https://www.premera.com/medicalpolicies/5.01.647.pdf#search=policy
POLICY - 5.01.647 Medical Necessity Criteria for Custom Open and Preferred Formularies Effective Date: Dec. 1, 2025* Last Revised: Nov. 24, 2025 Replaces: N/A *This policy has been ...
https://www.premera.com/medicalpolicies/2.01.544.pdf#search=policy
MEDICAL POLICY - 2.01.544 Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation for Benign Prostatic Hyperplasia BCBSA Ref. Policy: 2.01.49 Effective Date: ...
https://www.premera.com/medicalpolicies/2.04.26.pdf#search=policy
MEDICAL POLICY - 2.04.26 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis BCBSA Ref. Policy: 2.04.26 Effective Date: Mar. 1, 2025 Last Revised: Feb. 10, 2025 Replaces: N/A ...
https://www.premera.com/medicalpolicies/5.01.586.pdf#search=policy
MEDICAL POLICY - 5.01.586 Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders BCBSA Ref. Policy: 5.01.16 Effective Date: Feb. 1, ...
https://www.premera.com/medicalpolicies/7.01.563.pdf#search=policy
MEDICAL POLICY - 7.01.563 Ablative Treatments for Occipital Neuralgia, Chronic Headaches, ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/7.01.595.pdf#search=policy
MEDICAL POLICY - 7.01.595 Carpal Tunnel Release Surgical Techniques Effective Date: Dec. ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/7.01.597.pdf#search=policy
MEDICAL POLICY - 7.01.597 Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction BCBSA Ref. Policy: 7.01.156 Effective Date: May 1, 2025 Last Revised: Apr. 8, 2025 ...
https://www.premera.com/medicalpolicies/7.01.599.pdf#search=policy
MEDICAL POLICY - 7.01.599 Total Ankle Arthroplasty in Adults Effective Date: Nov. 7, 2025 ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.647_2026-01-02.pdf#search=policy
POLICY - 5.01.647 Medical Necessity Criteria for Custom Open and Preferred Formularies Effective Date: Jan. 2, 2026* Last Revised: Nov. 24, 2025 Replaces: N/A *This policy has been ...
https://www.premera.com/medicalpolicies/6.01.68.pdf#search=policy
MEDICAL POLICY - 6.01.68 Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung BCBSA Ref. Policy: 6.01.68 Effective Date: Jan. 1, 2025 Last ...
https://www.premera.com/medicalpolicies/7.01.168.pdf#search=policy
MEDICAL POLICY - 7.01.168 Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis BCBSA Ref. Policy: 7.01.168 Effective Date: May 1, 2025 Last ...
https://www.premera.com/medicalpolicies/7.01.172.pdf#search=policy
MEDICAL POLICY - 7.01.172 Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation BCBSA Ref. Policy: 7.01.172 Effective Date: Nov. 1, 2025 ...
https://www.premera.com/medicalpolicies/10.01.503.pdf#search=policy
below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ... This policy explains some of the circumstances when anesthesia may be covered by a ...
https://www.premera.com/medicalpolicies/15.01.014.pdf#search=policy
ROUTINE TEST MANAGEMENT POLICY - 15.01.014 Coronavirus Testing in the Outpatient Setting Ref. Policy: G2174 Effective Date: Feb. 6, 2026 Last Revised: Oct. 14, 2025 Replaces: N/A ...
https://www.premera.com/medicalpolicies/3.03.01.pdf#search=policy
PHARMACY / MEDICAL POLICY - 3.03.01 Prescription Digital Health Diagnostic Aid for Autism Spectrum Disorder BCBSA Ref. Policy: 3.03.01 Effective Date: Oct. 1, 2024 Last Revised: ...
https://www.premera.com/medicalpolicies/3.03.03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 3.03.03 Prescription Digital Therapeutics for Attention Deficit/Hyperactivity Disorder BCBSA Ref. Policy: 3.03.03 Effective Date: Oct. 1, 2024 Last ...
https://www.premera.com/medicalpolicies/4.01.502.pdf#search=policy
MEDICAL POLICY - 4.01.502 Surgical Interruption of Pelvic Nerve Pathways for Chronic ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/7.01.587.pdf#search=policy
MEDICAL POLICY - 7.01.587 Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures) BCBSA Ref. Policy: 7.01.14 Effective Date: ...
https://www.premera.com/medicalpolicies/7.01.594.pdf#search=policy
MEDICAL POLICY - 7.01.594 Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease BCBSA Ref. Policy: 7.01.178 Effective Date: Jun. 1, 2025 Last ...
https://www.premera.com/medicalpolicies/7.01.596.pdf#search=policy
MEDICAL POLICY - 7.01.596 Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia BCBSA Ref. Policy: 7.01.167 ...