| Medical Guidelines | Reason for Update |
|---|---|
| Allergen Testing AHS – G2031 | Reviewed by Avalon 2nd Quarter 2026 CAB. Description, Policy Guidelines, and References updated. Coverage criteria 1 under the When Covered section edited for clarity and now reads: “When limited to allergens chosen for testing based on an individual’s history, physical examination, and environment, reimbursement is allowed for specific IgE in-vitro allergy testing (up to 40 allergen specific antibodies per year).” Added new coverage criteria number 6 to Not Covered section: “Reimbursement is not allowed for specific IgE in-vitro allergy testing when performed on the same day as skin prick testing.” Added code 95004 to Billing/Coding section. Medical Director reviewed 4/2026. Notification given 5/27/26 for effective date 8/5/26. |
| Biomarker Testing for Autoimmune Rheumatic Disease AHS - G2022 | Reviewed by Avalon for 2nd Quarter 2026 CAB. Updated description, policy guidelines, and references. Updates made to coverage criteria for clarity and consistency. Added 0522U to Billing/Coding section. No change to policy intent. Medical Director review 4/2026. |
| Cardiovascular Disease Risk Assessment AHS – G2050 | Reviewed by Avalon 2nd Quarter 2026 CAB. Policy Guidelines and References updated. Code 83876 added to Billing/Coding section. Updates to When Covered section: “For individuals 18 years of age or older” removed from CC1. Changed “Every 4 years” to “Every 5 years” in CC1) a) i) Added “10-year ASCVD risk cannot be calculated for individuals 39 years of age or younger” to CC1) a) ii). Moved CC1) d) into CC1) b) annual testing based on elevated risk of dyslipidemia. Addition of CC1) b) xiii), 1) b) xiv), and 1) b) xv): “xiii) Family history of elevated lipids xiv. Premature heart disease xv. History of stroke”. Added “therapy (i.e., individuals with hyperlipidemia, transplant patients)” to CC1) c) Annual recommendation changed in CC1) c) iii) to “iii) Every three to twelve months as clinically indicated.” Added “(no more than once every four weeks)” to CC2). Removed CC4). Updates to the Not Covered section: Criteria bullet point 1 updated and now reads "CRP testing (conventional measurement or high-sensitivity measurement) for cardiovascular disease risk assessment," added "myeloperoxidase” to criteria bullet point 4. Removed "For CVD risk assessment" from criteria bullet point 7. Medical Director review 4/2026. Notification given 5/27/2026 for effective date 8/5/2026. |
| Colorectal Cancer Screening AHS - B0001 | Policy archived as a result of adoption of Colorectal Cancer Screening: AHS-G2181 policy. |
| Colorectal Cancer Screening AHS – G2181 | New policy developed with incorporation of criteria from the “When Covered” and “When Not Covered” sections from the recently archived policy, Colorectal Cancer Screening-B0001. BCBSNC will provide coverage for colorectal cancer screening when it is determined the medical criteria or reimbursement guidelines below are met. Medical Director review 4/2026. |
| Diagnosis of Vaginitis AHS - M2057 | Reviewed by Avalon 2nd Quarter 2026 CAB. Description, Policy Guidelines and Reference sections updated. All individual testing for Trichomonas is now addressed in Diagnostic Testing of Sexually Transmitted Infections AHS – G2157. Updates made to When Covered section for clarity and consistency. CC2 added “a multi-pathogen panel testing using,” as individual direct probe testing provides minimal information and use of direct probe testing should be restricted to the multi-pathogen panel test. CC4 changed qualitative PCR to NAAT, as individual Candida testing should be amplified probe testing, not direct probe testing. Updates made to When Not Covered section for clarity and consistency. CC3 changed NAAT to “nucleic acid testing (NAT),” added “direct probe testing, conditions not addressed above” to Candida and adding “or Gardnerella (e.g., direct probe testing).” Removed 87660 from Billing/Coding section. Medical Director review 4/2026. |
