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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 |
|---|---|---|---|---|---|
| 02.007.012 | Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions | Jul 16, 2024 | Jul 20, 2025 | Peripheral nerve stimulation as a treatment for chronic pain is considered... | View |
| 02.009.002 | CUIDADO CRITICO PEDIATRICO | May 10, 2016 | Policy Archived | Los servicios de cuidado pediátrico crítico se proveen (pero no están limitados) a pacientes con fallo en... | View |
| 02.009.003 | Neonatal Auditory Screening | Jun 23, 2023 | Policy Archived | The neonatal hearing screening program establishes performing hearing screening tests on all infants before... | View |
| 02.009.004 | PRUEBAS DE FUNCIÓN PULMOR EN INFANTES | May 10, 2016 | Policy Archived | Las pruebas de función pulmonar en infantes y niños no se consideran para pago ya que su utilidad no ha... | View |
| 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 |
| 03.001.002 | VISITA COLATERAL | May 10, 2016 | Policy Archived | Debe haber una nota separada en el expediente, donde se identifique la relación de la persona con el... | View |
| 03.001.003 | Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification | Apr 02, 2019 | Policy Archived | Opioid antagonists under heavy sedation or anesthesia are considered investigational as a technique for... | 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 | Nov 14, 2019 | 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 | Nov 07, 2023 | Nov 20, 2024 | Quantitative electroencephalographic-based assessment of the theta/beta ratio is considered investigational... | View |
| 03.001.009 | Digital Health Therapies for Substance Use Disorders | Aug 17, 2024 | Aug 20, 2024 | Digital health therapies for individuals with substance use disorders are... | View |
| 03.001.010 | Digital Health Technologies for Attention Deficit/Hyperactivity Disorder | Aug 14, 2023 | Aug 20, 2024 | The use of endeavorrx is considered investigational for all indications including... | View |
| 03.003.001 | Therapeutic Radiopharmaceuticals for Prostate Cancer | Sep 08, 2023 | Sep 20, 2024 | 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 |
| 04.001.005 | Cervical Cerclage | Jun 12, 2020 | Policy Archived | Cervical cerclage is medically necessary for the treatment of an incompetent cervix, which is one that has... | 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 |
