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 |
|---|---|---|---|---|---|
| 07.003.009 | Heart/Lung Transplant | Sep 20, 2024 | Sep 20, 2025 | 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 18, 2024 | Sep 20, 2025 | This evidence review addresses transplantation and retransplantation of an intestinal allograft in... | View |
| 07.003.011 | Islet Transplantation | Oct 23, 2024 | Oct 20, 2025 | Performed in conjunction with pancreatectomy for chronic pancreatitis, autologous islet transplantation is... | View |
| 07.003.012 | Amniotic Membrane And Amniotic Fluid | May 13, 2025 | Apr 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 | Sep 12, 2024 | Sep 20, 2025 | Composite tissue allotransplantation (also referred to as vascularized composite allotransplantation) is... | View |
| 07.003.014 | Kidney Transplant | Sep 12, 2024 | Sep 20, 2025 | 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 | Oct 24, 2024 | Oct 20, 2025 | 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 | Feb 19, 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 | Nov 26, 2024 | 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 | Apr 22, 2025 | Apr 20, 2026 | Verteporfin photodynamic therapy is a treatment modality designed to selectively occlude ocular choroidal... | View |
| 08.001.006 | Vertebral Axial Decompression | May 12, 2025 | May 20, 2026 | Vertebral axial decompression applies traction to the vertebral column to reduce intradiscal pressure and, in... | View |
| 08.001.007 | Dry Needling Of Myofascial Trigger Points | May 19, 2025 | May 20, 2026 | Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that... | View |
| 08.001.008 | Oncologic Applications Of Photodynamic Therapy, Including Barrett Esophagus | Aug 12, 2024 | Aug 20, 2025 | Photodynamic therapy (pdt; also called phototherapy, photoradiotherapy, photosensitizing therapy, or... | View |
| 08.001.009 | Low-Level Laser Therapy | Jul 19, 2024 | Jul 20, 2025 | Low-level laser therapy (lllt), also called photobiomodulation, is being evaluated to treat various... | View |
| 08.001.010 | High-Dose Rate Temporary Prostate Brachytherapy | Feb 13, 2025 | Aug 20, 2025 | High-dose rate (hdr) temporary prostate brachytherapy is a technique for delivering a high-intensity... | View |
| 08.001.011 | Manipulation Under Anesthesia | May 19, 2025 | May 20, 2026 | Manipulation under anesthesia consists of a series of mobilization, stretching, and traction procedures... | View |
