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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 |
|---|---|---|---|---|---|
| 06.001.069 | Whole Body Dual X-Ray Absorptiometry to Determine Body Composition | Oct 08, 2024 | Oct 20, 2025 | Dual-energy x-ray absorptiometry body composition studies are... | View |
| 06.001.070 | Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants | Oct 05, 2021 | 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 using indium 111 capromab pendetide (prostascint®) is considered investigational for... | View |
| 06.001.077 | Radioembolization for Primary and Metastatic Tumors of the Liver | Aug 22, 2024 | Aug 20, 2025 | Radioembolization may be considered medically necessary to treat primary hepatocellular carcinoma that is... | View |
| 06.001.078 | Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia | Dec 26, 2024 | Dec 20, 2025 | Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (wats3d) is considered... | 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, 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 05, 2024 | Mar 20, 2025 | Gastric electrical stimulation is considered investigational for the treatment of gastroparesis of diabetic,... | 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 Procedures | May 17, 2024 | May 20, 2025 | Computer-assisted surgical navigation for orthopedic procedures is considered... | View |
| 07.001.010 | ARTROPLASTIA DE CADERA POR METODO MINIMAMENTE INVASIVO | May 16, 2016 | Policy Archived | La artroplastia minimamente invasiva para reemplazo de cadera o reemplazo de rodilla se considera para pago... | 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 | Whole gland cryoablation of the prostate may be considered medically necessary as treatment of clinically... | View |
| 07.001.013 | Treatment of Varicose Veins/Venous Insufficiency | Jun 07, 2024 | Jun 20, 2025 | Saphenous veins great or small saphenous veins treatment of the great or small saphenous veins by... | View |
| 07.001.014 | Reduction Mammaplasty for Breast-Related Symptoms | Mar 14, 2024 | Mar 20, 2025 | Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. macromastia... | View |
| 07.001.015 | Reconstructive Breast Surgery/Management of Breast Implants | Jul 10, 2024 | Jul 20, 2025 | Coverage eligibility of breast implants for the purposes of augmentation may depend on contract language.... | View |
