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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
05.001.041 Injectable Clostridial Collagenase for Fibroproliferative Disorders Apr 14, 2023 Apr 20, 2024 Injectable clostridial collagenase for the treatment of dupuytren's contracture in adults with a palpable... View
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
M7.001.001 Laser Treatment of Wine Stains Jan 12, 2024 Policy Archived Laser treatment of port wine stains in the presence of functional impairment related to the port wine stains... View
PP.001.002 Leuprolide Aug 29, 2023 Jul 20, 2024 Initial approval criteria a. prostate cancer (must meet all): 1. diagnosis of prostate cancer; 2.... View
PP.002.001 Readmissions Review Quality Program (RRQP) Mar 01, 2024 Mar 01, 2025 Triple-s shall evaluate readmissions, either at the claims level or during the readmission. payment for... View
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