The Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policy manual contains Medical Policies used by Blue Cross Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. 

Medical Policies are based on research that provides evidence of scientific merit for a particular medical technology. Technology determinations used in Medical Policies are based in part on criteria found in the Blue Cross Blue Shield Association's Medical Policy Reference Manual. They are also based on data from the peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations. Medical Policies are used as guidelines for coverage determinations in health care benefit programs, unless otherwise indicated.

These BCBSTX Medical Policies apply only to members who have health insurance through BCBSTX, or who are covered by a self-insured group plan administered by this plan. If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan.

In the event of conflict between a Medical Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Medical technology is constantly evolving, and these Medical Policies are subject to change without notice, except as required by law. Additional Medical Policies may be developed from time to time, and some may be withdrawn from use. The Medical Policies generally apply to all fully-insured benefit plans, although some local variations may exist. Additionally, some benefit plans administered by BCBSTX, such as some self-funded employer plans or governmental plans, may not utilize BCBSTX Medical Policy. Members should contact their local customer services representative for specific coverage information.

Restrictions and Limitations

Medical Policies service as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the Medical Policies.

Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical Policy does not constitute plan authorization, nor is it an explanation of benefits.

The Medical Policies do not constitute medical advice or medical care. They do not guarantee any results or outcomes. Treating health care providers are solely responsible for diagnosis, treatment, and medical advice. Members should discuss the information in the Medical Policies with their treating health care providers. BCBSTX is not a provider of health care and does not render medical advice.

Medical Policies can be highly technical and complex and are provided here for informational purposes.

BCBSTX is under no obligation to update this site. Therefore, the Medical Policies displayed may be out of date. Contact your Plan representative if you have any questions.

Medical Policies are interpreted and applied at the sole discretion of the Plan.

CPT codes and descriptions are the property of the American Medical Association with all rights reserved.

The five-character codes included in the BCBSTX Medical Policies are obtained from the Physician's Current Procedural Terminology (CPT), copyright 2022 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. CPT is a registered trademark of the AMA.

The responsibility for the content of the Medical Policy is with BCBSTX, and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Medical Policy. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose.

No fee schedules, basis unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of the Medical Policy should refer to the most current Physician's Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.

If you understand and agree with the terms and conditions stated above, please click "I Agree".