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 |
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01.001.024 | Artificial Pancreas Device Systems | Aug 05, 2024 | Aug 20, 2025 | Policy statements use of a u.s. food and drug administration (fda) cleared or approved automated insulin... | View |
01.001.025 | Tumor Treating Fields Therapy | Aug 19, 2024 | Aug 20, 2025 | Tumor treating fields therapy to treat glioblastoma multiforme (gbm) is considered medically necessary as... | View |
01.001.026 | Cooling & Heating Devices Used in the Outpatient Setting | Oct 24, 2024 | Oct 20, 2025 | For individuals who have pain and/or swelling after knee surgery who receive a cooling device, the evidence... | View |
01.001.027 | Interferential Current Stimulation | Jul 15, 2024 | Jul 20, 2025 | Interferential current stimulation is... | View |
01.001.028 | Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis | Apr 15, 2024 | Apr 20, 2025 | Postsurgical home use of limb compression devices for vte prophylaxis may be considered medically... | View |
01.001.029 | Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence | Sep 09, 2024 | Sep 20, 2025 | Electrical or magnetic stimulation of the pelvic floor muscles (pelvic floor stimulation) as a treatment for... | View |
01.002.004 | Negative Pressure Wound Therapy in the Outpatient Setting | Oct 24, 2024 | Oct 20, 2025 | Initiation of powered negative pressure wound therapy an initial therapeutic trial of not less than 2... | View |
01.002.005 | Materials or Surgical Medical Supplies | Nov 11, 2020 | Policy Archived | Surgical medical supplies or materials are considered for payment if they meet the following criteria. •... | View |
01.002.006 | Digital Health Technologies: Therapeutic Applications | Aug 28, 2024 | Aug 20, 2025 | The use of freespira is considered investigational for all indications including treatment of panic disorder... | View |
01.003.004 | Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities | Apr 15, 2024 | Apr 20, 2025 | Use of a powered exoskeleton for ambulation in patients with lower-limb disabilities is... | View |
01.003.005 | Patient-Controlled End of Range Motion Stretching Devices | Apr 08, 2024 | Apr 20, 2025 | Patient-controlled end range of motion stretching devices are... | View |
01.004.001 | PROTÉSIS E IMPLANTES | Nov 21, 2016 | Policy Archived | El implante es un objeto, material o artefacto que se coloca dentro del cuerpo. una prótesis es un... | View |
01.005.002 | LOWER LIMB PROSTHESIS | Nov 10, 2021 | Policy Archived | Lower limb prosthesis complies with triple-s medical criteria for coverage when the following general... | View |
02.001.001 | Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions | Jul 15, 2024 | Jul 20, 2025 | Extracorporeal shock wave therapy using either a high- or low-dose protocol or radial extracorporeal shock... | View |
02.001.002 | Immunotherapy for Allergies | Jul 08, 2022 | Policy Archived | Immunotherapy for allergies is considered for payment in patients with hypersensitivity that cannot be... | View |
02.001.004 | Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy | Oct 22, 2020 | Policy Archived | Dermatoscopy, using either direct inspection, digitization of images, or computer-assisted analysis, is... | View |
02.001.005 | IMPEDANCIA ELECTRICA EN EL BARRIDO DEL SENO | May 06, 2016 | Policy Archived | El uso de la impedancia eléctrica en el barrido del seno envuelve la trasmisión continua de electricidad al... | View |
02.001.006 | Prolotherapy | Dec 09, 2024 | Dec 20, 2025 | Prolotherapy is considered investigational as a treatment of musculoskeletal... | View |
02.001.007 | ANTIBIOTICOS EN AEROSOL COMO TRATAMIENTO DE LA SINUSITIS CRONICA | Jun 28, 2016 | Policy Archived | Tratamiento de la sinusitis crónica o exacerbaciones agudas de la sinusitis crónica con antibióticos en... | View |
02.001.008 | MONITOREO DEL FLUJO SANGUÍNEO CEREBRAL REGIOL USANDO U SONDA TERMICA | May 06, 2016 | Policy Archived | Monitoreo de la circulación cerebral usando electrodos termales no se considera para pago. no hay datos... | View |