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.

Medical Policies table

ID Title Review Description Access
02.007.012 Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions Aug 2025 Peripheral nerve stimulation (pns) is a percutaneous system consisting of leads, electrodes, and a pulse... View
02.007.013 Tonic Motor Activation (TOMAC) for Restless Leg Syndrome Nov 2025 Tonic motor activation (tomac) is a peroneal nerve stimulation device that uses electrodes worn on the lower... View
02.009.002 Cuidado crítico pediátrico May 2016 ... View
02.009.003 Cernimiento auditivo neonatal Feb 2026 The diagnosis of congenital hearing loss was previously made at an average age of 13 months for infants with... View
02.009.004 PRUEBAS DE FUNCIÓN PULMONAR EN INFANTES May 2016 ... View
03.001.001 Psycotheraphy Nov 2020 The description of codes 90785-90840 contemplates the treatment of a mental condition or behavioral... View
03.001.004 Terapia Electroconvulsiva May 2016 ... View
03.001.005 Autism Disorders / Pervasive Develoment Disorders Dec 2024 ... View
03.001.006 Psychiatry Services Nov 2019 Psychiatric evaluation psychiatric evaluation is the method by which the physician establishes a diagnosis of... View
03.001.007 Home Psychiatry Services Nov 2019 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 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 2024 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 Nov 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 2025 ... View
04.001.001 Evaluación fetal anteparto Jun 2022 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 2019 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 2020 ... View
04.001.009 Laparoscopic And Percutaneous Techniques For The Myolysis Of Uterine Fibroids Mar 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 2016 ... View
04.001.011 Ovarian And Internal Iliac Vein Endovascular Occlusion As A Treatment Of Pelvic Congestion Syndrome Sep 2025 Pelvic congestion syndrome is characterized by chronic pelvic pain that is often aggravated by standing;... View