• Medical Policies

    Premera offers access to more than 300 medical policies online. Since we’re continually updating these pages, we encourage you to visit often. The policies are in Adobe PDF format. Individual plans use different medical policies. View individual plan medical policies and also View our HMO medical policies.

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370 results found for policy
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8.03.502 Physical Medicine and Rehabilitation - Physical Therapy...
https://www.premera.com/medicalpolicies/8.03.502.pdf#search=policy
MEDICAL POLICY - 8.03.502 Physical Medicine and Rehabilitation - Physical Therapy and ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
1.01.18 Pneumatic Compression Pumps for Treatment of Lymphedema...
https://www.premera.com/medicalpolicies/1.01.18.pdf#search=policy
MEDICAL POLICY - 1.01.18 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers BCBSA Ref. Policy: 1.01.18 Effective Date: June 1, 2023 Last Revised: May 5, ...
2.01.16 Recombinant and Autologous Platelet-Derived Growth Factors...
https://www.premera.com/medicalpolicies/2.01.16.pdf#search=policy
MEDICAL POLICY - 2.01.16 Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions BCBSA Ref. Policy: 2.01.16 Effective Date: ...
2.03.07 Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for...
https://www.premera.com/medicalpolicies/2.03.07.pdf#search=policy
MEDICAL POLICY - 2.03.07 Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Select Intra-Abdominal and Pelvic Malignancies BCBSA Ref. Policy: 2.03.07 Effective Date: Oct. 1, ...
2.04.73 Intracellular Micronutrient Analysis
https://www.premera.com/medicalpolicies/2.04.73.pdf#search=policy
MEDICAL POLICY - 2.04.73 Intracellular Micronutrient Analysis BCBSA Ref. Policy: 2.04.73 Effective Date: Mar. 1, 2024 Last Revised: Feb. 12, 2024 Replaces: N/A RELATED MEDICAL ...
5.01.518 BCR-ABL Kinase Inhibitors
https://www.premera.com/medicalpolicies/5.01.518.pdf#search=policy
PHARMACY POLICY - 5.01.518 BCR-ABL Kinase Inhibitors Effective Date: Dec. 1, 2023 Last ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
5.01.527 Ampyra® (Dalfampridine)
https://www.premera.com/medicalpolicies/5.01.527.pdf#search=policy
PHARMACY POLICY - 5.01.527 Ampyra® (Dalfampridine) Effective Date: June 1, 2023 Last ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
5.01.529 Management of Opioid Therapy
https://www.premera.com/medicalpolicies/5.01.529.pdf#search=policy
PHARMACY POLICY - 5.01.529 Management of Opioid Therapy Effective Date: Apr. 1, 2023 Last ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
6.01.521 Bone Mineral Density Studies
https://www.premera.com/medicalpolicies/6.01.521.pdf#search=policy
MEDICAL POLICY - 6.01.521 Bone Mineral Density Studies BCBSA Ref Policy: 6.01.01 Effective Date: Dec. 1, 2023 Last Revised: Nov. 6, 2023 Replaces: N/A RELATED MEDICAL POLICIES: ...
7.01.108 Artificial Intervertebral Disc: Cervical Spine
https://www.premera.com/medicalpolicies/7.01.108.pdf#search=policy
MEDICAL POLICY - 7.01.108 Artificial Intervertebral Disc: Cervical Spine BCBSA Ref. Policy: 7.01.108 Effective Date: July 1, 2022 Last Revised: June 13, 2022 Replaces: 7.01.537 ...
7.01.113 Bioengineered Skin and Soft Tissue Substitutes
https://www.premera.com/medicalpolicies/7.01.113.pdf#search=policy
MEDICAL POLICY - 7.01.113 Bioengineered Skin and Soft Tissue Substitutes BCBSA Ref. Policy: 7.01.113 Effective Date: April 1, 2023 Last Revised: April 1, 2024 Replaces: N/A RELATED ...
7.01.131 Transcatheter Pulmonary Valve Implantation
https://www.premera.com/medicalpolicies/7.01.131.pdf#search=policy
MEDICAL POLICY - 7.01.131 Transcatheter Pulmonary Valve Implantation BCBSA Ref. Policy: 7.01.131 Effective Date: Sept. 1, 2023 Last Revised: Aug. 7, 2023 Replaces: N/A RELATED ...
7.01.139 Peripheral Subcutaneous Field Stimulation
https://www.premera.com/medicalpolicies/7.01.139.pdf#search=policy
MEDICAL POLICY - 7.01.139 Peripheral Subcutaneous Field Stimulation BCBSA Ref. Policy: 7.01.139 Effective Date: July 1, 2023 Last Revised: Jan. 1, 2024 Replaces: N/A RELATED ...
7.01.547 Implantable Bone-Conduction and Bone-Anchored Hearing...
https://www.premera.com/medicalpolicies/7.01.547.pdf#search=policy
MEDICAL POLICY - 7.01.547 Implantable Bone-Conduction and Bone-Anchored Hearing Aids BCBSA Ref. Policy: 7.01.03 Effective Date: May 1, 2023 Last Revised: April 10, 2023 Replaces: ...
7.01.72 Percutaneous Intradiscal Electrothermal Annuloplasty...
https://www.premera.com/medicalpolicies/7.01.72.pdf#search=policy
POLICY - 7.01.72 Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty, and Intraosseous Basivertebral Nerve Ablation BCBSA Ref. Policy: ...
7.03.09 Heart Transplant
https://www.premera.com/medicalpolicies/7.03.09.pdf#search=policy
MEDICAL POLICY - 7.03.09 Heart Transplant BCBSA Ref. Policy: 7.03.09 Effective Date: Nov. 1, 2023 Last Revised: Oct. 9, 2023 Replaces: Extracted from 7.03.509 RELATED MEDICAL ...
8.01.535 Chelation Therapy
https://www.premera.com/medicalpolicies/8.01.535.pdf#search=policy
MEDICAL POLICY - 8.01.535 Chelation Therapy BCBSA Ref. Policy: 8.01.02 Effective Date: May 1, 2023 Last Revised: Apr. 10, 2023 Replaces: 8.01.02 RELATED MEDICAL POLICIES: None ...
9.02.501 Orthognathic Surgery
https://www.premera.com/medicalpolicies/9.02.501.pdf#search=policy
MEDICAL POLICY - 9.02.501 Orthognathic Surgery Effective Date: Jan. 1, 2024 Last Revised: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
2.01.535 Temporomandibular Joint Disorder
https://www.premera.com/medicalpolicies/2.01.535.pdf#search=policy
MEDICAL POLICY - 2.01.535 Temporomandibular Joint Disorder BCBSA Ref. Policy: 2.01.21, 5.01.05 Effective Date: May 1, 2023 Last Revised: Apr. 10, 2023 Replaces: 2.01.21 RELATED ...
2.04.507 Testing Serum Vitamin D Levels
https://www.premera.com/medicalpolicies/2.04.507.pdf#search=policy
MEDICAL POLICY - 2.04.507 Testing Serum Vitamin D Levels BCBSA Ref Policy: 2.04.135 Effective Date: Mar. 1, 2024 Last Revised: Feb. 12, 2024 Replaces: 2.04.135 RELATED MEDICAL ...
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