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Medical Policies
Medical policies are documents that define the plan coverage for technologies, procedures and treatments. The statements of medical necessity in the policies, about whether a technology, procedure, treatment, supply, equipment, drug or other service improves the health outcome of the population for which said technology or treatment was designed are based on scientific evidence, clinical studies and professional opinions from our providers and recognized medical organizations.
Each document displayed on this website is provided for informational purposes only and is not an authorization, explanation of benefits, or contract. Receiving benefits is subject to satisfaction of all terms and conditions of coverage. Medical technology is constantly changing, and we reserve the right to periodically review and update our policies.
| ID | Title | Last Review | Next Review | Description | Access |
|---|---|---|---|---|---|
| 01.001.001 | SUMINISTRO DE EQUIPO MEDICO DURADERO Y MATERIALES O SUMINISTROS MEDICO QUIRURGICOS | Aug 22, 2017 | Policy Archived | Los suministros de equipo y accesorios necesarios para el funcionamiento efectivo del equipo médico duradero... | View |
| 01.001.002 | SUMINISTRO DE EQUIPO MEDICO DURADERO Y MATERIALES O SUMINISTROS MEDICO QUIRURGICOS | Aug 22, 2017 | Policy Archived | Los suministros de equipo y accesorios necesarios para el funcionamiento efectivo del equipo médico duradero... | View |
| 01.001.003 | SERVICIOS Y ARTÍCULOS CON CARACTERÍSTICAS DE LUJO Y COSTO ADICIOL EQUIPO MÉDICO DURADERO | May 10, 2016 | Policy Archived | Servicio o artículo rentado o comprado que no es considerado médicamente necesario ni razonable (ver... | View |
| 01.001.005 | External Infusion Pumps | Dec 27, 2019 | Policy Archived | Use of the eip for the administration of the following drugs is considered medically necessary for selected... | View |
| 01.001.006 | Low Intensity Pulsed Ultrasound Fracture Healing Device | Apr 05, 2024 | Apr 20, 2025 | Low-intensity pulsed ultrasound is considered investigational as a treatment of fresh fractures (surgically... | View |
| 01.001.007 | External Infusion Pumps and Chemotherapy in the Home | Sep 10, 2024 | Policy Archived | The use of external infusion pumps is considered for payment for the administration of the following... | View |
| 01.001.008 | Transtympanic Micropressure Applications as a Treatment of Meniere Disease | Mar 30, 2020 | Policy Archived | Transtympanic micropressure applications as a treatment of meniere disease are considered not medically... | View |
| 01.001.009 | Mechanical Insufflation-Exsufflation as an Expiratory Muscle Aid | Sep 09, 2020 | Sep 09, 2021 | The published data suggest that mi-e can improve the intermediate outcome of peak cough expiratory flow. data... | View |
| 01.001.010 | Continuous Passive Motion in the Home Setting | Apr 10, 2024 | Apr 20, 2025 | For individuals who have total knee arthroplasty who receive continuous passive motion in the home setting,... | View |
| 01.001.011 | Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses | Apr 18, 2024 | Apr 20, 2025 | Use of an adjustable cranial orthosis may be considered medically necessary following cranial vault... | View |
| 01.001.012 | Electrical and Electromagnetic Stimulation for the Treatment of Arthritis | Apr 15, 2024 | Apr 20, 2025 | Electrical or electromagnetic stimulation is considered investigational for the treatment of... | View |
| 01.001.013 | Microprocessor-Controlled Prostheses for the Lower Limb | Apr 05, 2024 | Apr 20, 2025 | A microprocessor-controlled knee may be considered medically necessary in individuals with transfemoral... | View |
| 01.001.014 | MONOCROMATIC ENERGY INFRARED CONTACT IN THE TREATMENT OF SKIN ULCERS, DIABETIC NEUROPATHY AND MUSCULOSKELETAL CONDITIONS | Dec 26, 2018 | Policy Archived | Skin contact monochromatic infrared energy is considered investigational as a technique to treat cutaneous... | View |
| 01.001.015 | ESTIMULACION ELECTRICA AL UMBRAL COMO TRATAMIENTO DE DESORDENES DE MOVIMIENTO | Apr 15, 2016 | Policy Archived | Estimulación eléctrica al umbral se define como la aplicación en el hogar de estimulación eléctrica de... | View |
| 01.001.016 | Myoelectric Prosthetic and Orthotic Components for the Upper Limb | Apr 05, 2024 | Apr 20, 2025 | Myoelectric upper-limb prosthetic components may be considered medically necessary when the following... | View |
| 01.001.017 | Home Prothrombin Time Monitoring | Oct 30, 2023 | Policy Archived | At-home monitoring of chronic warfarin therapy may be considered medically necessary in patients who require... | View |
| 01.001.018 | Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions | Sep 09, 2024 | Jul 20, 2025 | Use of an oscillatory positive expiratory pressure device may be considered medically necessary in... | View |
| 01.001.020 | Transcutaneous Electrical Nerve Stimulation | Jan 07, 2025 | Jan 20, 2026 | A trial of transcutaneous electrical nerve stimulation (tens) of at least 30 days may be... | View |
| 01.001.021 | Home Cardiorespiratory Monitoring | Jul 18, 2024 | Jul 20, 2025 | Home cardiorespiratory monitoring may be considered medically necessary when initiated in infants... | View |
| 01.001.023 | Hemophilia Antihemophilic Factor | Jul 24, 2024 | Policy Archived | Criteria for the management of anti-hemophilic factors 1. the prescription must be written by a... | View |
