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 |
|---|---|---|---|---|
| 05.003.003 | Gene Therapies for Metachromatic Leukodystrophy | Jul 2025 | 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 | Feb 2026 | 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 | Oct 2025 | Most commonly, hemophilia is a recessive x-linked congenital bleeding disorder that predominantly affects... | View |
| 05.003.006 | Gene Therapies for Cerebral Adrenoleukodystrophy | Jan 2026 | Cerebral adrenoleukodystrophy (cald) is an x-linked genetic neurodegenerative disease that most severely... | View |
| 05.003.007 | Gene Therapies for Aromatic L-amino Acid Decarboxylase Deficiency | Sep 2025 | Aromatic l-amino acid decarboxylase (aadc) deficiency is a rare autosomal recessive neurodevelopmental... | View |
| 05.003.008 | Gene Therapy For Inherited Retinal Dystrophy | Feb 2026 | Inherited retinal dystrophy can be caused by recessive variants in the rpe65 gene. individuals with biallelic... | View |
| 06.001.001 | Doppler Transcraneal | Jun 2017 | ... | View |
| 06.001.002 | Imagén por resonancia magnética | May 2016 | ... | View |
| 06.001.003 | Biopsia de Mama dirijida por MRI | May 2016 | ... | View |
| 06.001.004 | Magnetic Resonance Angiography (Mra) Of The Chest (Excluding The Heart) | Jul 2023 | Magnetic resonance angiography (mra) is the general term used to describe magnetic resonance imaging of... | View |
| 06.001.005 | Bone Mineral Density Studies | Dec 1969 | Bone mineral density (bmd) studies can be used to identify individuals with osteoporosis and monitor response... | View |
| 06.001.006 | Screening And Diagnostic Mammography | Sep 2023 | Screening mammogram a screening mammography is a radiologic procedure furnished to a woman without signs or... | View |
| 06.001.007 | Magnetic Resonance Spectroscopy | Nov 2025 | Magnetic resonance spectroscopy (mrs) is a noninvasive technique that can be used to measure the... | View |
| 06.001.008 | Contraste (Gadolinium) | May 2016 | ... | View |
| 06.001.010 | Magnetic Resonance Imaging For Detection And Diagnosis Of Breast Cancer | Nov 2025 | Magnetic resonance imaging (mri) of the breast is performed using scanners and intravenous imaging contrast... | View |
| 06.001.011 | Miscellaneous (Noncardiac, Nononcologic) Applications Of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography | Nov 2025 | Positron emission tomography (pet) images biochemical and physiologic functions by measuring concentrations... | View |
| 06.001.014 | Oncologic Applications Of Positron Emission Tomography Scanning | Oct 2025 | 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 | Nov 2025 | Stereotactic radiosurgery (srs) and stereotactic body radiotherapy (sbrt) are 3-dimensional conformal... | View |
| 06.001.016 | Brachytherapy For Clinically Localized Prostate Cancer Using Permanently Implanted Seeds | Aug 2025 | Brachytherapy is a procedure in which a radioactive source (eg, radioisotope "seeds") is... | View |
| 06.001.018 | Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine | May 2026 | Percutaneous vertebroplasty, percutaneous balloon kyphoplasty, radiofrequency kyphoplasty, and mechanical... | View |