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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 |
|---|---|---|---|---|---|
| 06.001.057 | INTENSITY MODULATED RADIATION THERAPY (IMRT) | Oct 26, 2023 | Oct 20, 2024 | Imrt is considered reasonable and medically necessary in instances where sparing the surrounding normal... | View |
| 06.001.059 | Dopamine Transporter Single-Photon Emission Computed Tomography | Nov 13, 2023 | Nov 20, 2024 | Dopamine transporter imaging with single-photon emission computed tomography may be considered medically... | View |
| 06.001.060 | Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer | Oct 18, 2023 | Oct 20, 2024 | Endobronchial ultrasound-guided transbronchial needle aspiration (ebus-tbna) may be considered medically... | View |
| 06.001.061 | Diagnosis and Treatment of Sacroiliac Joint Pain | Dec 04, 2023 | Dec 20, 2024 | Arthrography of the sacroiliac joint (sij) is considered investigational. injection of anesthetic for... | View |
| 06.001.062 | Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve | Jun 18, 2024 | Jun 20, 2025 | The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography... | View |
| 06.001.063 | Therapeutic Radiopharmaceuticals in Oncology | Aug 07, 2023 | Aug 20, 2024 | Lutetium 177 initial treatment lutetium 177 (lu 177) dotatate treatment is considered medically... | View |
| 06.001.064 | Thermography | Oct 12, 2023 | Oct 20, 2024 | The use of all forms of thermography is... | View |
| 06.001.068 | Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure | Oct 11, 2023 | Oct 20, 2024 | Myocardial sympathetic innervation imaging with iodine 123 meta-iodobenzylguanidine is considered... | View |
| 06.001.069 | Whole Body Dual X-Ray Absorptiometry to Determine Body Composition | Oct 12, 2023 | Oct 20, 2024 | Dual-energy x-ray absorptiometry body composition studies are considered... | View |
| 06.001.070 | Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants | Oct 05, 2021 | Policy Archived | Magnetic resonance imaging may be considered medically necessary to confirm the clinical diagnosis of rupture... | View |
| 06.001.076 | Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer | Nov 10, 2020 | Policy Archived | Radioimmunoscintigraphy using indium 111 capromab pendetide (prostascint®) is considered investigational for... | View |
| 06.001.077 | Radioembolization for Primary and Metastatic Tumors of the Liver | Aug 14, 2023 | Aug 20, 2024 | Radioembolization may be considered medically necessary to treat primary hepatocellular carcinoma that is... | View |
| 06.001.078 | Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia | Sep 08, 2023 | Sep 20, 2024 | Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (wats3d) is... | View |
| 07.001.001 | Insulin Pump | Nov 14, 2018 | Nov 14, 2019 | The use of the insulin pump is considered for payment for adults and pediatric population with diabetes under... | View |
| 07.001.002 | Implantable Infusion Pump for Pain and Spasticity | Mar 11, 2020 | Mar 11, 2021 | Implantable infusion pumps are considered medically necessary when used to deliver drugs having u. food and... | View |
| 07.001.003 | Breast Duct Endoscopy | May 07, 2019 | Policy Archived | Breast duct endoscopy is a technique that provides for direct visual examination of the breast ducts through... | View |
| 07.001.004 | Percutaneous Balloon Valvuloplasty | Dec 20, 2023 | Policy Archived | Pulmonic balloon valvotomy for pulmonary stenosis percutaneous balloon valvuloplasty may be considered... | View |
| 07.001.005 | Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) | May 17, 2024 | May 20, 2025 | Laser discectomy and radiofrequency coblation (disc nucleoplasty) are considered investigational as... | View |
| 07.001.006 | Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone | Aug 09, 2023 | Aug 20, 2024 | Cryosurgical ablation may be considered medically necessary to treat localized renal cell carcinoma that is... | View |
| 07.001.007 | Gastric Electrical Stimulation | Mar 05, 2024 | Mar 20, 2025 | Gastric electrical stimulation is considered investigational for the treatment of gastroparesis of diabetic,... | View |
