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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 |
|---|---|---|---|---|---|
| 01.001.021 | Home Cardiorespiratory Monitoring | Jul 18, 2024 | Jul 20, 2025 | Home cardiorespiratory monitors track respiratory effort and heart rate to detect episodes of apnea. they... | View |
| 01.001.022 | Electrical Stimulation For The Treatment Of Arthritis | Apr 04, 2019 | Apr 04, 2020 | Pulsed electrical and electromagnetic stimulation are being investigated to improve functional status and... | View |
| 01.001.023 | Hemophilia Antihemophilic Factor | Jul 24, 2024 | Policy Archived | The hemophilias are a group of related bleeding disorders that most commonly are inherited. inherited... | View |
| 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 |
| 01.002.001 | CERTIFICADO DE EVIDENCIA TERAPIAS DE NUTRICIÓN PARENTERAL Y NUTRICIÓN ENTERAL | Jul 01, 2024 | Retired Policy | Definition a. the certificate of evidence of medical necessity for nutrition therapies parenteral and enteral... | View |
| 01.002.002 | Nutrición enteral en el hogar | Dec 31, 1969 | NA | Na... | View |
| 01.002.003 | Nutrición parenteral en el hogar | Dec 31, 1969 | NA | Na... | 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 | ... | 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 |
| 01.003.001 | Orthotics | Jul 01, 2024 | Retired Policy | An orthotic (orthosis) is a rigid or semi-rigid device used to support, restore, or protect body function.... | 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 | Dec 31, 1969 | NA | Na... | View |
| 01.005.001 | Aparatos Ortopédicos | Jul 01, 2024 | Retired Policy | Definition those devices that are used after surgical or mechanical correction of the deviations, deformities... | View |
