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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
07.001.151 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

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