View and download Blue Shield Promise medical policy treatment authorization request (TAR) forms.
- Actigraphy (PDF, 170 KB)
- Amniotic Membrane and Amniotic Fluid (PDF, 154 KB)
- Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (PDF, 132 KB)
- Balloon Dilation of the Eustachian Tube (PDF, 166 KB)
- Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis (PDF, 157 KB)
- Behavioral Health Treatment (PDF, 197 KB)
- Bioengineered Skin and Soft Tissue Substitutes (PDF, 162 KB)
- Bone Morphogenetic Protein (PDF, 160 KB)
- Bronchial Thermoplasty (PDF, 168 KB)
- Bronchial Valves (PDF, 166 KB)
- Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) (PDF, 152 KB)
- Closure Devices for Patent Foramen Ovale and Atrial Septal Defects (PDF, 159 KB)
- Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies (PDF, 151 KB)
- Cooling Devices Used in the Outpatient Setting (PDF, 168 KB)
- Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone (PDF, 159 KB)
- Electromagnetic Navigational Bronchoscopy (PDF, 169 KB)
- Extracorporeal Shock Wave Treatment for Plantar Fasciitis (PDF, 172 KB)
- Gender Affirmation Surgery (PDF, 167 KB)
- Gene Expression Profiling for Cutaneous Melanoma (PDF, 137 KB)
- Gene Expression Profiling, Protein Biomarkers, and Multimodal Artificial Intelligence for Prostate Cancer Management (PDF, 134 KB)
- General Approach to Evaluating the Utility of Genetic Panels (PDF, 133 KB)
- General Approach to Genetic Testing (PDF, 133 KB)
- General Treatment Authorization Request (PDF, 211 KB)
- Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer (PDF, 132 KB)
- Genetic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer (PDF, 124 KB)
- Genetic Testing for Alzheimer Disease (PDF, 134 KB)
- Genetic Testing for Cardiac Ion Channelopathies (PDF, 130 KB)
- Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies (PDF, 132 KB)
- Genetic Testing for Diagnosis and Management of Mental Health Conditions (PDF, 147 KB)
- Genetic Testing for Epilepsy (PDF, 131 KB)
- Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes (PDF, 152 KB)
- Genetic Testing for Mitochondrial Disorders (PDF, 134 KB)
- Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) (PDF, 136 KB)
- High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bells Palsy (PDF, 169 KB)
- Hip Resurfacing (PDF, 159 KB)
- Home Cardiorespiratory Monitoring (PDF, 153 KB)
- Hyperbaric Oxygen Therapy (PDF, 164 KB)
- Identification of Microorganisms Using Nucleic Acid Probes (PDF, 129 KB)
- Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions (PDF, 168 KB)
- Low-Level Laser Therapy (PDF, 153 KB)
- Molecular Genomic Profiling for Cancers of Unknown Primary (PDF, 151 KB)
- Multimarker Serum Testing Related to Ovarian Cancer (PDF, 135 KB)
- Myocardial Strain Imaging (PDF, 169 KB)
- Orthopedic Applications of Platelet-Rich Plasma (PDF, 169 KB)
- Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome (PDF, 169 KB)
- Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti (PDF, 163 KB)
- Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain (PDF, 174 KB)
- Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence (PDF, 171 KB)
- Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome (PDF, 171 KB)
- Photodynamic Therapy for Choroidal Neovascularization (PDF, 154 KB)
- Reconstructive Services (PDF, 163 KB)
- Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer (PDF, 158 KB)
- Subtalar Arthroereisis (PDF, 171 KB)
- Surgical Deactivation of Headache Trigger Sites (PDF, 158 KB)
- Surgical Treatment of Femoroacetabular Impingement (PDF, 161 KB)
- Synthetic Cartilage Implants for Joint Pain (PDF, 171 KB)
- Treatment of Varicose Veins/Venous Insufficiency (PDF, 162 KB)
- Tumor Treating Fields Therapy (PDF, 134 KB)
- Tumor-Informed Circulating Tumor DNA Testing for Cancer Management (PDF, 124 KB)
- Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer (PDF, 133 KB)
- Vertical Expandable Prosthetic Titanium Rib (PDF, 171 KB)
- Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders (PDF, 148 KB)
Medical care solutions
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Prior authorization list
View the list of medical services and procedures requiring medical necessity review or supplemental documentation prior to payment.
Tips for submitting Medi-Cal claims
Learn about best practices for billing Medi-Cal claims.