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.
Medical Policies table
| ID | Title | Review | Description | Access |
|---|---|---|---|---|
| 01.001.006 | Low Intensity Pulsed Ultrasound Fracture Healing Device | May 2026 | Low-intensity pulsed ultrasound (lipus) has been investigated as a technique to accelerate healing of fresh... | View |
| 01.001.010 | Continuous Passive Motion In The Home Setting | Apr 2026 | Continuous passive motion devices are used to keep a joint in motion without patient assistance. continuous... | View |
| 01.001.011 | Adjustable Cranial Orthoses For Positional Plagiocephaly And Craniosynostoses | Apr 2026 | Cranial orthoses involve an adjustable helmet or band that progressively molds the shape of the infant... | View |
| 01.001.012 | Electrical And Electromagnetic Stimulation For The Treatment Of Arthritis | Apr 2026 | Pulsed electrical and electromagnetic stimulation are being investigated to improve functional status and... | View |
| 01.001.013 | Microprocessor-Controlled Prostheses For The Lower Limb | Apr 2026 | Microprocessor-controlled prostheses use feedback from sensors to adjust joint movement on a real-time... | View |
| 01.001.016 | Myoelectric Prosthetic And Orthotic Components For The Upper Limb | Apr 2026 | Myoelectric prostheses are powered by electric motors with an external power source. the joint movement of an... | View |
| 01.001.018 | Oscillatory Devices For The Treatment Of Cystic Fibrosis And Other Respiratory Conditions | Sep 2026 | Oscillatory devices are alternatives to the standard daily percussion and postural drainage method of airway... | View |
| 01.001.021 | Home Cardiorespiratory Monitoring | Jul 2026 | ... | View |
| 01.001.024 | Automated Insulin Delivery Systems | Apr 2026 | Automated insulin delivery systems, also known as artificial pancreas device systems, link a glucose monitor... | View |
| 01.001.025 | Tumor Treating Fields Therapy | Sep 2026 | Tumor treating fields (ttf) therapy is a noninvasive technology intended to treat glioblastoma, malignant... | View |
| 01.001.026 | Cooling Devices Used In The Outpatient Setting | Apr 2026 | Cooling devices use chilled water to decrease the local temperature of tissue. there are a variety of cooling... | View |
| 01.001.028 | Postsurgical Home Use Of Limb Compression Devices For Venous Thromboembolism Prophylaxis | Apr 2026 | Antithrombotic prophylaxis is recommended for surgical individuals at moderate-to-high risk of postoperative... | View |
| 01.001.029 | Pelvic Floor Stimulation As A Treatment Of Urinary Incontinence | Sep 2026 | Pelvic floor stimulation is proposed as a nonsurgical treatment option for women and men with urinary or... | View |
| 01.003.004 | Powered Exoskeleton For Ambulation In Patients With Lower-Limb Disabilities | Apr 2026 | The goal of the powered exoskeleton is to enable people who do not have volitional movement of their lower... | View |
| 01.003.005 | Patient-Controlled End Of Range Motion Stretching Devices | Apr 2026 | Patient-controlled stretching devices are used at home to increase range of motion in individuals who have... | View |
| 01.004.001 | Protesis e Implantes | Nov 2016 | ... | View |
| 02.001.001 | Extracorporeal Shock Wave Treatment For Plantar Fasciitis And Other Musculoskeletal Conditions | Jul 2026 | Extracorporeal shock wave therapy (eswt) is a noninvasive method used to treat pain with shock or sound waves... | View |
| 02.001.011 | Hyperbaric Oxygen Therapy | Mar 2026 | Hyperbaric oxygen therapy (hbot) involves breathing 100% oxygen at pressures between 1.5 and 3.0 atmospheres.... | View |
| 02.001.020 | Endovascular Procedures For Intracranial Arterial Disease (Atherosclerosis And Aneurysms) | May 2026 | Intracranial arterial disease includes thromboembolic events, vascular stenoses, and aneurysms. endovascular... | View |
| 02.001.030 | Actigraphy | Jul 2026 | Actigraphy refers to the assessment of body movement activity patterns using devices, typically placed on the... | View |