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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 |
|---|---|---|---|---|---|
| 04.001.010 | 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 | Oct 20, 2023 | Oct 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 18, 2023 | Oct 20, 2024 | 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 | Oct 20, 2024 | The robot-assisted gynecologic surgery (robotic surgery) is considered a modality of conventional... | View |
| 04.001.020 | Obstetric Ultrasonography | Jun 26, 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 |
| 04.002.001 | TRATAMIENTO DEL SINDROME DE TRANSFUSION DE FETO A FETO UTILIZANDO AMNIOREDUCCION Y/O CIRUGIA FETOSCOPICA ASISTIDA POR LASER | Dec 13, 2017 | Policy Archived | Reducción de líquido amniótico y/o terapia de coagulación por ablación con láser se considera para pago... | View |
| 04.002.002 | Fetal Surgery for Prenatally Diagnosed Malformations | Dec 08, 2022 | Policy Archived | Vesicoamniotic shunting as a treatment of urinary tract obstruction may be considered medically necessary in... | View |
| 04.002.004 | GENDER AFFIRMING SURGERY | Oct 26, 2023 | Oct 20, 2024 | Gender affirming surgery is considered medically necessary for the treatment of individuals with gender... | View |
| 04.002.005 | Infertility Treatment | Oct 26, 2023 | Policy Archived | Evaluation and treatment of infertility is considered medicaly necessary and maybe submitted for... | View |
| 05.001.002 | SEVELAMER (REGEL, RENVELA) y FOSRENOL | May 16, 2016 | Policy Archived | Se considera para pago el uso de sevelamer en pacientes de enfermedad renal de último estadío ó diálisis... | View |
| 05.001.004 | Botulinum Toxin | Mar 12, 2024 | Nov 20, 2024 | The use of botulinum toxin may be considered medically necessary for the following:... | View |
| 05.001.005 | Human Growth Hormone | Nov 13, 2023 | Nov 20, 2024 | Recombinant human growth hormone (gh) therapy may be considered medically necessary for the following... | View |
| 05.001.006 | Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other NonâOrthopedic Conditions | Feb 12, 2024 | Feb 20, 2025 | Recombinant platelet-derived growth factor (ie, becaplermin) may be considered medically necessary when used... | View |
| 05.001.007 | HEPATITIS-C CRONICA (PEG-INTRON & REBETOL) | May 16, 2016 | Policy Archived | Triple-s cubrirá medicamentos para el tratamiento de infección crónica de hepatitis-c a los asegurados que... | View |
| 05.001.008 | Immunoglobulin Therapy | Nov 14, 2023 | Nov 20, 2024 | Intravenous immunoglobulin therapy intravenous immunoglobulin (ivig) therapy may be considered medically... | View |
| 05.001.009 | Infliximab (Remicade, Inflectra, Renflexis, Avsola and Unbranded Infliximab) | Apr 05, 2024 | Oct 20, 2024 | Infliximab is a tumor necrosis factor (tnf) blocker that may be used and medically necessary for treatment... | View |
| 05.001.010 | Immune Prophylaxis for Respiratory Syncytial Virus | Sep 07, 2022 | Policy Archived | Monthly administration of immune prophylaxis for respiratory syncytial virus (rsv) with palivizumab during... | View |
| 05.001.011 | Acute and Maintenance Tocolysis | Aug 07, 2019 | Policy Archived | Acute tocolytic therapy with calcium channel blockers, magnesium sulfate, prostaglandin inhibitors, and... | View |
