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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 |
|---|---|---|---|---|---|
| 07.001.066 | Risk-Reducing Mastectomy | Oct 07, 2024 | Aug 20, 2025 | Risk-reducing mastectomy is defined as the removal of the breast in the absence of malignant disease to... | View |
| 11.003.027 | Gene Variants Associated With Breast Cancer In Individuals At High Breast Cancer Risk. | Sep 12, 2024 | Sep 20, 2025 | It is estimated that 3% to 5% of women presenting for assessment for hereditary breast/ovarian cancer risk... | View |
| 11.003.030 | Genetic Testing For Brca1 Or Brca2 For Hereditary Breast/Ovarian Cancer Syndrome And Other High-Risk Cancers | Feb 10, 2025 | Sep 20, 2025 | Hereditary breast and ovarian cancer syndrome describe the familial cancer syndromes related to variants in... | View |
| 11.003.036 | Genetic Testing For Familial Cutaneous Malignant Melanoma | Apr 18, 2025 | Apr 20, 2026 | Cutaneous melanoma is the third most common type of skin cancer, but the most lethal. some cases of cutaneous... | View |
| 11.003.048 | Carrier Screening For Genetic Diseases | Oct 10, 2024 | Oct 20, 2025 | Carrier screening is performed to identify individuals at risk of having offspring with inherited recessive... | View |
| 11.003.064 | Genetic Cancer Susceptibility Panels Using Next Generation Sequencing | Dec 12, 2024 | Nov 20, 2025 | Commercially available cancer susceptibility gene panels can test for multiple variants associated with a... | View |
| 11.003.098 | Use Of Common Genetic Variants (Single Nucleotide Variants) To Predict Risk Of Nonfamilial Breast Cancer | Nov 15, 2024 | Nov 20, 2025 | Several single nucleotide variants (snvs), which are single base-pair variations in the dna sequence of the... | View |
| 11.003.107 | Genetic Testing For Hereditary Pancreatic Cancer | Mar 03, 2025 | Mar 20, 2026 | Pancreatic cancer is the fourth leading cause of cancer death in the united states, accounting for 8.3% of... | View |
| 11.003.134 | Molecular Testing For Variants Associated With Hereditary Ovarian Cancer | Dec 16, 2024 | Sep 20, 2025 | It is estimated that approximately 20% of women presenting for assessment for hereditary ovarian cancer (oc)... | View |
| 11.003.135 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer | Jan 20, 2025 | Jan 20, 2026 | Multiple biomarkers are being evaluated to predict response to targeted treatments for patients with advanced... | View |
| 11.003.137 | Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1) | Sep 20, 2024 | Sep 20, 2025 | Hereditary diffuse gastric cancer (hdgc, sometimes called signet ring gastric cancer) is an autosomal... | View |
| 11.003.138 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, Microsatellite Instability/Mismatch Repair, Tumor Mutational Burden) | Oct 08, 2024 | Oct 20, 2025 | Biomarker-targeted therapy has shown a clear survival benefit in individuals with metastatic prostate cancer.... | View |
| 11.003.139 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, Tumor Mutational Burden, Microsatellite Instability/Mismatch Repair) | Oct 16, 2024 | Oct 20, 2025 | Biomarker-targeted therapy has shown a clear survival benefit in patients with ovarian cancer. more recently,... | View |
