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: 11-30-2020

Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynotoses

Allergy Testing

Ambulance and Medical Transport Services

Ambulatory Cardiac Monitors (effective thru 12/31/2020)

Ambulatory Cardiac Monitors (effective 01/01/2021)

Applied Behavior Analysis (ABA)

Assays of Genetic Expression

Audiology - see "Evaluation of Hearing Impairment"

Autologous Chondrocyte Transplantation or Implantation

Bariatric Surgery

Bio-Engineered Skin and Soft Tissue Substitutes (effective thru 12/31/2020)

Bio-Engineered Skin and Soft Tissue Substitutes (effective 01/01/2021)

Blood and Blood Components and Recombinant and Autologous Platelet-Derived Growth Factors

Breast Surgery

Cardiac Imaging

Charged Particle Radiotherapy for Neoplastic Conditions

Chiropractic Services

Clinical Trials

Cochlear Implant and Implantable Bone Conduction Hearing Aids

Cognitive Rehabilitation

Continuous or Intermittent Glucose Monitoring (CGMS)

Continuous Passive Motion (CPM) in the Home Setting

Cosmetic and Reconstructive Procedures


Cranial/Scalp/Wig Prosthesis (effective thru 12/31/2020)

Cranial/Scalp/Wig Prosthesis (effective 01/01/2021)

Cytochrome P450 Genotype-Guided Treatment Strategy

Dental Services

Dermatologic Applications of Photodynamic Therapy

Diagnosis and Management of Idiopathic Environmental Illness

Diagnosis & Treatment of Sacroiliac Joint Pain

Drug Wastage

Dry Needling of Myofascial Trigger Points

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 (effective thru 12/31/2020)

External Insulin Pumps (effective 01/01/2021)

Fecal Analysis in Diagnosis of Intestinal Disorders

Gastric Electrical Stimulation

Genetic Testing, Including Chromosomal Microarray

GYN Care

Home Infusion Therapy

Home Infusion Therapy
NOTE: ONLY applies to SOV Members

Hospital Beds

Hospital Grade Electric Breast Pump

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

Infertility Services
NOTE: ONLY applies to UVM MC & CVMC Members

Interventions for Progressive Scoliosis

Investigational Services & Procedures

Laser Treatment of Port Wine Stains

Light Therapy for Dermatologic Conditions (formerly Light Therapy for Psoriasis)

Lumbar Spinal Fusion

Medical Equipment and Supplies Durable Medical Equipment (DME) and Supplies

Medical Equipment and Supplies Prosthetics and Orthotics

Medical Food for Inherited Metabolic Disease (IMD)

Monitored Anesthesia Care (MAC)

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

Select Blood, Serum and Cellular Allergy and Toxicity Tests

Sleep Disorders Diagnosis & Treatment

Speech Language Pathology/Therapy Services

Substance Use Disorder Treatment and Pain Management Urine Drug Testing

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

Wearable Cardioverter Defibrillators


Whole Body MRI

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

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.