinary
Electrical Stimulation, Transcutaneous Electrical Nerve Stimulator
Electrical Stimulation, Vagus Nerve Stimulation for the Treatment of Depres
Electrical Stimulation, Vagus Nerve Stimulation for the Treatment of Seizur
Electrical/Electromagnetic Stimulation for the Treatment of Arthritis
Electrogastrography (EGG)
Electrophrenic Pacemaker
Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic
Electrostimulation of Salivary Glands (Salitron)
End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascu
Endobronchial Brachytherapy
Endometrial Ablation
Endovascular Stent Grafts for Thoracic Aortic Aneurysms or Dissections
Epidural Adhesiolysis, Percutaneous
Epiduroscopy
Esophageal pH Monitoring
Etanercept (Enbrel)
External Counterpulsation (ECP)
Extracorporeal Membrane Oxygenation (ECMO)
Extracorporeal Shock Wave Lithotripsy for Gallstones
Extracorporeal Shock Wave Therapy For Plantar Fasciitis and Other Musculosk
Extracranial-Intracranial Bypass Surgery in Cerebrovascular Disease
Eye Refractions, Eyeglasses (Except after Cataract Surgery as limited by th
Fetal Fibronectin Enzyme Immunoassay
Fetal Surgery For Myelomeningocele
Fetal Surgery for Prenatally Diagnosed Malformations
Food and Chemical Sensitivity Testing
Gait Analysis
Gastric Neurostimulation
Gastric Neurostimulation for Morbid Obesity
Gender Dysphoria Syndrome or Transsexualism
Genetic Test: Alzheimer's Disease
Genetic Test: Amyotrophic Lateral Sclerosis
Genetic Test: Breast Ca_Predict Need_Adjuvant Chemotherapy, Assessment of R
Genetic Test: Breast cancer; Detection of Lymph Node Metastases (GeneSearch
Genetic Test: Breast Cancer; Risk Recurrence to Determine Need for Adjuvant
Genetic Test: Canavan Disease
Genetic Test: Carbamazepine HLA-B*1502
Genetic Test: Cytochrome p450 Genotyping
Genetic Test: Cytochrome P450, Depression
Genetic Test: Factor V Leiden
Genetic Test: Fecal DNA to Detect Colorectal Cancer, Screening
Genetic Test: Fragile X
Genetic Test: Germline Mutations of the RET Protooncogene in Medullary Carc
Genetic Test: Hemochromatosis
Genetic Test: HER2 Testing
Genetic Test: Inherited BRCA1 or BRCA2 Mutations
Genetic Test: Inherited Susceptibility to Colon Cancer Including Microsatel
Genetic Test: Long QT Syndrome
Genetic Test: Melanoma, Hereditary
Genetic Test: Mod 9A (TPMT)(patients on antimetabolite therapy)
Genetic Test: Mod OP (KIT, CD117)(gastrointestinal stromal tumor)
Genetic Test: NOTCH3 for Cerebral Autosomal Dominant Arteriopathy with Subc
Genetic Test: Prenatal and Chromosomal Metabolic
Genetic Test: Screening, Detection and/or Management of Prostate Cancer
Genetic Test: Warfarin Dose/Response
Glucose Monitoring, Continuous
Grenz Ray Therapy
Growth Hormone, Human
HDC & Allogeneic or Autologous Hematopoietic Stem Cell Support for Chronic
HDC & Allogeneic Stem &/or Progenitor Cell Support-Acute Lymphocytic Leukem
HDC & Allogeneic Stem &/or Progenitor Cell Support-Acute Myelogenous Leukem
HDC & Allogeneic Stem &/or Progenitor Cell Support-Chronic Myelogenous Leuk
HDC & Allogeneic Stem &/or Progenitor Cell Support-Ewing's Sarcoma
HDC & Allogeneic Stem &/or Progenitor Cell Support-Genetic Diseases & Acqui
HDC & Allogeneic Stem &/or Progenitor Cell Support-Hodgkin's Disease
HDC & Allogeneic Stem &/or Progenitor Cell Support-Myelodysplastic Disease
HDC & Allogeneic Stem &/or Progenitor Cell Support-Neuroblastoma of Childho
HDC & Allogeneic Stem &/or Progenitor Cell Support-Non-Hodgkin's Lymphoma
HDC & Allogeneic Stem Cell Support-Hematophagocytic lymphohistiocytosis
HDC & Autologous Stem &/or Progenitor Cell Support for Primitive Neuroectod
HDC & Autologous Stem &/or Progenitor Cell Support- Myelodysplastic Syndrom
HDC & Autologous Stem &/or Progenitor Cell Support-Acute Lymphocytic Leukem
HDC & Autologous Stem &/or Progenitor Cell Support-Acute Myelogenous Leukem
HDC & Autologous Stem &/or Progenitor Cell Support-Ewing's Sarcoma
HDC & Autologous Stem &/or Progenitor Cell Support-Hodgkin's Disease
