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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 |
|---|---|---|---|---|---|
| 06.001.070 | Magnetic Resonance Imaging To Monitor The Integrity Of Silicone Gel-Filled Breast Implants | Feb 25, 2025 | Policy Archived | This evidence review addresses the use of magnetic resonance imaging (mri) to monitor the integrity of... | View |
| 06.001.076 | Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide For Prostate Cancer | Nov 10, 2020 | Policy Archived | Radioimmunoscintigraphy (ris) involves the administration of radiolabeled monoclonal antibodies, which are... | View |
| 06.001.077 | Radioembolization For Primary And Mestastatic Tumors Of The Liver | Aug 22, 2024 | Aug 20, 2025 | Radioembolization (re), also referred to as selective internal radiotherapy, delivers small beads... | View |
| 06.001.078 | Adjunctive Techniques For Screening And Surveillance Of Barrett Esophagus And Esophageal Dysplasia | Dec 26, 2024 | Dec 20, 2025 | Several adjunctive technologies and tests are available for screening, surveillance, and risk stratification... | View |
| 07.001.001 | Insulin Pump | Nov 14, 2018 | Policy Archived | Since early in the 1970s, there was evidence that supported the theory that firm control of diabetes... | View |
| 07.001.002 | Implantable Infusion Pump For Pain And Spasticity | Mar 11, 2020 | Policy Archived | Implantable infusion pumps can provide long-term drug infusion at constant or variable rates; several devices... | 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 | VALVULOPLASTIA PERCUTANEA | Dec 20, 2023 | Policy Archived | Percutaneous balloon valvuloplasty is a method of treating stenotic pulmonary, mitral, and aortic valves... | 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 energy (laser discectomy) and radiofrequency coblation (nucleoplasty) are being evaluated for... | View |
| 07.001.006 | Cryoablation Of Tumors Located In The Kidney, Lung, Breast, Pancreas, Or Bone | Aug 09, 2024 | Aug 20, 2025 | Cryosurgical ablation (hereafter referred to as cryosurgery or cryoablation) involves freezing of target... | View |
| 07.001.007 | Gastric Electrical Stimulation | Mar 04, 2025 | Mar 20, 2026 | Gastric electrical stimulation (ges) is performed using an implantable device designed to treat chronic... | View |
| 07.001.008 | Endovascular Stent Grafts For Disorders Of The Thoracic Aorta | Sep 23, 2024 | Jul 20, 2025 | Thoracic endovascular aortic repair (tevar) involves the percutaneous placement of a stent graft in the... | View |
| 07.001.009 | Computer-Assisted Navigation For Orthopedic Procedure | May 17, 2024 | May 20, 2025 | Computer-assisted navigation in orthopedic procedures describes the use of computer-enabled tracking systems... | View |
| 07.001.010 | Artroplastía de cadera por método mínimamente invasivo | May 16, 2016 | Policy Archived | ... | View |
| 07.001.011 | Transurethral Water Vapor Thermal Therapy For Benign Prostatic Hyperplasia | Jul 16, 2024 | Jul 20, 2025 | Transurethral water vapor thermal therapy and transurethral waterjet ablation (aquablation) have been... | View |
| 07.001.012 | Whole Gland Cryoablation Of Prostate Cancer | Oct 15, 2024 | Policy Archived | Cryoablation, also known as cryotherapy or cryosurgery, is a procedure that attacks cancer cells using... | View |
| 07.001.013 | Treatment Of Varicose Veins/Venous Insufficiency | Jun 07, 2024 | Jun 20, 2025 | A variety of treatment modalities are available to treat varicose veins/venous insufficiency, including... | View |
| 07.001.014 | Reduction Mammaplasty For Breast-Related Symptoms | Mar 12, 2025 | Mar 20, 2026 | Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. macromastia... | View |
| 07.001.015 | Reconstructive Breast Surgery/Management Of Breast Implants After Mastectomy | Jul 10, 2024 | Jul 20, 2025 | Reconstructive breast surgery is defined as a surgical procedure that is designed to restore the normal... | View |
| 07.001.016 | Stereotactic, Ultrasound Guided Breast Biopsy (Mibb) | Oct 24, 2024 | Oct 20, 2025 | Minimally invasive breast biopsy (mibb) is a breast biopsy that is done with a needle to obtain a diagnosis... | View |
