We’re committed to supporting you in providing quality care and services to our members. Here you will find information on our medical policies, quality improvement program standards, and billing guidelines. The Provider Resource Center provides access to many of our forms, policies, and updates.
Access our Out-of-Area Medical Policy router.
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.
BlueCard Members: To look up out-of-area member's medical policies, please use the Out-of-Area Network Policy option at the bottom of this page.
- Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynotoses
- Allergy Testing, including Selected Blood, Serum and Cellular Testing and Toxicity 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
- Autologous Chondrocyte Transplantation or Implantation
- Bariatric Surgery
- Bioengineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid
- Blood and Blood Components, Platelet Derived Growth Factors and Prolotherapy
- Breast Surgery and Breast Prothesis
- 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 Glucose Monitoring
- Continuous Passive Motion (CPM) in the Home Setting
- Cosmetic and Reconstructive Procedures
- Cosmetic and Reconstructive Procedures (03/01/24)
- Cranial/Scalp/Wig Prosthesis
- Cytochrome P450 Genotype-Guided Treatment Strategy
- Dental Services for Accidental Injury, Gross Deformity, Head and Neck Cancers, and Congenital/Genetic Disorders
- Dental Services for Accidental Injury, Gross Deformity, Head and Neck Cancers, and Congenital/Genetic Disorders (Eff. 03/01/24)
- Dental Services Pediatric (Qualified Health Plans and Applicable Plans)
- Dermatologic Applications of Photodynamic Therapy
- Dermatologic Applications of Photodynamic Therapy (Eff. 03/01/24)
- Diagnosis and Management of Idiopathic Environmental Illness/Intolerance (IEI) (ie, Multiple Chemical Sensitivities)
- Diagnosis and Treatment of Sacroiliac Joint Pain
- Diagnosis and Treatment of Sacroiliac Joint Pain (Eff. 04/01/24)
- Drug Testing in Pain Management and Substance Use Disorder
- Drug Wastage
- Dry Needling of Myofascial Trigger Points
- Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
- Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) (Eff. 03/01/24)
- 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
- Fecal Analysis in Diagnosis of Intestinal Disorders
- Fecal Analysis in Diagnosis of Intestinal Disorders (Eff. 03/01/24)
- Gender Affirming Services (Trans Services)
- 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
- Home Infusion Therapy
- Home Infusion Therapy (NOTE: Applies to State of Vermont Members Only)
- Hospital Beds
- Hospital Grade Electric Breast Pump
- Infertility Treatment Services (NOTE: Applies to ASO Groups Only - does not apply to State of Vermont)
- Interventions for Progressive Scoliosis
- Investigational Services & Procedures
- Light Therapy of Dermatologic Conditions
- Light Therapy of Dermatologic Conditions (Eff. 03/01/24)
- Lumbar Spinal Fusion
- Medical Food for Inherited Metabolic Disease
- Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
- 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
- Nutrient/Nutritional Panel Testing & Intracellular Micronutrient Analysis
- Nutritional Counseling
- Occipital Nerve Stimulation
- Occupational Therapy
- Oral Appliances for Obstructive Sleep Apnea
- Pediatric Neurodevelopmental & Autism Spectrum Disorder (ASD) Screening
- Physical Therapy Medicine
- Radiology - All other Non-Cardiac Imaging
- Radiology - Cardiac Related Imaging
- Single Photon Emission Computed Tomography (SPECT/CT) Imaging for the Evaluation of the Spine
- Sleep Disorders Diagnosis & Treatment
- Speech Language Pathology/Therapy Service
- 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)
- 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 for Gastrointestinal (GI) Disorders
- Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders (Eff. 03/01/24)
Archived medical policies are inactive and no longer updated. Archived policies will remain available for a period of one year. Policies may be archived due to the technology being obsolete or discarded, the technology becoming standard of care and details about its use are well known, and/or 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.
- Access to Obstetrical Gynecological
- Allergy Testing
- Laser Treatment of Port Wine Stains
- Medical Equipment and Supplies/Durable Medical Equipment (DME) and Supplies
- Medical Equipment and Supplies Prosthetics and Orthotics
- New Drugs to Market (NDTM) 2023 (Eff. 07-01-23)
- Nonpharmacologic Treatment of Rosacea
- Out-of-Network Services
View Blue Cross and Blue Shield of Vermont’s practice standards and how we monitor those as part of our quality program.
