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 |
|---|---|---|---|---|---|
| 07.001.151 | Prostatic Urethral Lift | Sep 08, 2023 | Sep 20, 2024 | Use of prostatic urethral lift in individuals with moderate-to-severe lower urinary tract obstruction due to... | View |
| 10.001.014 | TELEMEDICINE | Oct 26, 2023 | Oct 20, 2024 | Numerous states have enacted laws regarding coverage of health care services delivered through telemedicine... | View |
| M5.001.020 | Givosiran for Acute Hepatic Porphyria | Jun 01, 2024 | Jun 20, 2025 | Initial treatment givosiran may be considered medically necessary if all of the following conditions are... | View |
| M5.001.021 | Biological Treatments for Refractory Myasthenia Gravis | Jun 27, 2024 | Jun 20, 2025 | Eculizumab and ravulizumab-cwvz - initial treatment eculizumab and ravulizumab-cwvz may be... | View |
| M7.001.001 | Laser Treatment of Wine Stains | May 10, 2024 | Policy Archived | Laser treatment of port wine stains in the presence of functional impairment related to the port wine stains... | View |
| MP.001.001 | Dose Rounding of Drug Covered Under The Medical Benefit | May 10, 2024 | May 20, 2025 | I. dose rounding for infused drug products to the nearest lowest vial size if within +/- 10% of the original... | View |
| MP.001.002 | Leuprolide | May 10, 2024 | May 20, 2025 | Initial approval criteria a. prostate cancer (must meet all): 1. diagnosis of prostate cancer; 2.... | View |
| PP.001.001 | Dose Rounding of Drug Covered Under The Medical Benefit | May 10, 2024 | May 20, 2025 | I. dose rounding for infused drug products to the nearest lowest vial size if within +/- 10% of the original... | View |
| PP.001.002 | Leuprolide | May 10, 2024 | May 20, 2025 | Initial approval criteria a. prostate cancer (must meet all): 1. diagnosis of prostate cancer; 2.... | View |
| PP.002.001 | Readmissions Review Quality Program (RRQP) | Apr 24, 2024 | Retired | Triple-s shall evaluate readmissions, either at the claims level or during the readmission. payment for... | View |
