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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 |
|---|---|---|---|---|---|
| 04.002.002 | Cirugía fetal para malformaciones congénitas diagnosticadas en periodo perinatal | Dec 08, 2022 | Policy Archived | Fetal surgery is used for specific congenital abnormalities associated with a poor postnatal prognosis.... | View |
| 04.002.004 | Gender Affirming Surgery | Oct 24, 2024 | Oct 20, 2025 | This policy addresses gender affirming surgery (also known as sex affirmation surgery, gender or sex... | View |
| 04.002.005 | Infertility Treatment | Oct 26, 2023 | Policy Archived | A person is considered infertile if he or she is unable to conceive or produce conception after 1 year of... | View |
| 05.001.002 | Renagel | May 10, 2016 | Policy Archived | ... | View |
| 05.001.004 | Botulinum Toxin | Nov 04, 2024 | Nov 20, 2025 | ... | View |
| 05.001.005 | Human Growth Hormone | Nov 14, 2024 | Nov 20, 2025 | Recombinant human growth hormone (gh) is approved by the u.s. food and drug administration (fda) for various... | View |
| 05.001.006 | Recombinant And Autologous Platelet-Derived Growth Factors For Wound Healing And Other Non‒Orthopedic Conditions | Feb 13, 2025 | Feb 20, 2026 | The use of blood-derived growth factors, including recombinant platelet-derived growth factors (pdgfs) and... | View |
| 05.001.007 | Hepatitis-C crónica (Peg-Intron & Rebetol) | May 16, 2016 | Policy Archived | ... | View |
| 05.001.008 | Immunoglobulin Therapy | Dec 05, 2024 | Nov 20, 2025 | Immunoglobulins are derived from human donor plasma and used to treat an array of disorders, including... | View |
| 05.001.009 | Infliximab | Oct 24, 2024 | Oct 20, 2025 | Description- intro infliximab (remicade®) is a tumor necrosis factor α (tnf-α) blocking agent... | View |
| 05.001.010 | Immune Prophylaxis For Respiratory Syncytial Virus | Sep 11, 2024 | Policy Archived | Respiratory syncytial virus (rsv) is the most common cause of lower respiratory tract infections in children.... | View |
| 05.001.011 | TOCOLISIS CON TERBUTALINA INTRAVENOSA O SUBCUTANEO | Aug 07, 2019 | Policy Archived | Of... | View |
| 05.001.012 | (Trastuzumab) Herceptin | Sep 11, 2024 | Sep 20, 2025 | In certain cancers, the human epidermal growth factor receptor 2 (her2) gene is amplified and overexpressed.... | View |
| 05.001.014 | Intravenous Anesthetics For The Treatment Of Chronic Pain And Psychiatric Disorders | Dec 03, 2024 | Dec 20, 2025 | Intravenous (iv) infusion of lidocaine or ketamine has been investigated for the treatment of migraine and... | 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 |
| 05.001.016 | Uses Of Monoclonal Antibodies For The Treatment Of Non-Hodgkin Lymphoma | Dec 04, 2024 | Policy Archived | Monoclonal antibodies targeted to cancer-associated antigens have been approved by the u.s. food and drug... | View |
| 05.001.017 | Bevacizumab | Oct 24, 2024 | Oct 20, 2025 | Bevacizumab is a humanized monoclonal antibody directed against vascular endothelial growth factor a... | View |
| 05.001.019 | Abatacept (Orencia) | Oct 24, 2024 | Oct 20, 2025 | From the decade of 1990 the advances in molecular biology have shown new approaches to the treatment for... | View |
| 05.001.021 | Vandetanib | Oct 24, 2024 | Policy Archived | The medication vandetanib is an inhibitor of the "tyrosine kinase" which is selectively targeted to... | View |
| 05.001.023 | Newer Oral Anticoagulants | Jul 27, 2020 | Policy Archived | ... | View |
