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 | Jan 07, 2025 | Jan 20, 2026 | Transcutaneous electrical nerve stimulation (tens) describes the application of electrical stimulation to the... | View |
| 01.001.027 | Interferential Current Stimulation | Jul 15, 2024 | Jul 20, 2025 | Interferential current stimulation (ifs) is a type of electrical stimulation used to reduce pain. the... | View |
| 02.001.015 | Paraspinal Surface Electromyography To Evaluate And Monitor Back Pain | Jul 15, 2024 | Jul 20, 2025 | A noninvasive procedure that records the summation of muscle electrical activity, paraspinal surface... | View |
| 02.001.020 | Endovascular Procedures For Intracranial Arterial Disease (Atherosclerosis And Aneurysms) | May 19, 2025 | May 20, 2026 | Intracranial arterial disease includes thromboembolic events, vascular stenoses, and aneurysms. endovascular... | View |
| 02.001.026 | Electromyography And Nerve Conduction Studies | Sep 09, 2024 | Jul 20, 2025 | Electromyography (emg) and nerve conduction studies (ncs), also collectively known as an electrodiagnostic... | View |
| 02.001.031 | Biofeedback As A Treatment Of Chronic Pain | Dec 09, 2024 | Dec 20, 2025 | Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not... | View |
| 02.001.077 | Epidural Steroid Injections For Neck Or Back Pain | Dec 20, 2024 | Dec 20, 2025 | Epidural steroid injections (esis) are a treatment for neck or back pain that has not responded to... | View |
| 02.001.087 | Low-Dose Radiotherapy for Non-Oncologic Indications | Nov 19, 2024 | Nov 20, 2025 | Or (95% ci): 3 mos: 0.69 (0.22 to 2.17) 6 mos: 0.57 (0.18 to 1.81) 12 mos: 1.23 (0.37 to 4.12) mean treatment... | View |
| 02.001.106 | High Intensity Laser Therapy for Chronic Pain Conditions | Aug 09, 2024 | Aug 20, 2025 | High-intensity laser therapy (hilt) is a class iv therapeutic non-surgical laser device with a power output... | View |
| 02.002.018 | Progenitor Cell Therapy For The Treatment Of Damaged Myocardium Due To Ischemia | Jul 18, 2024 | Policy Archived | Progenitor cell therapy describes the use of multipotent cells of various cell lineages (autologous or... | View |
| 02.007.004 | Somatosensory Evoked Potential Studies Visual/Auditory | Nov 10, 2021 | Policy Archived | Evoked potentials are somatosensory stimuli, visual and/or auditory. the same, when applied activate... | View |
| 05.001.004 | Botulinum Toxin | Nov 04, 2024 | Nov 20, 2025 | ... | View |
| 05.001.015 | Advanced Therapies For Pharmacologic Treatment Of Pulmonary Hypertension | Dec 20, 2024 | Dec 20, 2025 | Pulmonary hypertension (ph) is a chronic, progressive condition characterized by abnormally high pulmonary... | View |
| 06.001.039 | Dynamic Spinal Visualization And Vertebral Motion Analysis | Oct 08, 2024 | Policy Archived | Dynamic spinal visualization is a general term addressing different imaging technologies that simultaneously... | View |
| 06.001.045 | Positional Magnetic Resonance Imaging | Dec 14, 2023 | Policy Archived | Positional magnetic resonance imaging (mri) permits imaging of a patient in various positions, including... | View |
| 06.001.050 | Duplex Sanning | Nov 14, 2019 | Policy Archived | A duplex scanning is a procedure of tracking by ultrasound that demonstrates the structures in two dimensions... | View |
| 06.001.061 | Diagnosis And Treatment Of Sacroiliac Joint Pain | Dec 09, 2024 | Dec 20, 2025 | Sacroiliac joint (sij) arthrography using fluoroscopic guidance with an injection of an anesthetic has been... | View |
| 07.001.009 | Computer-Assisted Navigation For Orthopedic Procedure | May 07, 2025 | May 20, 2026 | Computer-assisted navigation in orthopedic procedures describes the use of computer-enabled tracking systems... | View |
| 07.001.014 | Reduction Mammaplasty For Breast-Related Symptoms | Mar 12, 2025 | Mar 20, 2026 | Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. macromastia... | View |
| 07.001.029 | Spinal Cord And Dorsal Root Ganglion Stimulation | May 19, 2025 | May 20, 2026 | Spinal cord stimulation delivers low-voltage electrical stimulation to the dorsal columns of the spinal cord... | View |