| Diagnostic Testing of Sexually Transmitted Infections AHS – G2157 | Reviewed by Avalon 2nd Quarter 2026 CAB. When covered section updated as follows: Moving prenatal STI screening from the Prenatal Screening policy into this policy. These can be found under antibody screening for syphilis, qualitative NAAT testing and NAAT screening for chlamydia, and NAAT screening for gonorrhea. “At least three months after initial gonorrhea diagnosis as a TOC.” Added to qualitative NAAT for gonorrhea. Changed serologic testing for HSV-2 to antibody testing for HSV-2. Removed Hepatitis B testing for those being considered for PrEP is now addressed in the Hepatitis Testing: AHS-G2036 policy. When Not Covered section addition as follows: Added “Reimbursement for treponemal Ig testing is not allowed for individuals who are currently diagnosed with a syphilis infection or who have a past history of a syphilis infection.” and replaced “immunoassay” with “antibody and antigen” for clarity on HSV-1 testing and added “antigen testing for HSV-2,” now reads: “Reimbursement is not allowed for antibody and antigen testing for HSV-1 and/or herpes simplex (non-specific type test) and antigen testing for HSV-2.” Addition of antigen testing, now reads: “Reimbursement is not allowed for polymerase chain reaction (PCR) testing, nucleic acid amplification testing (NAAT), and antigen testing for syphilis.” Addition of culture testing, changing “serology” to “antibody and antigen testing,” now reads: “Reimbursement is not allowed for culture testing, antibody testing, and antigen testing for chlamydia or lymphogranuloma venereum (LGV).” Removed HPV, as ordering HPV testing is no longer defined by direct/amplified/quantitative and instead just by HPV type. Changes to the vaginitis policy result in all targeted Trich testing being managed by this policy, results in addition of “6. Trichomonas vaginalis.” Note 7 updated to include Prostatitis. All Notes updated to reference correct coverage/noncoverage stance due to changes in the When Covered and When Not Covered sections. Policy Guidelines and References also updated. Billing and Coding section updated as follows: removed CPT codes:86704, 86706, 87340, and G0499, then added 87140, 87270, 87285, 87320, 87660, and 87810. Medical Director review 4/2026. Notification given 5/27/2026 for effective date 8/5/2026. |
| Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS - G2059 | Reviewed by Avalon 2nd Quarter 2026 CAB. When Epithelial Cell Cytology in Breast Cancer Risk Assessment is not covered updated to read “Reimbursement is not allowed for cytologic analysis of epithelial cells (e.g., nipple aspiration, fine-needle aspiration [FNA]) to diagnose, to screen for, or to assess risk of developing breast cancer.” Policy Guidelines updated, added National Cancer Institute (NCI) under guidelines and recommendations. References update. No change to policy intent. Medical Director review 4/2026. |
| Esophageal Pathology Testing AHS - M2171 | Reviewed by Avalon 2nd Quarter 2026 CAB. Policy Guidelines and References updated. Coverage criteria 4. a. under the When Covered section updated to add repotrectinib as indicated medication, changed “NTRK gene fusion” to “NTRK1/2/3 gene fusion”. Coverage criteria 3 under Not Covered section updated to replace “BarreGEN test” with “TissueCypher® Barrett's Esophagus Assay,” as BarreGEN is no longer available on the market. Codes 88112, 88160, 88305, and 88312 removed from the Billing/Coding section. Medical Director review 4/2026. |
| Evaluation of Dry Eyes AHS - G2138 | Reviewed by Avalon 2nd Quarter 2026 CAB. When covered section updated to add a) For individuals who are suspected of having dry eye disease. Policy Guidelines updated. References updated. Medical Director review 4/2026. |
| Fibromyalgia Testing AHS - M2177 | Reviewed by Avalon 2nd Quarter 2026 CAB. Policy Guidelines, and References updated. No change to policy statement. Medical Director review 4/2026. |
| Flow Cytometry AHS - F2019 | Reviewed by Avalon 2nd Quarter 2026 CAB. Medical Director review 4/2026. Updated Policy Guidelines and references. Updated reimbursement limitations found in the Billing/Coding section, specifically “Codes 88184-88189 should not be used in conjunction with codes 86355, 86356, 86357, 86359, 86360, 86361, 86367.” No change to policy intent. |