- Accessibility of Service and Provider Administrative Standards
- Availability of Network Practitioners Analysis Policy
- Clinical Practice Guidelines Policy
- PCP Selection Criteria Policy
- Procedures for Continuity of Care
- Provider Contract Termination Policy
- Quality of Care Risk Investigation
- Site Visit and Medical Record Keeping Policy
- Supervised Practice of Mental Health and Substance Use Trainees
- Vermont Designated Agency Policy
By accessing these policies, I acknowledge the following:
Blue Cross and Blue Shield of Vermont’s payment policies:
- Serve as a reference to assist providers and facilities in submitting accurate claims.
- Outline the basis for reimbursement for covered services.
- Apply to services rendered by participating providers.
- Are subject to changes in coding rules and guidelines, such as those established by CPT and HCPCS; there may be instances where coding changes are applied before the policies are amended.
- May be revised from time to time based on state or federal requirements or changes to provider contracts.
Blue Cross VT payment policies do NOT:
- Provide billing or coding advice.
- Guarantee or determine benefits.
- Control in the event of a conflict with member contracts, provider contracts, medical policies, or claim edits.
- Dictate how other Blue Plans set allowances for care rendered by non-participating providers.
- Constitute medical advice.
Permanent Payment Policy Name
- Acupuncture CPP_02
- Claims Editing CPP_32
- Frequency of Supplies (Diabetic and CPAP BIPAP) CPP_33
- Global Maternity Obstetric Package CPP_16
- Home Births CPP_18
- Home Infusion Therapy CPP_14
- Hub and Spoke System for Opioid Addiction Treatment CPP_05
- Inpatient Hospital Room and Board, Routine Services, Supplies, and Equipment CPP_08
- Medication Therapy Management (MTM) Pharmacy Services CPP_35
- Modifier 22 CPP_06
- Modifier 52 CPP_22
- Multiple Procedure Payment Reduction-Diagnostic Imaging Procedures CPP_09
- Never Events and Hospital-Acquired Conditions CPP_23
- Observation Services CPP_07
- Operating and Recovery Room Services and Supplies CPP_15
- Preventable Readmissions (30-day readmission) CPP_21
- Provider Audit, Sampling and Extrapolation, and Re-Audit Process CPP_19
- Provider-Based Billing CPP_11
- Robotic and Computer Assisted Surgery CPP_04
- Telemedicine CPP_03
- Urgent Care Clinics CPP_12
- Use of Non-Participating Providers CPP_20
In effect until December 31, 2024
- Telephone Only CPP_24 (Eff. 01-01-24)
Blue Cross and Blue Shield of Vermont is required to: “Maximize the number of members receiving care consistent with treatment protocols and practices that are informed by generally accepted medical and scientific evidence and practice parameters consistent with prevailing standards of medical practice as recognized by health care professions in the same specialties as typically provide the procedure or treatment, or diagnose or manage the medical condition, and that are developed with the appropriate clinical input.”
Consistent with this requirement, Blue Cross and Blue Shield of Vermont's quality program has adopted the following guidelines for clinical practice:
Center for Disease Control and Prevention (CDC)
U.S. Preventive Services Task Force (USPST)
- Colorectal Cancer Screenings
- Breast Cancer Screenings
- Cervical Cancer Screenings
- Chlamydia Screenings
- Depression Screenings
American Psychiatric Association (APA)
National Heart, Lung and Blood Institute (NHLBI)
American College of Cardiology (ACC)
American Academy of Child and Adolescent Psychology
Global Initiative for Chronic Obstructive Lung Disease
American Diabetes Association
If you would like to receive any or all of these guidelines by mail, please call (800) 924-3494 or email email@example.com.
Out-of-Area Medical Policy Access
To view the out-of-area Blue Plan's medical policies or general pre-certification/pre-authorization information, please select the type of information requested, enter the first three letters of the member's identification number on their Blue Cross Blue Shield ID card, and click "GO".
If you experience difficulties or need additional information, please contact (800) 676-BLUE or provider services at (800) 924-3494.
Date modified : 09/08/2010