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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 |
|---|---|---|---|---|---|
| 07.003.012 | Amniotic Membrane and Amniotic Fluid | Apr 19, 2024 | Apr 20, 2025 | Treatment of nonhealing diabetic lower-extremity ulcers using the following human amniotic membrane products... | 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 transplants with either a living or cadaver donor may be considered medically necessary for carefully... | View |
| 07.004.001 | Implantation of Intrastromal Corneal Ring Segments | May 17, 2021 | Policy Archived | Implantation of intrastromal corneal ring segments may be considered medically necessary for the treatment of... | View |
| 07.004.002 | Vascular Endothelial Growth Factor Inhibitors for the Treatment of Ophthalmological Diseases | Oct 24, 2024 | Oct 20, 2025 | Intravitreal bevacizumab (avastin) intravitreal bevacizumab (avastin) injections is considered medically... | View |
| 08.001.001 | Physical Therapy in the home | Nov 11, 2020 | Policy Archived | Physical therapy in the home is considered for payment if it meets the following criteria: a. prior to... | View |
| 08.001.002 | Physical Therapy Services | Nov 26, 2024 | Policy Archived | However, not all studies have found a benefit for mld over standard management for reducing limb volume... | View |
| 08.001.003 | HOME BASED OCCUPATIONAL THERAPY | Nov 11, 2020 | Policy Archived | Occupational therapy services home based are considered for payment when performed to address the need for a... | View |
| 08.001.004 | Speech Therapy | Nov 26, 2024 | Policy Archived | Speech therapy services are considered for payment when: • they are prescribed or recommended by a... | View |
| 08.001.005 | Photodynamic Therapy for Choroidal Neovascularization | May 06, 2024 | Apr 20, 2025 | Verteporfin photodynamic therapy as monotherapy may be considered medically necessary as a treatment of... | View |
| 08.001.006 | Vertebral Axial Decompression | May 20, 2024 | May 20, 2025 | Vertebral axial decompression is considered... | View |
| 08.001.007 | Dry Needling of Trigger Points for Myofascial Pain | May 20, 2024 | May 20, 2025 | Dry needling of trigger points for the treatment of myofascial pain is considered investigational.... | View |
| 08.001.008 | Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus | Aug 12, 2024 | Aug 20, 2025 | One or more courses of photodynamic therapy may be considered medically necessary for the following... | View |
| 08.001.009 | Low-Level Laser Therapy | Jul 19, 2024 | Jul 20, 2025 | Low-level laser therapy may be considered medically necessary for prevention of oral mucositis in patients... | View |
| 08.001.010 | High-Dose Rate Temporary Prostate Brachytherapy | Aug 13, 2024 | Aug 20, 2025 | High-dose rate prostate brachytherapy may be considered medically necessary as monotherapy or in... | View |
| 08.001.011 | Manipulation Under Anesthesia | May 20, 2024 | May 20, 2025 | Manipulation under anesthesia consists of a series of mobilization, stretching, and traction procedures... | View |
| 08.001.012 | Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions | Jun 10, 2024 | Jun 20, 2025 | Charged-particle irradiation with proton or helium ion beams may be considered medically necessary for... | View |
| 08.001.013 | Interferon Therapy | Jun 06, 2022 | Policy Archived | The use of recombinant or natural interferon alfa for the treatment of hematologic malignancies (lymphomas,... | View |
| 08.001.014 | Chelation Therapy for Off-Label Uses | Mar 19, 2024 | Mar 20, 2025 | Off-label applications of chelation therapy (see policy guidelines section for uses approved by the u.s. food... | View |
| 08.001.015 | Inhaled Nitric Oxide | Jun 11, 2024 | Jun 20, 2025 | Inhaled nitric oxide may be considered medically necessary as a component of treatment of: hypoxic... | View |
