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 |
|---|---|---|---|---|
| 02.001.032 | Dynamic Posturography | Mar 2026 | Dynamic posturography tests an individual's balance control in situations intended to isolate factors... | View |
| 02.001.033 | Transcranial Magnetic Stimulation As A Treatment Of Depression And Other Psychiatric/Neurologic Disorders | Sep 2026 | Transcranial magnetic stimulation (tms) is a noninvasive method of delivering electrical stimulation to the... | View |
| 02.001.043 | Interventions For Progressive Scoliosis | May 2026 | ... | View |
| 02.001.050 | Chronic Intermittent Intravenous Insulin Therapy | Mar 2026 | Chronic intermittent intravenous insulin therapy (ciiit) is a technique for delivering variable-dose insulin... | View |
| 02.001.051 | Orthopedic Applications Of Platelet-Rich Plasma | May 2026 | The use of platelet-rich plasma has been proposed as a treatment for various musculoskeletal conditions and... | View |
| 02.001.059 | KEYTRUDA® (pembrolizumab) | May 2026 | Pembrolizumab (keytruda®) is a programmed death receptor-1 (pd-1) blocking antibody that enhances t-cell... | View |
| 02.001.063 | Intra-Articular Hyaluronan Injections For Osteoarthritis | May 2026 | Intra-articular injection of hyaluronan into osteoarthritic joints is proposed to reduce pain and improve... | View |
| 02.001.065 | Polysomnography For Non-Respiratory Sleep Disorders | Jul 2026 | Polysomnography records multiple physiologic parameters relevant to sleep. video recording may also be... | View |
| 02.001.071 | Vestibular Function Testing | Mar 2026 | Dizziness, vertigo, and balance impairments can arise from a loss of vestibular function. a number of... | View |
| 02.001.103 | Trigger Point And Tender Point Injections | May 2026 | Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that... | View |
| 02.001.105 | Digital Health Technologies: Diagnostic Applications | Mar 2026 | Digital health technologies is a broad term that includes categories such as mobile health, health... | View |
| 02.001.108 | Immersive Virtual Reality Therapy for Chronic Lower Back Pain | Sep 2026 | This evidence review addresses prescription digital therapeutics (pdts) that deliver therapeutic benefit... | View |
| 02.001.110 | Digital Health Technologies: Eye-Tracking Diagnostic Device for Autism Spectrum Disorder | Sep 2026 | Eye-tracking–based diagnostic aids for autism spectrum disorder (asd) are computerized cognitive... | View |
| 02.001.111 | Mammography-based AI (Image-only) Risk Prediction Models | Sep 2026 | This evidence review addresses the use of mammography-based ai risk prediction software intended to generate... | View |
| 02.002.004 | Electrocardiography (Ekg, Ecg) | Jun 2026 | The electrocardiogram (ecg or ekg) is a noninvasive test that is used to reflect underlying heart conditions... | View |
| 02.002.006 | MYOCARDIAL PERFUSION STRESS TEST | Jun 2026 | In the stress test (cardiovascular “stress test”), cardiac angina is induced by gradually... | View |
| 02.002.019 | Catheter Ablation As Treatment For Atrial Fibrillation | Apr 2026 | Atrial fibrillation frequently arises from an abnormal focus at or near the junction of the pulmonary veins... | View |
| 02.002.022 | Ambulatory Event Monitors And Mobile Cardiac Outpatient Telemetry | Mar 2026 | Various devices are available for outpatient cardiac rhythm monitoring. these devices differ in the types of... | View |
| 02.002.031 | Transcatheter Mitral Valve Repair | Sep 2026 | Mitral transcatheter edge-to-edge repair (m-teer) and replacement are alternatives to surgical therapy for... | View |
| 02.002.034 | Percutaneous Left Atrial Appendage Closure Devices For Stroke Prevention In Atrial Fibrillation | Sep 2026 | Stroke prevention in patients with atrial fibrillation (af) is an important goal of treatment. treatment with... | View |