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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 |
|---|---|---|---|---|---|
| 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 02, 2023 | Oct 20, 2024 | 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 15, 2023 | Nov 20, 2024 | Magnetic resonance spectroscopy is considered... | View |
| 06.001.009 | Low-Osmolarity Radiocontrast Agents non ionic | Nov 11, 2020 | Policy Archived | Low osmolality contrast medium is considered medically necessary in patients with high risk of severe... | View |
| 06.001.010 | Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer | Oct 18, 2023 | Oct 20, 2024 | All policy statements below refer to performing magnetic resonance imaging (mri) of the breast with contrast... | View |
| 06.001.011 | Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography | Nov 13, 2023 | Nov 20, 2024 | Positron emission tomography (pet) using 2-[fluorine-18]-fluoro-2-deoxy-d-glucose (fdg) may be considered... | View |
| 06.001.014 | Oncologic Applications of Positron Emission Tomography Scanning | Oct 20, 2023 | Oct 20, 2024 | Positron emission tomography (pet) scans are based on the use of positron-emitting radionuclide tracers... | View |
| 06.001.015 | Stereotactic Radiosurgery and Stereotactic Body Radiotherapy | Aug 09, 2023 | Aug 20, 2024 | Stereotactic radiosurgery using a gamma-ray or linear accelerator unit may be considered medically necessary... | View |
| 06.001.016 | Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds | Aug 16, 2023 | Aug 20, 2024 | Brachytherapy using permanent transperineal implantation of radioactive seeds may be considered medically... | View |
| 06.001.018 | Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine | May 10, 2024 | May 20, 2025 | Percutaneous vertebroplasty may be considered medically necessary for the treatment of symptomatic... | View |
| 06.001.020 | Virtual Colonoscopy/Computed Tomography Colonography | Oct 02, 2023 | Oct 20, 2024 | Computed tomography colonography (ctc) may be considered medically necessary for the purposes of colon... | View |
| 06.001.021 | Computer-Aided detection in Conjuction with Digitized Screen-Film Mammography or Ful-Field Digital Mammography | Dec 16, 2019 | Policy Archived | Computer-aided detection devices as an adjunct to single-reader interpretation of digitized screen-film... | View |
| 06.001.022 | Intravascular Ultrasound Imaging of Coronary Arteries | Aug 31, 2023 | Policy Archived | The use of ivus in transcatheter revascularization therapy of coronary artery disease may be considered... | View |
| 06.001.023 | Magnetic Resonance Angiography of Vessels of the Head, Neck,Abdomen, Pelvis, and Lower Extremity | Jul 19, 2022 | Policy Archived | Mra of the head may be considered medically necessary for the assessment of: ï· patients suspected of... | View |
| 06.001.024 | Magnetic Resonance Cholangiopancreatography | Sep 02, 2019 | Policy Archived | Magnetic resonance cholangiopancreatography (mrcp) may be considered medically necessary for diagnostic... | View |
| 06.001.025 | TOMOGRAFIA COMPUTADORIZADA DEL CUERPO ENTERO COMO METODO DE CERNIMIENTO | May 16, 2016 | Policy Archived | Tomografía computadorizada de cuerpo entero cómo un método de cernimiento no se considera para pago. el... | View |
| 06.001.026 | Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation | Oct 03, 2023 | Oct 20, 2024 | Contrast-enhanced coronary computed tomography angiography (ccta) for evaluation of individuals with acute... | View |
| 06.001.027 | Vertebral Fracture Assessment with Densitometry | Oct 17, 2023 | Oct 20, 2024 | Screening for vertebral fractures using dual-energy x-ray absorptiometry is... | View |
