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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 | Oct 12, 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 | No se consideran para pago artículos costosos o de lujo por: razones estéticas o de comodidad que añadan... | View |
| 01.001.004 | Durable Medical Equipment Accesory | Jul 01, 2024 | Retired | Medical accessories must be appropriate for patient care and of value doctor. the medical determination must... | 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 |
| 01.001.008 | 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, 2021 | Policy Archived | Mechanical insufflation-exsufflation (mi-e) may be considered medically necessary in patients with... | View |
| 01.001.010 | Continuous Passive Motion in the Home Setting | Apr 10, 2024 | Apr 20, 2025 | Use of continuous passive motion in the home setting may be considered medically necessary as an adjunct to... | 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 | May 16, 2016 | Policy Archived | Estimulación eléctrica al umbral como tratamiento de desórdenes de movimiento, incluyendo pero no... | 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 | Nov 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 | Jul 12, 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 | Feb 28, 2024 | Jan 20, 2025 | 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 |