| Folate Testing AHS - G2154 | Reviewed by Avalon 2nd Quarter 2026 CAB. Updated policy guidelines. Added references. No change to policy statement. Medical Director review 4/2026. |
| Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 | Reviewed by Avalon 2nd Quarter 2026 CAB. References updated. When covered section updated to combine coverage criteria #1 and #2 to now read “For individuals who have prostate cancer, who have no significant co-morbidities, including advanced age, to suggest they have an estimated life expectancy of less than ten years, and for whom pathological examination showed localized adenocarcinoma of the prostate with no clinical evidence of metastasis or lymph node involvement, the one-time use of one of the following tumor-based assays to guide the management of prostate cancer is considered medically necessary. a) For individuals with low-risk or favorable intermediate-risk disease, as defined by the NCCN (see Note 1): Prolaris®, Genomic Prostate Score®, or Decipher®. b) For individuals with intermediate-risk disease, as defined by the NCCN (see Note 1): ArteraAI Prostate. c)For individuals with unfavorable intermediate-risk and high-risk disease, as defined by the NCCN (see Note 1), the one-time use of Prolaris® or Decipher®.” When not covered section updated to add the following statements, “For individuals for whom a tumor-based assay to guide the management of prostate cancer (i.e., ArteraAI Prostate, Decipher®, Genomic Prostate Score®, Prolaris®) has already been ordered, the use of a different approved tumor-based assay reimbursement is not allowed, and For individuals for whom a non-invasive test designed to assess the probability of prostate cancer and inform the need for prostate biopsy (i.e., EPI, 4Kscore, IsoPSA, PHI) has already been ordered, the use of a different approved non-invasive test reimbursement is not allowed.” Update Policy Guidelines. Added CPT code 0376U to the Billing/Coding section and deleted CPT code 0550U. Medical Director review 4/2026. |
| Genetic Testing for Connective Tissue Disorders AHS - M2144 | Reviewed by Avalon 2nd Quarter 2026 CAB. Updated Policy Guidelines and References. Medical Director review 4/2026. |
| Genetic Testing for Hereditary Hearing Loss AHS – G2148 | Reviewed by Avalon 2nd Quarter 2026 CAB. Policy Guidelines and References updated. Medical Director review 4/2026. |
| Genetic Testing for Polyposis Syndromes AHS-M2024 | Reviewed by Avalon 2nd Quarter 2026 CAB. Formatting changes made to When Covered and When Not Covered sections. When Covered section updated as follows: “pathogenic” was changed to “pathogenic/likely pathogenic (P/LP)” throughout criteria and “mutation” was changed to variant throughout criteria. CC3: Removed CC3.a. and moved CC3.a.i. into former CC3.b., now CC3.a., number remains CC3.a.i. Removed CC3.b.iii. Primary brain tumor (e.g., medulloblastoma)., CC3.b.vi. Osteomas, and CC3.b.vii. Supernumerary teeth, as these conditions are no longer included in the genetic testing workflow provided by the NCCN. Added new CC3.b. and CC3.c.: “b) For individuals who meet criteria for serrated polyposis syndrome (see Note 4) with at least some of the qualifying polyps being adenomas. c) For individuals who were diagnosed with any cancer before 30 years of age and for whom an APC P/LP variant was found on tumor-only genomic testing.” New CC5.d.: “d) For individuals for whom a BMPR1A or SMAD4 P/LP variant was detected on any tumor type by tumor genomic profiling in the absence of germline mutation testing.” New CC6.d.: “d) For individuals for whom an STK11 P/LP variant was detected on any tumor type by tumor genomic profiling in the absence of germline mutation testing.”Added Note 4 defining serrated polyposis syndrome. Policy Guidelines and References updated. Medical Director review 4/2026. |
| Genetic Testing of Mitochondrial Disorders AHS – M2085 | Code 0537U added to the Billing/Coding section. |
| Helicobacter Pylori Testing AHS – G2044 | Reviewed by Avalon 2nd Quarter 2026 CAB. Policy Guidelines and References updated. No change to policy statement. Medical Director review 4/2026. |
