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) | Apr 24, 2024 | Retired | Triple-s shall evaluate readmissions, either at the claims level or during the readmission. payment for... | View |
