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 07, 2023 | Aug 20, 2024 | Use of a u.s. food and drug administration (fda) cleared or approved automated insulin delivery system... | View |
| 01.001.025 | Tumor Treating Fields Therapy | Aug 09, 2023 | Aug 20, 2024 | Tumor treating fields therapy to treat glioblastoma multiforme (gbm) is considered medically necessary as... | View |
| 01.001.026 | Cooling Devices Used in the Outpatient Setting | Apr 14, 2023 | Apr 20, 2024 | Circulating and noncirculating cooling devices are considered investigational. combination circulating... | View |
| 01.001.027 | Interferential Current Stimulation | Jul 03, 2023 | Jul 20, 2024 | Interferential current stimulation is... | View |
| 01.001.028 | Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis | Apr 14, 2023 | Apr 20, 2024 | Postsurgical home use of limb compression devices for vte prophylaxis may be considered medically necessary... | View |
| 01.001.029 | Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence | Sep 05, 2023 | Sep 20, 2024 | Electrical or magnetic stimulation of the pelvic floor muscles (pelvic floor stimulation) as a treatment for... | View |
| 01.002.001 | CERTIFICADO DE EVIDENCIA TERAPIAS DE NUTRICIÓN PARENTERAL Y NUTRICIÓN ENTERAL | Nov 04, 2016 | Policy Archived | Este certificado debe presentarse en el momento de solicitar servicios de nutrición enteral y/o parenteral.... | View |
| 01.002.004 | Negative Pressure Wound Therapy in the Outpatient Setting | Oct 26, 2023 | Oct 20, 2024 | 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 | May 03, 2023 | May 20, 2024 | The use of freespira is considered investigational for all indications including treatment of panic disorder... | View |
| 01.003.001 | Orthotics | May 07, 2019 | Policy Archived | Orthotic devices are considered medically necessary when prescribed by a qualified provider to be used for... | View |
| 01.003.004 | Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities | Apr 14, 2023 | Apr 20, 2024 | 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 14, 2023 | Apr 20, 2024 | Patient-controlled end range of motion stretching devices are... | View |
| 01.004.001 | PROTÉSIS E IMPLANTES | Nov 21, 2016 | Policy Archived | I. prótesis e implantes quirúrgicos que se consideran para pago: a. prótesis articulaciones artificiales... | View |
| 01.005.001 | APARATOS ORTOPEDICOS | May 10, 2016 | Policy Archived | Aquellos aparatos que se utilizan después de una corrección quirúrgica o mecánica de las desviaciones,... | 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 03, 2023 | Jul 20, 2024 | 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 | Impedancia eléctrica en el barrido del seno es un procedimiento que no se considera para pago, ya que una... | View |