HDC & Autologous Stem &/or Progenitor Cell Support-Multiple Myeloma
HDC & Autologous Stem &/or Progenitor Cell Support-Neuroblastoma of Childho
HDC & Autologous Stem &/or Progenitor Cell Support-Non Hodgkin's Lymphomas
HDC & Autologous Stem &/or Progenitor Cell Support-Waldenstrom's Macroglobu
HDC & Autologous Stem&/or Progenitor Cell Support for Treatment of Germ Cel
HDC_Progenitor Cell Support_AL Amyloidosis (Light Chain Amyloidosis)
Heartsbreath Test for Heart Transplant Rejection Detection
Helicobacter Pylori, Noninvasive Testing
Hepatic Tumors, Ablative Procedures
High Dose Chemotherapy with Autologous Stem Cell Support Followed by Nonmye
Hippotherapy
HIV Tropism, Testing
Home Apnea Monitors
Home Phototherapy for Neonatal Jaundice
Home Spirometry
Home Uterine Activity Monitor
Homocysteine Measurement
Human Papilloma Virus Testing of Cervical Pap Smears
Hyperbaric Oxygen Pressurization (HBO)
Hyperhidrosis Treatment
Hyperthermia, Local
Hyperthermic Intraperitoneal Chemotherapy following Cytoreduction Surgery
Identification of Microorganisms Using Nucleic Acid Probes
Ileal Bypass for Hypercholesterolemia
Ilizarov Bone Lengthening Procedure
Immune Globulin, Intravenous and Subcutaneous
Immunoadsorption Using Protein A Columns (Protein A Column Apheresis)-Patie
Implantable Bone Conduction Hearing Aids
In Vitro Chemoresistance and Chemosensitivity Assays
Infliximab (Remicade)
Infusion Pumps, External
Inotropic Agents for Congestive Heart Failure
Insulin Potentiation Therapy
Intensity Modulated Radiation Therapy (IMRT)
Interferon Alfa-2B
Interferon Alfa-N3
Interferon Gamma-1B
Interferon Neutralizing Antibody
Interleukin-2 for HIV Related Uses
Interspinous Distraction Devices (Spacers)
Intracardiac Electrophysiologic Studies
Intradialytic Parenteral Nutrition
Intradiscal Electrothermal Therapy
Intraoperative Neurophysiologic Monitoring
Intraoperative Radiation Therapy
Intrauterine Systems, Progesterone or Progestogen-Releasing
Intravenous Lidocaine for the Outpatient Management of Chronic Pain
Intravitreal Implant, Fluocinolone Acetonide
Iron Therapy, Parenteral
Isolated Limb Perfusion
Keratomileusis
Keratophakia
Keratoplasties, Refractive
Keratoprosthesis
Ketogenic Diet as a Treatment for Refractory Epilepsy
Knee Braces
Kyphoplasty, Percutaneous
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroi
Laser Assisted Myringotomy and Tympanostomy
Laser Instruments for Drawing Capillary Blood Samples
Laser Treatment of Congenital Port Wine Stain Hemangiomas
Left Ventricular End Diastolic Pressure (LVEDP), Non-Invasive Measurement i
Left Ventricular Reduction Surgery (LVRS, Partial Left Ventriculectomy, PLV
Leuprolide (Lupron)
Low Level Laser Therapy (LLLT)
Lung Volume Reduction Surgery (LVRS)
Macular Translocation
Magnetic Innervation Therapy for Urinary Incontinence
Magnetic Resonance Angiography, Chest (Excluding Heart)
Magnetic Resonance Angiography, Head
Magnetic Resonance Angiography, Neck
Magnetic Resonance Angiography, Peripheral Arteries of Lower Extremities
Magnetic Resonance Imaging (MRI), Functional
Magnetic Resonance Imaging (MRI), Multiple Myeloma
Magnetic Resonance Imaging (MRI), Very Low Field (< 0.3 T (Tesla))
Magnetic Resonance Imaging, Breast
Magnetic Resonance Imaging, Cardiac Applications
Magnetic Resonance Neurography
Magnetic Resonance Spectroscopy
Magnetoencephalography / Magnetic Source Imaging
Mammoplasty, Reduction
Mastectomy for Male Gynecomastia
Mastectomy, Prophylactic
Maze Procedure
Measurement of Exhaled Nitric Oxide in the Diagnosis and Management of Asth
Measurement of Lipoprotein-associated Phospholipase A2 (Lp-PLA2) in the Ass
Meniscal Allograft Transplantation
Methyltertbutyl Ether for Treatment of Cholelithiasis
Microprocessor-Controlled Prosthetic Knees
Microwave Thermotherapy for Breast Cancer
Mohs' Micrographic Surgery
Monochromatic Infrared Energy to Treat Cutaneous Ulcers, Diabetic Neuropath
MR Guided Ultrasound Ablation - Uterine Fibroids
