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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 17, 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
01.001.004 ACCESORIO DE EQUIPO MEDICO DURARERO Aug 08, 2017 Policy Archived Equipo medico duradero “standard” (dme) es aquel que cumple con los siguientes requisitos:se usan... View
01.001.005 External Infusion Pumps Dec 27, 2019 Dec 27, 2019 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, 2022 Apr 05, 2023 Low-intensity pulsed ultrasound is considered investigational as a treatment of fresh fractures (surgically... View
01.001.007 BOMBAS DE INFUSION EXTER Y QUIMIOTERAPIA EN EL HOGAR Nov 16, 2017 Policy Archived Una bomba de infusión externa consiste en un aditamento portátil que ha sido diseñado para administrar una... View
01.001.008 Transtympanic Micropressure Applications as a Treatment of Meniere Disease Feb 19, 2020 Feb 19, 2021 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 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 07, 2022 Apr 07, 2023 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 29, 2022 Apr 29, 2023 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 07, 2022 Apr 07, 2023 Electrical or electromagnetic stimulation is considered investigational for the treatment of... View
01.001.013 Microprocessor-Controlled Prostheses for the Lower Limb Apr 06, 2022 Apr 06, 2023 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, 2008 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 06, 2022 Apr 06, 2023 Myoelectric upper-limb prosthetic components may be considered medically necessary when the following... View
01.001.017 MONITOREO DEL TIEMPO DE PROTROMBI EN EL HOGAR Sep 20, 2016 Policy Archived Los pacientes a los que se le prescriben anticoagulación con warfarina crónica necesitan monitoreo de la... View
01.001.018 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions Jul 06, 2022 Jul 06, 2023 Use of an oscillatory positive expiratory pressure device may be considered medically necessary in patients... View
01.001.020 Transcutaneous Electrical Nerve Stimulation Jan 20, 2022 Jan 20, 2023 A trial of transcutaneous electrical nerve stimulation (tens) of at least 30 days may be considered medically... View
01.001.021 Home Cardiorespiratory Monitoring Jul 21, 2021 Jul 21, 2022 Home cardiorespiratory monitoring may be considered medically necessary when initiated in infants... View
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