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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 |
|---|---|---|---|---|---|
| 03.001.001 | Psycotheraphy | Nov 11, 2020 | Policy Archived | The patient receives medical evaluation and management services. these services involve a variety of unique,... | View |
| 03.001.004 | TERAPIA ELECTROCONVULSIVA | May 10, 2016 | Policy Archived | La terapia electroconvulsiva se considera para pago como tratamiento para la depresión mayor, desórdenes... | View |
| 03.001.005 | AUTISM DISORDERS / PERVASIVE DEVELOPMENT DISORDERS | Dec 26, 2024 | Policy Archived | Triple - s will cover for payment the following services as medically necessary in the evaluation of a known... | View |
| 03.001.006 | PSYCHIATRY SERVICES | Nov 14, 2019 | Policy Archived | Psychiatric services are medically... | View |
| 03.001.007 | HOME PSYCHIATRIC SERVICES | Nov 14, 2019 | Policy Archived | Psychiatric services in the home will be covered for payment when they comply with what is expressed in the... | View |
| 03.001.008 | Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder, Cognitive Impairment, or Autism Spectrum Disorder | Nov 06, 2024 | Nov 20, 2025 | Patients with attention-deficit/hyperactivity disorder (adhd) may have alterations in their brain wave... | View |
| 03.001.009 | Digital Health Therapies for Substance Use Disorders | Aug 22, 2024 | Policy Archived | Digital health therapies for individuals with substance use disorders are... | View |
| 03.001.010 | Digital Health Technologies for Attention Deficit/Hyperactivity Disorder | Aug 22, 2024 | Aug 20, 2025 | Digital health technologies is a broad term that includes categories such as mobile health, health... | View |
| 03.003.001 | Therapeutic Radiopharmaceuticals for Prostate Cancer | Nov 26, 2024 | Nov 20, 2025 | Therapeutic radiopharmaceuticals for prostate cancer using lutetium (lu) 177 vipivotide tetraxetan... | View |
| 04.001.001 | Antepartum Fetal Evaluation | Jun 16, 2022 | Policy Archived | Conditions for which antepartum evaluation is considered for payment: decrease in fetal movements... | View |
| 04.001.003 | Home Uterine Activity monitoring | May 08, 2019 | Policy Archived | Home uterine activity monitoring through a monitoring device and/or daily nursing contact is considered not... | View |
| 04.001.007 | Occlusion of Uterine Arteries Using Transcatheter Embolization | Sep 21, 2020 | Sep 21, 2021 | Transcatheter embolization of uterine arteries as a treatment of uterine fibroids or as a treatment of... | View |
| 04.001.009 | Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids | Mar 18, 2024 | Mar 20, 2025 | Laparoscopic or transcervical radiofrequency ablation (rfa) as a treatment of symptomatic uterine fibroids is... | View |
| 04.001.010 | OCLUSION HISTEROSCOPICA DE LOS TUBOS DE FALOPIO COMO METODO CONTRACEPTIVO | May 16, 2016 | Policy Archived | La oclusión histeroscópica de los tubos de falopio como método de esterilización permanente se considera... | View |
| 04.001.011 | Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome | Sep 18, 2024 | Sep 20, 2024 | Endovascular occlusion of the ovarian vein and internal iliac veins is considered investigational as a... | View |
| 04.001.012 | Progesterone Therapy as a Technique to Reduce Preterm Delivery in High-Risk Pregnancies | Oct 22, 2024 | Policy Archived | For individuals with a singleton pregnancy and prior spontaneous preterm birth before 37 weeks of gestation,... | View |
| 04.001.017 | INTERRUPCION QUIRURGICA DEL NERVIO PELVICO COMO TRATAMIENTO DE DISMENORREA PRIMARIA O SECUNDARIA | Nov 16, 2017 | Policy Archived | Ablación laparoscópica del nervio uterino (lu) y la neurectomia presacral laparoscópica (lpsn) no se... | View |
| 04.001.019 | Robotic Surgery in Gynecology | Oct 26, 2023 | Policy Archived | The robot-assisted gynecologic surgery (robotic surgery) is considered a modality of conventional... | View |
| 04.001.020 | Obstetric Ultrasonography | Sep 11, 2024 | Policy Archived | Ultrasonographic evaluation of the fetomaternal complex in the different stages of pregnancy is considered... | View |
| 04.001.024 | SERVICES FOR INTRA-UTERINE DEVICE MANAGEMENT | Nov 09, 2022 | Policy Archived | Intrauterine devices are considered medically necessary in the prevention of... | View |
