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Blue Cross and Blue Shield of Minnesota policies, page 4

Search Blue Cross and Blue Shield of Minnesota's public medical, payment and drug policies by CPT or HCPCS code, keyword or policy number, with links to the payer's own documents. Links open the payer's own document; check its current version before relying on it.

240 public policies Substrate tracks for Blue Cross and Blue Shield of Minnesota, by title.

Blue Cross and Blue Shield of Minnesota policies
PolicyDetailsCodesSource
Orthognathic SurgeryIV-16 · Effective Sep 28, 2026 · Commercial, Medicaid36Original policy ↗
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders in the HomeVII-35 · Effective Jul 6, 2026 · Commercial, Medicaid7Original policy ↗
Osteochondral Allografts and Autografts in the Treatment of Focal Articular Cartilage LesionsIV-115 · Effective Aug 3, 2026 · Commercial, Medicaid5Original policy ↗
Ovarian and Internal Iliac Vein Embolization as a Treatment for Pelvic Congestion SyndromeV-26 · Effective Oct 27, 2025 · Commercial, Medicaid3Original policy ↗
Panniculectomy/Excision of Redundant Skin or TissueIV-24 · Effective Sep 28, 2026 · Commercial, Medicaid15Original policy ↗
Pelvic Floor Stimulation as a Treatment of Urinary IncontinenceIV-134 · Effective Dec 1, 2025 · Commercial, Medicaid4Original policy ↗
Penile Prosthesis ImplantationIV-166 · Effective Mar 2, 2026 · Commercial, Medicaid7Original policy ↗
Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation TherapyII-81 · Effective Apr 27, 2026 · Commercial, Medicaid10Original policy ↗
Percutaneous Facet Joint DenervationIV-95 · Effective Sep 28, 2026 · Commercial, Medicaid6Original policy ↗
Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial DiseaseIV-183 · Effective Apr 6, 2026 · Commercial, Medicaid70Original policy ↗
Percutaneous Ultrasonic Ablation of Soft TissueIV-160 · Effective Oct 27, 2025 · Commercial, Medicaid2Original policy ↗
Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of PainII-149 · Effective Aug 31, 2026 · Commercial, Medicaid19Original policy ↗
Perirectal Spacer for Use During Radiotherapy for Prostate CancerIV-164 · Effective Jun 1, 2026 · Commercial, Medicaid1Original policy ↗
Peroral Endoscopic MyotomyIV-159 · Effective Apr 27, 2026 · Commercial, Medicaid2Original policy ↗
Photodynamic Therapy for Ocular IndicationsII-205 · Effective Jun 29, 2026 · Commercial, Medicaid3Original policy ↗
Photodynamic Therapy for Skin ConditionsII-46 · Effective Mar 2, 2026 · Commercial, Medicaid5Original policy ↗
Phototherapy in the Treatment of PsoriasisII-39 · Effective Feb 2, 2026 · Commercial, Medicaid11Original policy ↗
Plasma ExchangeII-192 · Effective Aug 31, 2026 · Commercial, Medicaid1Original policy ↗
Platelet-Rich PlasmaII-76 · Effective Mar 2, 2026 · Commercial, Medicaid3Original policy ↗
Positron Emission Tomography (PET) for Cardiac ApplicationsV-31 · Effective Jul 27, 2026 · Commercial, Medicaid9Original policy ↗
Positron Emission Tomography (PET) for Miscellaneous IndicationsV-30 · Effective Jul 27, 2026 · Commercial, Medicaid3Original policy ↗
Positron Emission Tomography (PET) for Oncologic ApplicationsV-32 · Effective Jul 27, 2026 · Commercial, Medicaid10Original policy ↗
