Medical Policies

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.

2.04.119 Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis
2.04.120 Gene Expression Profiling for Uveal Melanoma
2.04.121 Miscellaneous Genetic and Molecular Diagnostic Tests
2.04.122 Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss
2.04.123 Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
2.04.124 Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia
2.04.125 Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer
2.04.126 Germline Genetic Testing for Gene Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk (CHEK2, ATM, and BARD1)
2.04.128 Genetic Testing for Fanconi Anemia
2.04.129 Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
2.04.131 Pharmacogenetic Testing for Pain Management
2.04.136 Nutrient/Nutritional Panel Testing
2.04.137 Genetic Testing for Neurofibromatosis
2.04.139 Genetic Testing for Heterozygous Familial Hypercholesterolemia
2.04.140 Proteogenomic Testing for Patients With Cancer
2.04.141 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
2.04.142 Molecular Testing in the Management of Pulmonary Nodules
2.04.146 Gene Expression Profiling for Cutaneous Melanoma
2.04.147 Next-Generation Sequencing for the Assessment of Measurable Residual Disease
2.04.148 Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes (ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, and TP53)
2.04.149 Molecular Testing for Germline Variants Associated with Ovarian Cancer (BRIP1, RAD51C, RAD51D, NBN)
2.04.150 Serologic Genetic and Molecular Screening for Colorectal Cancer
2.04.151 Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Breast Cancer (BRCA1, BRCA2, PIK3CA, Ki-67, RET, BRAF, ESR1)
2.04.152 Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes
2.04.153 Tumor Informed Circulating Tumor DNA Testing for Cancer Management
2.04.154 Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1)
2.04.155 Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, NTRK Gene Fusion)
2.04.156 Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, NTRK)
2.04.157 Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB)
2.04.159 Laboratory Testing Investigational Services
3.03.01 Digital Health Technologies: Diagnostic Applications
3.03.02 Digital Health Technologies: Therapeutic Applications
3.03.03 Digital Health Therapies for Attention Deficit/Hyperactivity Disorder
4.01.19 Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis
5.01.017 Relenza (zanamivir)
5.01.018 Itraconazole
5.01.019 Tamiflu (oseltamivir)
5.01.020 Zyvox (linezolid)
5.01.022 Valcyte (valganciclovir)
5.01.023 Ketoconazole
5.01.031 Sivextro (tedizolid)
5.01.034 Xifaxan (rifaximin)
5.01.035 Cresemba (isavuconazonium)
5.01.038 Daraprim (pyrimethamine)
5.01.041 Hepatitis C
5.01.042 Anthelmintic Drugs
5.01.043 Prevymis (letermovir)
5.01.044 Vfend (voriconazole)
5.01.045 Trogarzo (ibalizumab-uiyk)
5.01.047 Pegasys Pegintron Ribavirin