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Medicine Section

Policy Name	Policy ID Number	Date Modified
Auricular Electrostimulation	M-MED146	05/01/2023
Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions	M-MED77	01/01/2024
Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products	M-MED170	04/01/2024
Cardiac Hemodynamic and Thoracic Fluid Index Monitoring for the Management of Heart Failure in the Outpatient Setting	M-MED33	08/01/2023
Cell Therapy for Peripheral Arterial Disease	M-MED141	01/01/2024
Charged-Particle (Proton) Radiotherapy	M-MED49	10/01/2023
Clinical Trials and Investigational Device Exemption (IDE) Studies	M-MED150	02/01/2024
Coverage with Evidence Development (CED) Studies and Registries	M-MED156	09/01/2023
Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder	M-MED175.01	12/01/2023
Digital Therapeutic Products for Chronic Low Back Pain	M-MED175.03	12/01/2023
Digital Therapeutic Products for Substance Use Disorders	M-MED175.02	12/01/2023
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults	M-MED152	12/01/2023
Extracorporeal Shock Wave Therapy (ESWT)	M-MED90	01/01/2024
Gender Affirming Interventions for Gender Dysphoria	M-MED153	01/01/2024
Hyperoxemic Reperfusion Therapy	M-MED173	09/01/2023
Immunological Cellular Therapies and Gene Therapies	M-MED42	07/01/2023
In Vivo Analysis of Colorectal Lesions	M-MED104	02/01/2024
Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS) Head, Neck and Thyroid	M-MED164	03/01/2024
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities	M-MED165	03/01/2024
Intensity Modulated Radiotherapy (IMRT) for Breast Cancer	M-MED166	03/01/2024
Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk	M-MED167	03/01/2024
Investigational (Experimental) Services, New and Emerging Medical Technologies and Procedures, and Other Non-Covered Services	M-MED149	04/01/2024
Laser Interstitial Thermal Therapy	M-MED177	04/01/2024
Low-Level Laser Therapy	M-MED105	01/01/2024
Measurement of Exhaled Breath Condensates in the Diagnosis and Management of Respiratory Disorders	M-MED108	03/01/2024
Myocardial Strain Imaging	M-MED168	04/01/2024
Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow	M-MED142	01/01/2024
Periurethral Transperineal Adjustable Balloon Continence Device	M-MED176	01/01/2024
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia	M-MED100	12/01/2023
Quantitative Sensory Testing	M-MED91	09/01/2023
Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE)	M-MED140	04/01/2024
Signal-Averaged Electrocardiography (SAECG)	M-MED21	06/01/2023
Skin Lesion Imaging and Spectroscopy	M-MED174	11/01/2023
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy	M-MED121	02/01/2024
Surface Electromyography (SEMG) Including Paraspinal SEMG	M-MED73	09/01/2023
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders	M-MED148	01/01/2024
Vestibular Evoked Myogenic Potential Testing	M-MED169	03/01/2024
Whole Body Hyperthermia	M-MED15	10/01/2023


	The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state. The Regence Group and each of its affiliate Plans are independent licensees of the Blue Cross and Blue Shield Association.