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 |
|---|---|---|---|---|---|
| 06.001.059 | Dopamine Transporter Single-Photon Emission Computed Tomography | Nov 05, 2025 | Nov 20, 2026 | Dopamine transporter imaging with single-photon emission computed tomography (dat-spect), using... | View |
| 06.001.060 | Endobronchial Ultrasound For Diagnosis And Staging Of Lung Cancer | Jan 23, 2026 | Oct 20, 2026 | Endobronchial ultrasound (ebus) is an imaging technique for adjunctive use with standard flexible... | View |
| 06.001.061 | Diagnosis And Treatment Of Sacroiliac Joint Pain | Dec 04, 2025 | Dec 20, 2026 | Sacroiliac joint (sij) arthrography using fluoroscopic guidance with an injection of an anesthetic has been... | View |
| 06.001.062 | Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve | Jun 19, 2025 | Jun 20, 2026 | Invasive coronary angiography (ica) is clinically useful in stable ischemic heart disease when there is... | View |
| 06.001.063 | Therapeutic Radiopharmaceuticals In Oncology | Jan 08, 2026 | Jan 20, 2027 | Radiopharmaceuticals are composed of a radioisotope bond to an organic molecule and are used for diagnostic... | View |
| 06.001.064 | Thermography | Dec 03, 2024 | Policy Archived | Thermography is a noninvasive imaging technique that measures temperature distribution in organs and tissues.... | View |
| 06.001.068 | Myocardial Sympathetic Innervation Imaging In Patients With Heart Failure | Oct 22, 2025 | Oct 20, 2026 | In individuals with heart failure, activation of the sympathetic nervous system is an early response to... | View |
| 06.001.069 | Whole Body Dual X-Ray Absorptiometry To Determine Body Composition | Oct 08, 2025 | Oct 20, 2026 | Using low-dose x-rays of 2 different energy levels, whole-body dual-energy x-ray absorptiometry (dxa)... | View |
| 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 18, 2025 | Aug 20, 2026 | 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 08, 2025 | Dec 20, 2026 | 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 19, 2025 | May 20, 2026 | 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 13, 2025 | Aug 20, 2026 | 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 | Jan 13, 2026 | Jan 20, 2027 | Thoracic endovascular aortic repair (tevar) involves the percutaneous placement of a stent graft in the... | View |