Posterior Tibial Nerve StimulationIV-135 · Effective Dec 1, 2025 · Commercial, Medicaid13Original policy ↗
Powered ExoskeletonVII-63 · Effective Mar 30, 2026 · Commercial, Medicaid4Original policy ↗
Pressure-Reducing Support SurfacesVII-54 · Effective Jun 29, 2026 · Commercial, Medicaid18Original policy ↗
ProlotherapyII-06 · Effective Mar 2, 2026 · Commercial, Medicaid1Original policy ↗
Prostatic Artery Embolization for Benign Prostatic Hyperplasia (BPH)IV-177 · Effective Jun 29, 2026 · Commercial, Medicaid2Original policy ↗
Prostatic Urethral LiftIV-148 · Effective Mar 2, 2026 · Commercial, Medicaid4Original policy ↗
Quantitative Sensory TestingII-54 · Effective Apr 27, 2026 · Commercial, Medicaid5Original policy ↗
Reduction MammoplastyIV-32 · Effective Sep 28, 2026 · Commercial, Medicaid1Original policy ↗
Remote Electrical Neuromodulation for MigrainesII-295 · Effective Aug 31, 2026 · Commercial, Medicaid1Original policy ↗
Removal of Skin LesionsIV-138 · Effective Jun 1, 2026 · Commercial, Medicaid29Original policy ↗
Renal Sympathetic DenervationIV-185 · Effective Apr 6, 2026 · Commercial, Medicaid5Original policy ↗
Responsive Neurostimulation for the Treatment of Refractory Focal (Partial) EpilepsyIV-161 · Effective Feb 2, 2026 · Commercial, Medicaid12Original policy ↗
Rhinoplasty, Septorhinoplasty, and SeptoplastyIV-73 · Effective Sep 28, 2026 · Commercial, Medicaid8Original policy ↗
Risk-Reducing MastectomyIV-27 · Effective Sep 28, 2026 · Commercial, Medicaid1Original policy ↗
Sacral Nerve Neuromodulation/Stimulation for Selected ConditionsIV-83 · Effective Sep 1, 2025 · Commercial, Medicaid19Original policy ↗
Sacroiliac Joint FusionIV-126 · Effective Oct 6, 2025 · Commercial, Medicaid3Original policy ↗
Saliva Hormone TestsVI-08 · Effective Apr 27, 2026 · Commercial, Medicaid1Original policy ↗
Saturation Biopsy of the ProstateIV-142 · Effective Mar 2, 2026 · Commercial, Medicaid3Original policy ↗
Secretin Infusion Therapy for AutismII-23 · Effective Feb 2, 2026 · Commercial, Medicaid1Original policy ↗
Selected Treatments for HyperhidrosisII-55 · Effective Dec 1, 2025 · Commercial, Medicaid6Original policy ↗
Selected Treatments for TinnitusII-42 · Effective Aug 3, 2026 · Commercial, Medicaid2Original policy ↗
Selected Treatments for Varicose Veins of the Lower ExtremitiesIV-129 · Effective Mar 30, 2026 · Commercial, Medicaid17Original policy ↗
Single Photon Emission Computed Tomography (SPECT) of the HeadV-29 · Effective Sep 29, 2025 · Commercial, Medicaid2Original policy ↗
Single-Nucleotide Polymorphism (SNP) Breast Cancer Risk AssessmentVI-32 · Effective Mar 2, 2026 · Commercial, Medicaid2Original policy ↗
Site of Service for Selected Outpatient Procedures: Outpatient Hospital and Ambulatory Surgery CenterXI-03 · Effective Mar 2, 2026 · Commercial, Medicaid97Original policy ↗
Speech Generating Devices (SGD)VII-52 · Effective Dec 1, 2025 · Commercial, Medicaid13Original policy ↗
Sphenopalatine Ganglion Nerve BlockII-195 · Effective Jun 29, 2026 · Commercial, Medicaid2Original policy ↗
Spinal Cord and Dorsal Root Ganglion StimulationIV-74 · Effective Sep 7, 2026 · Commercial, Medicaid50Original policy ↗

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Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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