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Vermont Medical Policies
These documents are provided for informational purposes only and are not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the subscriber certificate that is in effect at the time services are rendered. Medical practices and knowledge are constantly changing and we reserve the right to review and revise medical policies periodically and without notice.
When available, we may utilize BCBSVT approved medical policies or those specific to plans as outlined below. When an appropriate policy does not exist we may utilize the medical policies of the national Blue Cross & Blue Shield Association as guidance to determine medical necessity. These policies are available on request by providers.
Note: All Medical Polices are in Adobe PDF file () format.
Archived Medical Policies
BCBSVT archived medical policies are inactive; once archived, policies are no longer updated. Archived policies will remain available for a period of one year.
Policies may be archived because:
- the technology is obsolete or discarded
- the technology has become standard of care and details about its use are well known
- BCBSVT is no longer implementing the policy
The information in the archived policies is current through the last review date before the policy was archived. These policies may be useful for providing background information or for understanding benefit determinations made when the policy was active. However, because archived policies are not updated, providers should not rely on them as a source of information with respect to current requests for coverage.
- Cancer Antigen 125 Testing
- Cardiac Rehabilitation
- Early Childhood Developmental Disorders, Including Autism
- Evaluation and Management of Autism Spectrum Disorder and/or Moderate or Severe Intellectual Disability
- Out-of-Network Medical Travel Reimbursement Policy
NOTE: ONLY applies to UVM MC Members
- Oxygen Therapy
- Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction
- Private Duty Nursing
- Pulmonary Rehab