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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 |
|---|---|---|---|---|---|
| 05.001.037 | Medical Cannabis for the Treatment of Pain and Spasticity | Sep 07, 2023 | Policy Archived | Inhaled cannabis or extracted cannabinoids are considered investigational for the treatment of the... | View |
| 05.001.038 | Erythropoiesis-Stimulating Agents | Nov 10, 2023 | Nov 20, 2024 | The use of epoetin alfa, darbepoetin, or pegylated epoetin beta may be considered medically necessary for:... | View |
| 05.001.039 | Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease | Nov 15, 2023 | Nov 20, 2024 | Lyme disease treatment of lyme disease consists of oral antibiotics, except for the following indications.... | View |
| 05.001.040 | Repository Corticotropin Injection | Nov 15, 2023 | Nov 20, 2024 | Repository corticotropin injection may be considered medically necessary for the treatment of infantile... | View |
| 05.001.041 | Injectable Clostridial Collagenase for Fibroproliferative Disorders | Apr 17, 2024 | Apr 20, 2025 | Injectable clostridial collagenase for the treatment of dupuytren's contracture in adults with a palpable... | View |
| 05.001.042 | Esketamine Nasal Spray for Treatment-Resistant Depression | Nov 15, 2023 | Nov 20, 2024 | Treatment-resistant depression esketamine nasal spray may be considered medically necessary if all of... | View |
| 05.001.043 | Hematopoietic Colony-Stimulating Factors (CSFs) | Apr 12, 2024 | Oct 20, 2024 | Trple s considers short-acting granulocyte colony stimulating factors (g-csfs), medically necessary for... | View |
| 05.001.044 | Polivy® (polatuzumab vedotin-piiq) | Oct 26, 2023 | Oct 20, 2024 | Polatuzumab vedotin-piiq (polivy) is considered medically necessary for the treatment of adult patients with... | View |
| 05.001.045 | Lumasiran for Primary Hyperoxaluria Type 1 | Jul 22, 2024 | Aug 20, 2024 | Initial treatment lumasiran may be considered medically necessary if all of the following conditions are... | View |
| 05.001.046 | Monoclonal Antibodies for Treatment of Alzheimer Disease | Nov 15, 2023 | Nov 20, 2024 | The use of aducanumab and lecanemab is considered investigational for all indications including treatment... | View |
| 05.001.047 | Fibrin Sealant | Oct 26, 2023 | Oct 20, 2024 | The use of fibrin sealants is considered medically necessary in situations where usual and standard... | View |
| 05.001.048 | Biological Treatments for Refractory Myasthenia Gravis | Jun 19, 2024 | Jan 20, 2025 | Eculizumab and ravulizumab-cwvz - initial treatment eculizumab and ravulizumab-cwvz may be... | View |
| 05.001.049 | Givosiran for Acute Hepatic Porphyria | Aug 16, 2023 | Aug 20, 2024 | Initial treatment givosiran may be considered medically necessary if all of the following conditions are... | View |
| 05.001.050 | Omidubicel as Adjunct Treatment for Hematologic Malignancies | Sep 08, 2023 | Sep 20, 2024 | Omidubicel the product label of omidubicel recommends that patients be treated under the supervision of a... | View |
| 05.002.001 | Chimeric Antigen Receptor Therapy for Multiple Myeloma | Apr 19, 2024 | Apr 20, 2025 | Idecabtagene vicleucel and ciltacabtagene autoleucel may be considered medically necessary for individuals... | View |
| 05.003.001 | Gene Therapies for Thalassemia | Jul 22, 2024 | Apr 20, 2025 | Betibeglogene autotemcel and exagamglogene autotemcel are considered medically necessary for individuals with... | View |
| 05.003.002 | Gene Therapies for Sickle Cell Disease | Jul 18, 2024 | Apr 20, 2025 | Exagamglogene autotemcel and lovotibeglogene autotemcel exagamglogene autotemcel and lovotibeglogene... | View |
| 05.003.003 | Gene Therapies for Metachromatic Leukodystrophy | Jul 16, 2024 | Jul 20, 2025 | Atidarsagene autotemcel atidarsagene autotemcel is considered medically necessary for individuals if... | View |
| 06.001.001 | DOPPLER TRANSCRANEAL | Jun 23, 2017 | Policy Archived | El doppler transcraneal se considera para pago en: monitoreo del vasoespasmo en pacientes con hemorragia... | View |
| 06.001.002 | IMAGEN POR RESONCIA MAGNÉTICA | May 10, 2016 | Policy Archived | La resonancia magnética requiere preautorización para evaluar la necesidad médica del servicio en las... | View |