Multiple Sclerosis, Immunomodulating Drugs
Multiple Sleep Latency/Maintenance of Wakefulness Test
Muscle Force Measurement by Manual Muscle Testing, Hand Held Dynamometer or
Myocardial Damage, Autologous Cell Therapy(progenitor, hematopoietic stem c
Myocardial Perfusion Imaging
Natriuretic peptide (BNP, NT-proBNP)
Nerve Conduction Studies (NCS), Electromyography (EMG)
Nerve Graft For Patients Undergoing Radical Non-Nerve-Sparing Prostatectomy
Nesiritide (Natrecor)
Neurofeedback
Neuromuscular Stimulation, Functional
Neutron Beam Radiotherapy
Noncontact Radiant Heat Bandage for Treatment of Wounds
Nonmyeloablative Allogeneic Stem Cell Transplantation
Obstructive Sleep Apnea Syndrome, Surgical Management
Ocular Photoscreening as Screening Tool to DetectAmblyogenic Factors
Omega-3 Fatty Acids in Red Blood Cell Membranes as a Cardiac Risk Factor
Oophorectomy, Prophylactic
Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Techniqu
Oprelevkin (Neumega)
Optic Nerve Decompression for Nonarteritic Anterior Ischemic Optic Neuropat
Optical Imaging, Anterior Eye Segment
Orthoptic or Pleoptic Therapy
Orthotics
Oscillatory Devices for Chest Physical Therapy
Osteochondral Allograft and/or Mosaicplasty for Osteochondral Defects of th
Osteochondral Autograft Transfer (OATS) and/or Mosaicplasty For Osteochondr
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Conge
Pain Management, Facet Joint Block
Pain Management, Facet Nerve Denervation
Pain Management, Intercostal Nerve Block/Neurolysis
Pain Management, Sympathetic Blocks
Pain Management, Transforaminal Nerve Block
Pain Mapping for Chronic Pelvic Pain (Conscious Sedation Pain Measurement)
Palatal Stiffening Procedures
Parkinson's Disease, Treatment with Fetal Mesencephalic Transplantation (FM
Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss
PathFinderTG® Molecular Testing
Pegaptanib (Macugen) for Age Related Macular Degeneration
Penile Plethysmography and Nocturnal Penile Tumescence
Percutaneous Lumbar Discectomy, Manual or Automated
Percutaneous Transluminal Endovascular Graft for Abdominal Aortic Aneurysm
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
Periurethral Bulking Agents for the Treatment of Incontinence
PET Scan, Positron Emission Tomography for Alzheimer's
PET Scan, Positron Emission Tomography for Brain Imaging, Non-malignant Dis
PET Scan, Positron Emission Tomography for Breast Cancer
PET Scan, Positron Emission Tomography for Colorectal Cancer
PET Scan, Positron Emission Tomography for Esophageal Cancer
PET Scan, Positron Emission Tomography for Head and Neck Malignant Disease
PET Scan, Positron Emission Tomography for Lung Cancer
PET Scan, Positron Emission Tomography for Lymphoma
PET Scan, Positron Emission Tomography for Malignancy of Unknown Primary
PET Scan, Positron Emission Tomography for Malignant Brain Tumors
PET Scan, Positron Emission Tomography for Melanoma
PET Scan, Positron Emission Tomography for Mesothelioma
PET Scan, Positron Emission Tomography for Myocardial Perfusion Imaging
PET Scan, Positron Emission Tomography for Other Solid Tumors
PET Scan, Positron Emission Tomography for Ovarian Cancer
PET Scan, Positron Emission Tomography for Pancreatic Cancer
PET Scan, Positron Emission Tomography for Pancreatic Neuroendocrine Tumors
PET Scan, Positron Emission Tomography for Prostate Cancer
PET Scan, Positron Emission Tomography for Testicular Germ Cell Cancer
PET Scan, Positron Emission Tomography for Thyroid Cancer
Phenotypic And Genotypic Resistance Assays In HIV Management
Photochemotherapy (PUVA)
Photochemotherapy, Extracorporeal (Photopheresis) as a Treatment of Autoimm
Photochemotherapy, Extracorporeal (Photopheresis) as a Treatment of Cutaneo
Photochemotherapy, Extracorporeal (Photopheresis) as a Treatment of Graft-v
Photochemotherapy, Extracorporeal (Photopheresis) as a Treatment with Heart
Photocoagulation of Macular Drusen
Photodynamic Therapy for Dermatologic Conditions
Photodynamic Therapy for