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 |
|---|---|---|---|---|---|
| 07.003.002 | Placental And Umbilical Cord Blood As A Source Of Stem Cells | Mar 19, 2021 | Policy Archived | This evidence review addresses the collection, storage, and transplantation of placental and umbilical cord... | View |
| 07.003.003 | Isolated Small Bowel Transplant | Oct 20, 2025 | Oct 20, 2026 | A small bowel transplant may be performed as an isolated procedure or in conjunction with other visceral... | View |
| 07.003.005 | Allogeneic Pancreas Transplant | Oct 10, 2025 | Oct 20, 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 | Dec 31, 1969 | Sep 20, 2026 | Liver transplantation is currently the treatment of last resort for individuals with end-stage liver disease.... | View |
| 07.003.007 | Heart Transplant | Oct 10, 2025 | Oct 20, 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 | Oct 22, 2025 | Sep 20, 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 | Oct 20, 2025 | Oct 20, 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 | Oct 20, 2025 | Oct 20, 2026 | This evidence review addresses transplantation and retransplantation of an intestinal allograft in... | View |
| 07.003.011 | Islet Transplantation | Oct 17, 2025 | Oct 20, 2026 | Performed in conjunction with pancreatectomy for chronic pancreatitis, autologous islet transplantation is... | View |
| 07.003.012 | Amniotic Membrane And Amniotic Fluid | Jan 23, 2026 | May 20, 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 | Oct 16, 2025 | Oct 20, 2026 | Composite tissue allotransplantation (also referred to as vascularized composite allotransplantation) is... | View |
| 07.003.014 | Kidney Transplant | Sep 05, 2025 | Sep 20, 2026 | Kidney transplant, a treatment option for end-stage renal disease, involves the surgical removal of a kidney... | View |
| 07.004.001 | Implantation Of Intrastromal Corneal Ring Segments Archived | May 17, 2021 | Policy Archived | 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 | Sep 25, 2025 | Sep 20, 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 18, 2025 | Apr 20, 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 23, 2025 | Policy Archived | Physical therapy is the treatment of an illness or injury with the use of therapeutic exercises or... | View |
| 08.001.002 | Physical Therapy Services | Jul 23, 2025 | Policy Archived | 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 11, 2020 | Policy Archived | ... | View |
| 08.001.004 | Speech Therapy | Aug 06, 2025 | Policy Archived | Developmental language disorder is the most common developmental disability of childhood, occurring in 5 to... | View |
| 08.001.005 | Photodynamic Therapy For Choroidal Neovascularization | Oct 16, 2025 | Apr 20, 2026 | Verteporfin photodynamic therapy is a treatment modality designed to selectively occlude ocular choroidal... | View |
