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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 |
|---|---|---|---|---|---|
| 01.001.024 | Artificial Pancreas Device Systems | Aug 05, 2024 | Aug 20, 2025 | Automated insulin delivery systems, also known as artificial pancreas device systems, link a glucose monitor... | View |
| 01.001.025 | Tumor Treating Fields Therapy | Aug 19, 2024 | Aug 20, 2025 | Tumor treating fields (ttf) therapy is a noninvasive technology intended to treat glioblastoma and malignant... | View |
| 01.001.026 | Cooling Devices Used In The Outpatient Setting | Oct 24, 2024 | Oct 20, 2025 | Cooling devices use chilled water to decrease the local temperature of tissue. there are a variety of cooling... | View |
| 01.001.027 | Interferential Current Stimulation | Jul 15, 2024 | Jul 20, 2025 | Interferential current stimulation (ifs) is a type of electrical stimulation used to reduce pain. the... | View |
| 01.001.028 | Postsurgical Home Use Of Limb Compression Devices For Venous Thromboembolism Prophylaxis | Apr 15, 2024 | Apr 20, 2025 | Antithrombotic prophylaxis is recommended for surgical patients at moderate-to-high risk of postoperative... | View |
| 01.001.029 | Pelvic Floor Stimulation As A Treatment Of Urinary Incontinence | Sep 09, 2024 | Sep 20, 2025 | Pelvic floor stimulation is proposed as a nonsurgical treatment option for women and men with urinary or... | View |
| 01.002.004 | Negative Pressure Wound Therapy In The Outpatient Setting | Oct 24, 2024 | Oct 20, 2025 | Negative pressure wound therapy (npwt) involves the use of negative pressure or suction device to aspirate... | View |
| 01.002.005 | Materials Or Surgical Medical Supplies | Nov 11, 2020 | Policy Archived | Medical supplies that, due to their diagnostic or therapeutic characteristics, are essential for the... | View |
| 01.002.006 | Digital Health Technologies: Therapeutic Applications | Aug 28, 2024 | Aug 20, 2025 | Digital health technologies is a broad term that includes categories such as mobile health, health... | View |
| 01.003.004 | Powered Exoskeleton For Ambulation In Patients With Lower-Limb Disabilities | Apr 15, 2024 | Apr 20, 2025 | The goal of the powered exoskeleton is to enable people who do not have volitional movement of their lower... | View |
| 01.003.005 | Patient-Controlled End Of Range Motion Stretching Devices | Apr 08, 2024 | Apr 20, 2025 | Patient-controlled stretching devices are used at home to increase range of motion in patients who have... | View |
| 01.004.001 | Protesis e Implantes | Nov 21, 2016 | Policy Archived | ... | View |
| 01.005.002 | Lower Limb Prosthesis | Nov 10, 2021 | Policy Archived | A prosthesis is an artificial substitute that replaces all or part of an organ of the body, or replaces all... | 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 (eswt) is a noninvasive method used to treat pain with shock or sound waves... | View |
| 02.001.002 | Immunotherapy For Allergies | Jul 08, 2022 | Policy Archived | Immunotherapy in allergies requires regular injections of an allergen for months in order to reduce symptoms.... | View |
| 02.001.004 | Optical Diagnostic Devices For Evaluating Skin Lesions Suspected Of Malignancy | Oct 22, 2020 | Policy Archived | There is interest in noninvasive devices that will improve the diagnosis of malignant skin lesions. one... | View |
| 02.001.005 | Impedancia eléctrica en el barrido del seno | May 06, 2016 | Policy Archived | ... | View |
| 02.001.006 | Prolotherapy | Dec 09, 2024 | Dec 20, 2025 | Prolotherapy describes a procedure intended for healing and strengthening ligaments and tendons by injecting... | View |
| 02.001.007 | Antibióticos en aerosol como tratamiento de la sinusitis crónica | Jun 28, 2016 | Policy Archived | ... | View |
| 02.001.008 | Monitoreo del flujo sanguíneo cerebral regional usando una sonda térmica | May 06, 2016 | Policy Archived | ... | View |
