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 Blue Cross and Blue Shield of Vermont 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. 


BlueCard Members:  To look up out-of-area member's medical policies, please use the Medical Policy Router.


Note: All Medical Polices are in Adobe PDF file format.
 

Vermont Medical Policies

Updated: 05-03-2021

Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynotoses 

Allergy Testing 

Ambulance and Medical Transport Services (Ground, Air and Water)

Ambulatory Cardiac Monitors and Outpatient Telemetry 

Applied Behavior Analysis (ABA)

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer 

Audiology - see "Evaluation of Hearing Impairment"

Autologous Chondrocyte Transplantation or Implantation

Bariatric Surgery

Bio-Engineered Skin and Soft Tissue Substitutes

Blood and Blood Components, Platelet Derived Growth Factors and Prolotherapy 

Breast Surgery and Breast Prothesis 

Cardiac Imaging

Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

Chiropractic Services

Clinical Trials

Cochlear Implant and Implantable Bone Conduction Hearing Aids

Cognitive Rehabilitation

Continuous or Intermittent Glucose Monitoring (CGMS) in Interstitial Fluid 

Continuous Passive Motion (CPM) in the Home Setting

Cosmetic and Reconstructive Procedures

COVID-19 Acute Outpatient Treatment

Cranial/Scalp/Wig Prosthesis

Cytochrome P450 Genotype-Guided Treatment Strategy

Dental Services

Dermatologic Applications of Photodynamic Therapy 

Diagnosis and Management of Idiopathic Environmental Illness/Intolerance (IEI) (ie, Multiple Chemical Sensitivities)

Diagnosis & Treatment of Sacroiliac Joint Pain

Drug Wastage 

Dry Needling of Myofascial Trigger Points

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) 

Electrical Bone Growth Stimulation of the Appendicular Skeleton

Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures

Enteral Nutrition

Evaluation of Hearing Impairment

External Insulin Pumps

External Insulin Pumps (Eff. 06-01-2021)

Fecal Analysis in Diagnosis of Intestinal Disorders 

Gastric Electrical Stimulation

Genetic Testing, Including Chromosomal Microarray Analysis and Next-Generation Sequencing Panels, for the Evaluation of Developmental Delay/Intellectual Disability, Autism Spectrum Disorder and/or Congenital Anomalies

Access to Obstetrical/Gynecological Health Care Services

Home Infusion Therapy

Home Infusion Therapy
NOTE: ONLY applies to SOV Members

Hospital Beds

Hospital Grade Electric Breast Pump

Infertility Treatment Services 
Applies to ASO groups only - Does not apply to UVMMC/CVMC

Infertility Treatment Services 
NOTE: ONLY applies to UVMMC & CVMC Members

Infertility Treatment Services 
NOTE: ONLY applies to UVMMC & CVMC Members (Eff. 06-01-2021)

Interventions for Progressive Scoliosis

Investigational Services & Procedures

Ketamine

Laser Treatment of Port Wine Stains 

Light Therapy for Dermatologic Conditions

Lumbar Spinal Fusion

Medical Food for Inherited Metabolic Disease (IMD)

Monitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy, Bronchoscopy, or Interventional Procedures in Outpatient Settings

Negative Pressure Wound Therapy in the Outpatient Setting

Neuromuscular Electrical Stimulator (NMES) 

Neuropsychological and Psychological Testing

Noninvasive Radiologic Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease

Nonpharmacologic Treatment of Rosacea 

Nutrient/Nutritional Panel Testing & Intracellular Micronutrient Analysis

Nutritional Counseling

Occipital Nerve Stimulation

Occupational Therapy 

Off-Label Drug

Oral Appliances for Obstructive Sleep Apnea (OSA)

Out-of-Network Services

Pediatric Neurodevelopmental & Autism Spectrum Disorder (ASD) Screening

Physical Therapy/Medicine 

Prostatic Urethral Lift

Radiology - All other Non-Cardiac Imaging

Radiology - Cardiac Related Imaging

Selected Blood, Serum and Cellular Allergy and Toxicity Tests

Single Photon Emission Computed Tomography (SPECT/CT) Imaging for the Evaluation of the Spine

Sleep Disorders Diagnosis & Treatment

Speech Language Pathology/Therapy Services

Substance Use Disorder Treatment and Pain Management: Urine Drug Testing 

Telemedicine and Telehealth 

Temporomandibular Joint (TMJ) Dysfunction 

Total Parenteral Nutrition (TPN) in the Home Setting

Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

Transcutaneous Electrical Nerve Stimulation (TENS)

Transgender Services

Treatment of Varicose Veins/Venous Insufficiency

Tumor Treatment Fields Therapy for CNS Cancers

Use of Intravascular Ultrasound and Optical Coherence Tomography 

Vision Services and Medical Coverage for Ocular Disease

Vision Services and Medical Coverage for Ocular Disease (Eff. 06-01-2021)

Wearable Cardioverter Defibrillators

Wheelchairs

Whole Body MRI 

Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus & Colon

Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus & Colon (Eff. 06-01-2021)


Archived Medical Policies

Blue Cross and Blue Shield of Vermont 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
  • Blue Cross and Blue Shield of Vermont 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.