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 |
|---|---|---|---|---|---|
| 05.001.044 | Polivy® (polatuzumab vedotin-piiq) | Sep 25, 2025 | Sep 20, 2026 | Polivy® (polatuzumab vedotin-piiq) is an antibody-drug conjugate directed against cd79b. it is... | View |
| 05.001.045 | Lumasiran For Primary Hyperoxaluria Type 1 | Aug 09, 2025 | Aug 20, 2026 | Primary hyperoxalurias are a group of rare genetic diseases. there are 3 subtypes each resulting in the... | View |
| 05.001.046 | Monoclonal Antibodies for Treatment of Alzheimer Disease | Aug 27, 2024 | Policy Archived | Alzheimer disease (ad) is a neurodegenerative disorder leading to progressive, irreversible destruction of... | View |
| 05.001.047 | Fibrin Sealant | Sep 25, 2025 | Sep 20, 2026 | ... | View |
| 05.001.048 | Biological Treatments for Refractory Myasthenia Gravis | Jul 11, 2025 | Jul 20, 2026 | Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness... | View |
| 05.001.049 | Givosiran for Acute Hepatic Porphyria | Oct 23, 2024 | Oct 20, 2025 | Acute hepatic porphyria (ahp) is a rare disease with a prevalence of 5 to 10 cases/100,000 people in the us... | View |
| 05.001.050 | Omidubicel as Adjunct Treatment for Hematologic Malignancies | Sep 02, 2025 | Sep 20, 2026 | Hematologic malignancies are a heterogeneous group of diseases characterized by distinct biological subtypes,... | View |
| 05.001.052 | Tofersen (Qalsody) | Sep 25, 2025 | Sep 20, 2026 | Tofersen (qalsody) is an antisense oligonucleotide indicated for the treatment of amyotrophic lateral... | View |
| 05.001.053 | Mitotic Inhibitors | Sep 25, 2025 | Sep 20, 2026 | Mitotic inhibitors (paclitaxel, docetaxel, abraxane) are chemotherapy agents used in multiple solid tumors,... | View |
| 05.002.001 | Chimeric Antigen Receptor Therapy For Multiple Myeloma | Aug 12, 2025 | Aug 20, 2026 | Multiple myeloma is a hematologic malignancy characterized by abnormal growth of plasma cells with production... | View |
| 05.003.001 | Gene Therapies for Thalassemia | Apr 21, 2025 | Apr 20, 2026 | Beta (β)-thalassemia is a genetic hemoglobinopathy that results from defects in β-globin synthesis... | View |
| 05.003.002 | Gene Therapies for Sickle Cell Disease | Apr 22, 2025 | Apr 20, 2026 | Sickle cell disease is a genetic hemoglobinopathy that results from a genetic variant in the hbb gene... | View |
| 05.003.003 | Gene Therapies for Metachromatic Leukodystrophy | Jul 15, 2025 | Jul 20, 2026 | Metachromatic leukodystrophy (mld) is a rare autosomal recessive lysosomal storage disorder. it arises due to... | View |
| 05.003.004 | Gene Therapies for Duchenne Muscular Dystrophy | Oct 16, 2024 | Oct 20, 2025 | Duchenne muscular dystrophy (dmd) is an inherited disorder that results in progressive muscle weakness and... | View |
| 05.003.005 | Gene Therapies for Congenital Hemophilia A or B | Jan 30, 2025 | Oct 20, 2025 | Most commonly, hemophilia is a recessive x-linked congenital bleeding disorder that predominantly affects... | View |
| 05.003.007 | Gene Therapies for Aromatic L-amino Acid Decarboxylase Deficiency | Sep 22, 2025 | Sep 20, 2026 | Aromatic l-amino acid decarboxylase (aadc) deficiency is a rare autosomal recessive neurodevelopmental... | View |
| 06.001.001 | Doppler Transcraneal | Jun 23, 2017 | Policy Archived | ... | View |
| 06.001.002 | Imagén por resonancia magnética | May 10, 2016 | Policy Archived | ... | View |
| 06.001.003 | Biopsia de Mama dirijida por MRI | May 10, 2016 | Policy Archived | ... | View |
| 06.001.004 | Magnetic Resonance Angiography (Mra) Of The Chest (Excluding The Heart) | Jul 11, 2023 | Policy Archived | Magnetic resonance angiography (mra) is the general term used to describe magnetic resonance imaging of... | View |