| Hepatitis Testing AHS – G2036 | Reviewed by Avalon 2nd Quarter 2026 CAB. Formatting changes made to When Covered and When Not Covered sections. When Covered section updated as follows: Removed the language “triple panel testing” from any criteria., but the applicable criteria still specify that HBsAg, anti-HBs, and anti-HBc testing are the primary three biomarkers used for most HBV antibody screening. New 2bxv sub-criterion, states: “For individuals who are about to begin or who are receiving pre-exposure prophylaxis (PrEP)” when discussing reimbursement for annual HBV infection screening for asymptomatic, non-pregnant individuals. For consistency in management, moving prenatal hepatitis testing recommendations from the Prenatal Screening (Nongenetic) AHS - G2035 policy to this policy, results in new criterion #3 under Hepatitis B and criterion #4 under Hepatitis C. Policy Guidelines and References updated. Removed CPT code 87799 from the Billing/Coding section. Medical Director review 4/2026. |
| Human Immunodeficiency Virus AHS – M2116 | Reviewed by Avalon 2nd Quarter 2026 CAB. When Not Covered section addition as follows: “Reimbursement is not allowed for screening for HIV-1 and HIV-2 using an antibody test that does not provide rapid results and does not incorporate antigen testing.” Policy Guidelines and References also updated. Billing and Coding section updated as follows: removed cpt code 86689. Medical Director review 4/2026. Notification given 5/27/2026 for effective date 8/5/2026. |
| Lyme Disease Testing AHS – G2143 | Reviewed by Avalon 2nd Quarter 2026 CAB. Wording edits made to When Covered and When Not Covered sections for clarity and information moved to newly created Note 1 which define signs/symptoms of early and late untreated Lyme disease and note that individuals presenting with EM should be clinically diagnosed and treated without a need for laboratory testing. When Covered section updated as follows: combined the contents of criterion #1 (now deleted) into updated criterion 1 resulting in new 1a and 1b. New criterion #2 created which reads, “Reimbursement is allowed for repeat serologic testing (no sooner than four weeks after previous test) when symptoms persist for individuals who tested negative by serologic testing.” Policy Guidelines and References updated. No change to policy intent. Medical Director review 4/2026. |
| Micronutrient Analysis AHS – G2099 | Reviewed by Avalon 2nd Quarter 2026 CAB. Description, Policy Guidelines and References updated. Title changed to Micronutrient Testing. Policy statement updated and now reads: “Reimbursement for Micronutrient Testing is not allowed.” Added new coverage criteria to Not Covered section: “Reimbursement is not allowed for serum micronutrient testing as a general screen for nutritional disorders.” Removed codes 82607, 82652, 82725, 82746, 84999, 86353, and 88348 from the Billing/Coding section. Medical Director review 4/2026. |
| Molecular Diagnostics for Breast Cancer Prognosis AHS - M2020 | Reviewed by Avalon 2nd Quarter 2026 CAB. When covered section updated for clarity and consistency, coverage criteria #2 updated to read “For individuals who have been diagnosed with invasive breast cancer who have completed staging, and who are being considered for adjuvant chemotherapy, use of the Oncotype DX 21-gene expression, assay (See Note 1) is considered medically when all of the following criteria are also met.” Coverage criteria #3 and #4 updated to add reference Note1. Coverage criteria #5 updated to read “For individuals who have been diagnosed with T1-T3, HR-positive, HER2-negative breast cancer, use of the Breast Cancer Index (BCI) test on a surgically excised sample to determine the benefit of extended adjuvant endocrine therapy is considered medically necessary.” No change to policy intent. Note 1 updated to read “The assay should only be ordered after subsequent pathology examination of the tumor has been completed and determined to meet the above criteria (i.e., a core needle biopsy sample may only be used for the molecular diagnostic test if staging has been performed on the tumor). For patients who have multiple primary tumors, a specimen from the tumor with the most aggressive histological characteristics should be submitted for testing. It is not necessary to conduct testing on each tumor; treatment is based on the most aggressive lesion.” Policy Guidelines updated. Medical Director review 4/2026. |
| Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 | Reviewed by Avalon 2nd Quarter 2026 CAB. Medical Director review 4/2026. Updated policy guidelines and references. No change to policy statement. |
| Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 | Reviewed by Avalon 2nd Quarter 2026 CAB. When Covered section updated coverage criteria #1 to read “For the diagnosis of individuals presenting with clinical, laboratory, or pathological findings suggesting classic forms of myeloproliferative neoplasms (MPN) (e.g. polycythemia vera [PV], essential thrombocythemia [ET], or primary myelofibrosis [PMF]), JAK2, CALR and MPL mutation testing is considered medically necessary in any the following situations:” word “and” replacing word “or.” References updated. Policy Guidelines updated. Medical Director review 4/2026. |
| Onychomycosis Testing AHS - M2172 | Reviewed by Avalon for 2nd Quarter 2026 CAB. Description, Policy Guidelines, and References updated. No change to policy statement. Medical Director review 4/2026. |
| Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153 | Reviewed by Avalon 2nd Quarter 2026 CAB. Description, Policy Guidelines and References updated. Coverage criteria 1 under the When Covered section edited and now reads: "1. For individuals presenting with signs and symptoms of acute pancreatitis (see Note 1), reimbursement is allowed for measurement of serum lipase (no more than one test per day in the outpatient setting)." Updates to the Not Covered section: removed coverage criteria 1 and 5 and renumbered remaining criteria, edited former coverage criteria 2 (now coverage criteria 1) to remove "serum." Code 86141 added to the Billing/Coding section. Medical Director review 4/2026. |
| Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS - G2164 | Reviewed by Avalon 2nd Quarter 2026 CAB. Updated description, policy guidelines, and references. Updated coverage criteria as follows: Added “hormone” to “serum intact parathyroid hormone” in #1. Updated remaining coverage criteria for consistency and clarity, and remove duplicative statements and wording. Medical Director review 4/2026. |
| Pharmacogenetics Testing AHS - M2021 | Reviewed by Avalon 2nd Quarter 2026 CAB. Updated Policy Guidelines and References. Medical Director review 4/2026. |
| Pre-Implantation Genetic Testing AHS - M2039 | Reviewed by Avalon 2nd Quarter 2026 CAB. Updated Policy Guidelines, and References. No change to policy statement. Medical Director review 4/2026. |
| Prostate Specific Antigen (PSA) Testing AHS - G2008 | Reviewed by Avalon 2nd Quarter 2026 CAB. When covered section updated for clarity coverage criteria #1 updated and the word initial added, statement now reads “Reimbursement is allowed for average-risk individuals 45 years of age and older (see Note 1), initial screening for prostate cancer with the total prostate-specific antigen (PSA) test.” Coverage criteria #4 updated and sub criteria moved into note #2. #4 now reads “For individuals who have elevated PSA (see Note 2), or a suspicious DRE, a follow-up in 6-12 months with total PSA reimbursement is allowed.” Coverage criteria #5 updated and now reads "For individuals who have elevated total PSA and who had an initial negative biopsy, follow-up testing (no more often than follow-up total PSA) with percent free PSA, reimbursement is allowed.” Note #2 relabeled Note #3 and new Note #2 added that reads “*Note 2: For individuals less than 76 years of age, elevated PSA requiring further evaluation is defined as a total PSA measurement of greater than 3 ng/mL. For individuals 76 years of age or older, elevated PSA requiring further evaluation is defined as a total PSA measurement of greater than or equal to 4 ng/mL.2.” Under when not covered section b. updated and now reads “Percent free PSA, or free-to-total PSA ratio for the routine screening of prostate cancer.” Under when not covered section c added and reads “Complexed PSA testing.” Policy Guidelines updated. References updated. Medical Director review 4/2026. |
| Salivary Hormone Testing AHS - G2120 | Reviewed by Avalon for 2nd Quarter 2026 CAB. Updated Policy Guidelines and references. No change to policy statement. Medical Director review 4/2026. |
