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 |
|---|---|---|---|---|
| 04.001.012 | Progesterone Therapy As A Technique To Reduce Preterm Delivery In High-Risk Pregnancies | Oct 2024 | Preterm birth is the leading cause of neonatal morbidity and mortality, and effective primary preventive... | View |
| 04.001.013 | Ablación del Endometrio | Aug 2017 | ... | View |
| 04.001.014 | Detección del síndrome de Down usando la translucencia de la nuca fetal y los ma | Nov 2017 | ... | View |
| 04.001.017 | Interrupción Quirúrgica del Nervio Pélvico como tratamiento de Dismenorrea Prima | Nov 2017 | ... | View |
| 04.001.019 | Robotic Surgery In Gynecology | Oct 2023 | 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 2024 | 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 2022 | 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 2017 | ... | View |
| 04.002.002 | Cirugía fetal para malformaciones congénitas diagnosticadas en periodo perinatal | Dec 2022 | Fetal surgery is used for specific congenital abnormalities associated with a poor postnatal prognosis.... | View |
| 04.002.004 | GENDER AFFIRMING SURGERY | Sep 2025 | This policy addresses gender affirming surgery (also known as sex affirmation surgery, gender or sex... | View |
| 04.002.005 | Infertility Treatment | Oct 2023 | 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 2016 | ... | View |
| 05.001.004 | Botulinum Toxin | Nov 2025 | Botulinum is a family of toxins produced by the anaerobic organism clostridia botulinum. multiple... | View |
| 05.001.005 | Human Growth Hormone | Nov 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 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 2016 | ... | View |
| 05.001.008 | Immunoglobulin Therapy | Jan 2026 | Immunoglobulins are derived from human donor plasma and used to treat an array of disorders, including... | View |
| 05.001.009 | Infliximab | Jan 2026 | Infliximab (remicade®) is a tumor necrosis factor α (tnf-α) blocking agent approved by the... | View |
| 05.001.010 | Immune Prophylaxis For Respiratory Syncytial Virus | Sep 2024 | 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 2019 | Of... | View |