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 |
|---|---|---|---|---|---|
| 01.001.020 | Transcutaneous Electrical Nerve Stimulation | Feb 28, 2024 | Jan 20, 2025 | A trial of transcutaneous electrical nerve stimulation (tens) of at least 30 days may be... | View |
| 01.001.027 | Interferential Current Stimulation | Jul 03, 2023 | Jul 20, 2024 | Interferential current stimulation is... | View |
| 02.001.015 | Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain | Jul 06, 2023 | Jul 20, 2024 | Paraspinal surface electromyography is considered investigational as a technique to diagnose or monitor back... | View |
| 02.001.020 | Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) | May 13, 2024 | May 20, 2025 | Intracranial stent placement may be considered medically necessary as part of the endovascular treatment of... | View |
| 02.001.026 | Electromyography and Nerve Conduction Studies | Jul 19, 2023 | Jul 20, 2024 | Electrodiagnostic assessment, consisting of electromyography, nerve conduction study, and related measures,... | View |
| 02.001.031 | Biofeedback as a Treatment of Chronic Pain | Dec 11, 2023 | Dec 20, 2024 | Biofeedback as a treatment of chronic pain, including but not limited to low back pain,... | View |
| 02.001.077 | Epidural Steroid Injections for Neck or Back Pain | Dec 20, 2023 | Dec 20, 2024 | The diagnosis of lumbar radiculopathy is typically made by a combination of suggestive signs and symptoms in... | View |
| 02.002.018 | Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia | Jun 18, 2024 | Jun 20, 2025 | Progenitor cell therapy, including but not limited to skeletal myoblasts or hematopoietic cells, is... | View |
| 02.007.004 | Somatosensory evoked potential studies visual/auditory | Nov 10, 2021 | Policy Archived | Triple-s will consider for payment studies of evoked potentials when they are performed with the purpose of:... | View |
| 05.001.004 | Botulinum Toxin | Mar 12, 2024 | Nov 20, 2024 | The use of botulinum toxin may be considered medically necessary for the following:... | View |
| 05.001.015 | Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension | Dec 20, 2023 | Dec 20, 2024 | Pulmonary arterial hypertension (pah) combination therapy for the treatment of pah (world health... | View |
| 06.001.039 | Dynamic Spinal Visualization and Vertebral Motion Analysis | Oct 05, 2023 | Oct 20, 2024 | The use of dynamic spinal visualization is considered investigational. vertebral motion analysis is... | View |
| 06.001.045 | Positional Magnetic Resonance Imaging | Dec 14, 2023 | Policy Archived | Positional (nonrecumbent) magnetic resonance imaging is considered investigational, including its use in the... | View |
| 06.001.050 | Duplex Sanning | Nov 14, 2019 | Policy Archived | The duplex scanning in the evaluation of the arterial / venous flow of abdominal, pelvic organs and of the... | View |
| 06.001.061 | Diagnosis and Treatment of Sacroiliac Joint Pain | Dec 04, 2023 | Dec 20, 2024 | Arthrography of the sacroiliac joint (sij) is considered investigational. injection of anesthetic for... | View |
| 07.001.009 | Computer-Assisted Navigation for Orthopedic Procedures | May 17, 2024 | May 20, 2025 | Computer-assisted surgical navigation for orthopedic procedures is considered... | View |
| 07.001.014 | Reduction Mammaplasty for Breast-Related Symptoms | Mar 14, 2024 | Mar 20, 2025 | Reduction mammaplasty may be considered medically necessary for the treatment of macromastia when... | View |
| 07.001.029 | Spinal Cord and Dorsal Root Ganglion Stimulation | May 17, 2024 | May 20, 2025 | Spinal cord stimulation with standard or high-frequency stimulation may be considered medically... | View |
| 07.001.037 | Bone Morphogenetic Protein | May 12, 2024 | May 20, 2025 | Use of recombinant human bone morphogenetic protein-2 (infuse™) may be considered medically necessary in... | View |
| 07.001.048 | Intraoperative Neurophysiologic Monitoring | May 06, 2024 | May 20, 2025 | Intraoperative neurophysiologic monitoring, which includes somatosensory-evoked potentials, motor-evoked... | View |