| Serum Tumor Markers for Malignancies AHS - G2124 | Reviewed by Avalon Q2 2026 CAB. When Covered section updated as follows: Clinical recommendations for almost all indications for almost all biomarkers were adjusted to reflect current recommendations in NCCN guidelines (e.g., for ALP testing for bone neoplasms, added “for osteosarcoma”). For BNP/NT-proBNP, added SLCA indications for testing based on NCCN compendium updates. For calcitonin, CEA, and inhibin, removed “occult primary” recommendations, as the NCCN recommends these as an IHC marker for occult primary, not as a serum biomarker. For CA-125, removed “peritoneal mesothelioma” and “Lynch syndrome,” as the NCCN no longer includes it as a recommended biomarker in the compendium. Billing/Coding section updated by removing the following CPT code 81479, 81599, 83789, 84078, 84080, 84703, and 84999. References updated. Medical Director review 4/2026. |
| Testing for Developmental Delay AHS - M2176 | Reviewed by Avalon 2nd Quarter 2026 CAB. Description and References updated. Coverage criteria 1. under the Not Covered section edited and now reads “For the diagnosis of autism spectrum disorder (ASD) or developmental delay, all other genetic testing (e.g., multi-gene panels of 50 or more genes) not discussed above is considered not medically necessary.” Medical Director review 4/2026. |
| Thyroid Disease Testing AHS – G2045 | Reviewed by Avalon 2nd Quarter 2026 CAB. Description, Policy Guidelines, and References updated. Edited When Covered section #1 to divide and clarify criteria using a cascade based approach for thyroid testing (TSH versus fT4/fT3/TT3), while retaining all clinical scenarios and testing frequency in which TSH remains the appropriate first line test. New coverage criteria was added for follow up testing following abnormal TSH results, monitoring of TSH and fT4 in clinical scenarios where initial monitoring with fT4 may be appropriate without requiring an abnormal TSH, and for monitoring of fT4 without concurrent TSH measurement in individuals with secondary hypothyroidism. Revised #6 to specify individuals who have not been diagnosed with autoimmune thyroid disease (e.g., Hashimoto disease, Graves’ disease). Updated When Not Covered to include only thyroxine binding globulin (TBG), thyrotropin releasing hormone (TRH), and reverse T3 testing. Remaining coverage criteria renumbered and edited for clarity. Medical Director review 4/2026. Notification given 5/27/2026 for effective date 8/5/2026. |
| Urinary Tumor Markers for Bladder Cancer AHS - G2125 | Reviewed by Avalon Quarter 2 2026 CAB. Background, Proprietary Testing, Analytical Validity, Clinical Utility and Validity, State and Federal Regulations and FDA moved from Description Section and placed in the Policy Guidelines to align with layout of other Laboratory Policies. Policy Guidelines updated. When covered section coverage criteria #1 updated to read “Reimbursement is allowed as an adjunct to cystoscopy, urinary biomarker,” it has previously read “Reimbursement is allowed for urinary biomarker.” Coverage criteria #1 under a and b the words “as an adjunct” removed. Coverage criteria #1a and #2 the word urinary inserted to read “urinary cytology.” Changes to when covered section for clarity and no change to coverage intent. Medical Director review 4/2026. |
| Venous and Arterial Thrombosis Risk Testing AHS - M2041 | Reviewed by Avalon 2nd Quarter 2026 CAB. Policy Guidelines and References sections updated. Updates to When Covered section: coverage criteria 1. d. edited for clarity, former coverage criteria 1. f. removed, coverage criteria 3. now reads "For individuals who are contemplating estrogen use (OCs or hormone replacement therapy) and who have a first-degree relative (see Note 2) with a known Factor V Leiden or prothrombin gene G20210A mutation, reimbursement is allowed for genetic testing for the known familial mutation." Edited Note 1 for clarity, removed “Assays for clotting inhibitors amount and function should be performed prior to any molecular testing.” Medical Director review 4/2026. |
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