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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 |
|---|---|---|---|---|---|
| 01.001.020 | 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 |
| 01.001.024 | Artificial Pancreas Device Systems | Aug 05, 2024 | Aug 20, 2025 | Policy statements use of a u.s. food and drug administration (fda) cleared or approved automated insulin... | View |
| 01.001.027 | Interferential Current Stimulation | Jul 15, 2024 | Jul 20, 2025 | Interferential current stimulation is... | View |
| 02.001.015 | Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain | Jul 15, 2024 | Jul 20, 2025 | Paraspinal surface electromyography is considered investigational as a technique to diagnose or monitor back... | View |
| 02.001.020 | Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) | May 13, 2024 | May 20, 2025 | Intracranial arterial disease includes thromboembolic events, vascular stenoses, and aneurysms. endovascular... | View |
| 02.001.026 | Electromyography and Nerve Conduction Studies | Sep 09, 2024 | Jul 20, 2025 | Electromyography (emg) and nerve conduction studies (ncs), also collectively known as an electrodiagnostic... | View |
| 02.001.031 | Biofeedback as a Treatment of Chronic Pain | Dec 09, 2024 | Dec 20, 2025 | Biofeedback as a treatment of chronic pain, including but not limited to low back pain,... | View |
| 02.001.077 | Epidural Steroid Injections for Neck or Back Pain | Dec 20, 2024 | Dec 20, 2025 | Epidural steroid injections performed with fluoroscopic guidance may be considered medically necessary for... | View |
| 02.001.087 | Low-Dose Radiotherapy for Non-Oncologic Indications | Nov 19, 2024 | Nov 20, 2025 | Low-dose radiotherapy is considered investigational for the treatment of osteoarthritis. low-dose... | View |
| 02.001.106 | High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell’s Palsy | Aug 09, 2024 | Aug 20, 2025 | High intensity laser therapy (hilt) for treatment of chronic musculoskeletal pain is considered... | View |
| 02.002.018 | Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia | Jul 18, 2024 | Policy Archived | Progenitor cell therapy, including but not limited to skeletal myoblasts or hematopoietic cells, is... | View |
| 02.007.004 | Somatosensory evoked potential studies visual/auditory | Nov 10, 2021 | Policy Archived | Triple-s will consider for payment studies of evoked potentials when they are performed with the purpose of:... | View |
| 05.001.004 | Botulinum Toxin | Nov 04, 2024 | Nov 20, 2025 | The use of botulinum toxin may be considered medically necessary for the following:... | View |
| 05.001.015 | Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension | Dec 20, 2024 | Dec 20, 2025 | Pulmonary arterial hypertension (pah) combination therapy for the treatment of pah (world health... | View |
| 06.001.039 | Dynamic Spinal Visualization and Vertebral Motion Analysis | Oct 08, 2024 | Policy Archived | The use of dynamic spinal visualization is considered investigational. vertebral motion analysis is... | View |
| 06.001.045 | Positional Magnetic Resonance Imaging | Dec 14, 2023 | Policy Archived | Positional (nonrecumbent) magnetic resonance imaging is considered investigational, including its use in the... | View |
| 06.001.050 | Duplex Sanning | Nov 14, 2019 | Policy Archived | The duplex scanning in the evaluation of the arterial / venous flow of abdominal, pelvic organs and of the... | View |
| 06.001.061 | Diagnosis and Treatment of Sacroiliac Joint Pain | Dec 09, 2024 | Dec 20, 2025 | Arthrography of the sacroiliac joint (sij) is considered investigational. injection of anesthetic for... | View |
| 07.001.009 | Computer-Assisted Navigation for Orthopedic Procedures | May 17, 2024 | May 20, 2025 | Computer-assisted surgical navigation for orthopedic procedures is considered... | View |
| 07.001.014 | Reduction Mammaplasty for Breast-Related Symptoms | Mar 14, 2024 | Mar 20, 2025 | Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. macromastia... | View |
