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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 |
|---|---|---|---|---|---|
| 03.001.004 | Terapia Electroconvulsiva | May 10, 2016 | Policy Archived | ... | View |
| 03.001.005 | Autism Disorders / Pervasive Develoment Disorders | Dec 26, 2024 | Policy Archived | ... | View |
| 03.001.006 | Psychiatry Services | Nov 14, 2019 | Policy Archived | Psychiatric evaluation psychiatric evaluation is the method by which the physician establishes a diagnosis of... | View |
| 03.001.007 | Home Psychiatry Services | Nov 14, 2019 | Policy Archived | Home psychiatric services are those psychiatric, psychological or psychotherapeutic services rendered by a... | View |
| 03.001.008 | Quantitative Electroencephalography As A Diagnostic Aid For Attention-Deficit/Hyperactivity 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 Abuse | Aug 22, 2024 | Policy Archived | The world health organization defines substance use disorder as “the harmful or hazardous use of... | View |
| 03.001.010 | Digital Health Therapies 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 | Radiopharmaceuticals are composed of a radioisotope (ie, a radioactive particle) bond to an organic molecule... | View |
| 04.001.001 | Evaluación fetal anteparto | Jun 16, 2022 | Policy Archived | In humans as well as in animals, the fetal heart rate pattern, activity level, and degree of fetal muscle... | View |
| 04.001.003 | Home Uterine Activity Monitoring | May 08, 2019 | Policy Archived | The home uterine activity monitor (huam) is a device that can be worn by pregnant women and is intended to... | View |
| 04.001.007 | Occlusion Of Uterine Arteries Using Transcatheter Embolization | Sep 21, 2020 | Policy Archived | ... | View |
| 04.001.009 | Laparoscopic And Percutaneous Techniques For The Myolysis Of Uterine Fibroids | Mar 19, 2025 | Mar 20, 2026 | Various minimally invasive treatments for uterine fibroids have been proposed as alternatives to surgery.... | View |
| 04.001.010 | Oclusión histeroscópica de los tubos de falopio como método contraceptivo | May 16, 2016 | Policy Archived | ... | View |
| 04.001.011 | Ovarian And Internal Iliac Vein Endovascular Occlusion As A Treatment Of Pelvic Congestion Syndrome | Sep 18, 2024 | Sep 20, 2024 | Pelvic congestion syndrome is characterized by chronic pelvic pain that is often aggravated by standing;... | View |
| 04.001.012 | Progesterone Therapy As A Technique To Reduce Preterm Delivery In High-Risk Pregnancies | Oct 22, 2024 | Policy Archived | Preterm birth is the leading cause of neonatal morbidity and mortality, and effective primary preventive... | View |
| 04.001.017 | Interrupción Quirúrgica del Nervio Pélvico como tratamiento de Dismenorrea Prima | Nov 16, 2017 | Policy Archived | ... | View |
| 04.001.019 | Robotic Surgery In Gynecology | Oct 26, 2023 | Policy Archived | In the decade of the ‘80s, the idea of having a military ambulance in the battlefield; equipped with a... | View |
| 04.001.020 | Obstetric Ultrasonography | Sep 11, 2024 | Policy Archived | Obstetric ultrasonography is an ultrasound examination with an instrument in real time, using transabdominal... | View |
| 04.001.024 | Services For Intra-Uterine Device Management | Nov 09, 2022 | Policy Archived | The intrauterine device (iud) is the most commonly used method of long-acting reversible contraception... | View |
| 04.002.001 | TRATAMIENTO DEL SÍNDROME DE TRANSFUSIÓN DE GEMELO A GEMELO UTILIZANDO AMNIOREDUC | Dec 13, 2017 | Policy Archived | ... | View |
