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 |
|---|---|---|---|---|
| 06.001.047 | Non-Invasive Arterial Vascular Studies Of Upper And Lower Extremities | Oct 2022 | Non-invasive studies of the arterial system of the upper and lower extremities are used primarily to... | View |
| 06.001.048 | Non Invasive Evaluation Of Extracranial Arteries | Jan 2025 | Non-invasive studies of the extracranial arteries consist of the direct and indirect use of ultrasound... | View |
| 06.001.049 | Estudios vasculares venosos no invasivos de extremidades superiores e inferiores | Nov 2018 | Noninvasive vascular studies of the upper and lower extremities veins are used primarily to establish the... | View |
| 06.001.050 | Duplex Sanning | Nov 2019 | A duplex scanning is a procedure of tracking by ultrasound that demonstrates the structures in two dimensions... | View |
| 06.001.051 | Digital Breast Tomosynthesis | Nov 2020 | Digital breast tomosynthesis (dbt) uses modified digital mammography (dm) equipment to obtain additional... | View |
| 06.001.053 | Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease | Jun 2025 | Alzheimer disease (ad) is a fatal neurodegenerative disease that causes progressive loss in memory, language,... | View |
| 06.001.057 | Intensity Modulated Radiation Therapy (Imrt) | Oct 2024 | ... | View |
| 06.001.059 | Dopamine Transporter Single-Photon Emission Computed Tomography | Nov 2025 | 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 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 2025 | 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 2025 | Invasive coronary angiography (ica) is clinically useful in stable ischemic heart disease when there is... | View |
| 06.001.063 | Therapeutic Radiopharmaceuticals In Oncology | Jan 2026 | Radiopharmaceuticals are composed of a radioisotope bond to an organic molecule and are used for diagnostic... | View |
| 06.001.064 | Thermography | Dec 2024 | 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 2025 | 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 2025 | 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 2025 | 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 2020 | 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 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 2025 | Several adjunctive technologies and tests are available for screening, surveillance, and risk stratification... | View |
| 07.001.001 | Insulin Pump | Nov 2018 | Since early in the 1970s, there was evidence that supported the theory that firm control of diabetes... | View |