Blue Cross Blue Shield Minnesota policy

Perirectal Spacer for Use During Radiotherapy for Prostate Cancer

Perirectal Spacer for Use During Radiotherapy for Prostate Cancer is a public Blue Cross Blue Shield Minnesota policy (policy IV-164, effective Jun 1, 2026). It lists 1 CPT or HCPCS code. Not a coverage decision; the payer's own document governs.

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Payer: Blue Cross Blue Shield Minnesota
Policy number: IV-164
Effective: Jun 1, 2026
Line of business: Commercial, Medicaid
Source: securecms.bluecrossmnonline.com

Codes in this policy

The CPT and HCPCS codes the policy names. A policy can name a code it excludes.

Code	Other Blue Cross Blue Shield Minnesota policies
55874	Policies naming 55874

All Blue Cross Blue Shield Minnesota policies

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.