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
07.003.003 Isolated Small Bowel Transplant Sep 2026 A small bowel transplant may be performed as an isolated procedure or in conjunction with other visceral... View
07.003.004 Transplante nomieloablativo de médula ósea o células germinales periféricas en e Nov 2012 ... View
07.003.005 Allogeneic Pancreas Transplant Sep 2026 Transplantation of a healthy pancreas is a treatment for individuals with insulin-dependent diabetes.... View
07.003.006 Liver Transplant And Combined Liver-Kidney Transplant Sep 2026 Liver transplantation is currently the treatment of last resort for individuals with end-stage liver disease.... View
07.003.007 Heart Transplant Sep 2026 A heart transplant and a retransplant consist of replacing a diseased heart with a healthy donor heart.... View
07.003.008 Lung And Lobar Lung Transplant Sep 2026 A lung transplant consists of replacing all or part of diseased lungs with healthy lung(s) or lobes.... View
07.003.009 Heart/Lung Transplant Sep 2026 Heart/lung transplantation involves a coordinated triple operative procedure consisting of procurement of a... View
07.003.010 Small Bowel/Liver And Multivisceral Transplant Sep 2026 This evidence review addresses transplantation and retransplantation of an intestinal allograft in... View
07.003.011 Islet Transplantation Sep 2026 Performed in conjunction with pancreatectomy for chronic pancreatitis, autologous islet transplantation is... View
07.003.012 Amniotic Membrane And Amniotic Fluid Jun 2026 Several commercially available forms of human amniotic membrane (ham) and amniotic fluid can be administered... View
07.003.013 Composite Tissue Allotransplantation Of The Hand And Face Sep 2026 Composite tissue allotransplantation (also referred to as vascularized composite allotransplantation) is... View
07.003.014 Kidney Transplant Sep 2026 Kidney transplant, a treatment option for end-stage renal disease, involves the surgical removal of a kidney... View
07.003.016 Amniotic Membrane Allograft (OrthoNovis GUARD AC) Aug 2026 Surgical, orthopedic, spinal, dermal or opthamic conditions for which a protective tissue covering is... View
07.004.001 Implantation Of Intrastromal Corneal Ring Segments Archived May 2021 Intrastromal corneal ring segments (icrs) are composed of microthin soft plastic inserts of variable... View
07.004.002 Vascular Endothelial Growth Factor Inhibitors for the Treatment of Ophthalmological Diseases Aug 2026 Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular... View
07.004.003 Vascular Endothelial Growth Factor Inhibitors for Sickle Cell Retinopathy Apr 2026 Sickle cell retinopathy is a known complication of sickle cell disease. sickle cell retinopathy is... View
08.001.001 Physical Therapy In The Home Apr 2025 Physical therapy is the treatment of an illness or injury with the use of therapeutic exercises or... View
08.001.002 Physical Therapy Services Jun 2026 Physical therapy is the treatment of illness or physical damage through the use of therapeutic exercise,... View
08.001.003 Home Based Occupational Therapy Nov 2020 ... View
08.001.004 Speech Therapy Jul 2026 Developmental language disorder is the most common developmental disability of childhood, occurring in 5 to... View