The HCSC Medical Policy Manual contains Medical
Policies used by Health Care Service Corporation, a Mutual Legal
Reserve Company (HCSC), operating through its divisions, Blue Cross
and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico,
Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield
Medical Policies are based on research that provides evidence of
scientific merit for a particular medical technology. Technology
determinations used in Medical Policies are based in part on criteria
developed by the Blue Cross Blue Shield Association's Technology
Evaluation Center (TEC). They are also based on data from the peer-reviewed
scientific literature, from criteria developed by specialty societies
and from guidelines adopted by other health care organizations.
Medical Policies are used as guidelines for coverage determinations
in health care benefit programs, unless otherwise indicated.
These HCSC Medical Policies apply only to members who have health
insurance through the Blue Cross and Blue Shield plans of Illinois, Texas, New Mexico
and Oklahoma or who are covered by a self-insured group plan administered by these plans.
If your patient is covered under a different Blue Cross and Blue Shield plan, please refer
to the Medical Policies of that plan.
In the event of conflict between a Medical Policy and any plan
document under which a member is entitled to Covered Services, the
Plan document will govern. Plan documents include, but are not limited
to, Certificates of Health Care Benefits, benefit booklets, Summary
Plan Descriptions, and other coverage documents.
Medical technology is constantly evolving and these Medical Policies
are subject to change without notice, except as required by law.
Additional Medical Policies may be developed from time to time and
some may be withdrawn from use. The Medical Policies generally apply
to all fully-insured benefits plans, although some local variations
may exist. Additionally, some benefit plans administered by HCSC,
such as some self-funded employer plans or governmental plans, may
not utilize HCSC Medical Policy. Members should contact their local
customer services representative for specific coverage information.
Restrictions and Limitations
- Medical Policies serve as one of the sets of guidelines
for coverage decisions. Benefit plans vary in coverage and some
plans may not provide coverage for certain services discussed in
the medical policies
- Coverage decisions are subject to all terms and conditions
of the applicable benefit plan, including specific exclusions and
limitations, and to applicable state and/or federal law. Medical
policy does not constitute plan authorization, nor is it an explanation
- The Medical Policies do not constitute medical advice or
medical care. They do not guarantee any results or outcomes. Treating
health care providers are solely responsible for diagnosis, treatment
and medical advice. Members should discuss the information in the
Medical Policies with their treating health care providers. HCSC
is not provider of health care and does not render medical advice.
- Medical Policies can be highly technical and complex and
are provided here for informational purposes.
- HCSC is under no obligation to update this site. Therefore,
the Medical Policies displayed may be out of date. Contact your
Plan representative if you have any questions.
- Medical Policies are interpreted and applied at the sole
discretion of the Plan.
- CPT codes and descriptions are the property of the American
Medical Association with all rights reserved.
The five character codes included in the Health Care Service Corporation's Medical Policy
are obtained from the Physician's Current Procedural Terminology (CPT®),
copyright 2013 by the American Medical Association (AMA). CPT is developed by the AMA as
a listing of descriptive terms and five character identifying codes and modifiers for
reporting medical services and procedures performed by physicians. CPT is a registered
trademark of the AMA.
The responsibility for the content of the Medical Policy is with the Health Care Service
Corporation, and no endorsement by the AMA is intended or should be implied. The AMA
disclaims responsibility for any consequences or liability attributable or related to any
use, nonuse or interpretation of information contained in the Medical Policy. CPT is
provided "as is" without warranty of any kind, either expressed or implied, including but
not limited to the implied warranties of merchantability and fitness for a particular
No fee schedules, basic unit values, relative value guides, conversion factors or scales
are included in any part of CPT. Any use of CPT outside of the Medical Policy should refer
to the most current Physician's Current Procedural Terminology which contains the complete
and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.
If you understand and agree with the terms and conditions stated above, please click "I Agree."