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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 |
|---|---|---|---|---|---|
| 05.001.045 | Lumasiran for Primary Hyperoxaluria Type 1 | Aug 09, 2024 | Aug 20, 2025 | 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 | Aug 27, 2024 | Policy Archived | The use of aducanumab and lecanemab is considered investigational for all indications including treatment... | View |
| 05.001.047 | Fibrin Sealant | Oct 24, 2024 | Oct 20, 2025 | 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 | Jul 17, 2024 | Jul 20, 2025 | Eculizumab and ravulizumab-cwvz - initial treatment eculizumab and ravulizumab-cwvz may be... | View |
| 05.001.049 | Givosiran for Acute Hepatic Porphyria | Oct 23, 2024 | Oct 20, 2025 | Initial treatment givosiran may be considered medically necessary if the following conditions are met:... | View |
| 05.001.050 | Omidubicel as Adjunct Treatment for Hematologic Malignancies | Sep 23, 2024 | Sep 20, 2025 | Omidubicel is considered medically necessary in individuals 12 years or older with hematologic malignancies... | View |
| 05.001.052 | Tofersen (Qalsody) | Oct 24, 2024 | Oct 20, 2025 | Amyotrophic lateral sclerosis (als) is a debilitating disease caused by degeneration of cortical, brainstem,... | View |
| 05.002.001 | Chimeric Antigen Receptor Therapy for Multiple Myeloma | Jan 15, 2025 | Aug 20, 2025 | Idecabtagene vicleucel may be considered medically necessary for individuals with multiple myeloma if they... | 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 |
| 05.003.004 | Gene Therapies for Duchenne Muscular Dystrophy | Oct 16, 2024 | Oct 20, 2025 | The use of delandistrogene moxeparvovec-rokl is considered investigational for all indications including the... | View |
| 05.003.005 | Gene Therapies for Congenital Hemophilia A or B | Jan 30, 2025 | Oct 20, 2025 | Etranacogene dezaparvovec-drlb and fidanacogene elaparvovec-dzkt etranacogene dezaparvovec-drlb and... | 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 |
| 06.001.003 | BIOPSIA DE MAMA DIRIGIDA POR MRI | May 10, 2016 | Policy Archived | La biopsia de mama asistida por vacío y guiada con mri se considera para pago bajo las siguientes... | View |
| 06.001.004 | Magnetic Resonance Angiography (MRA) of the Chest (excluding the heart) | Jul 11, 2023 | Policy Archived | Mra of the chest may be considered medically necessary in patients with the following indications in whom... | View |
| 06.001.005 | Bone Mineral Density Studies | Oct 16, 2024 | Oct 20, 2025 | Initial or repeat bone mineral density (bmd) measurement is not indicated unless the results will influence... | View |
| 06.001.006 | Screening and Diagnostic Mammography | Sep 07, 2023 | Policy Archived | Screening mammogram a screening mammography is a radiologic procedure furnished to a woman without signs... | View |
| 06.001.007 | Magnetic Resonance Spectroscopy | Nov 12, 2024 | Nov 20, 2025 | Magnetic resonance spectroscopy (mrs) is a noninvasive technique that can be used to measure the... | View |
