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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 | 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 |
| 08.001.001 | Physical Therapy In The Home | Nov 11, 2020 | 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 | May 06, 2024 | Apr 20, 2025 | Verteporfin photodynamic therapy is a treatment modality designed to selectively occlude ocular choroidal... | View |
| 08.001.006 | Vertebral Axial Decompression | May 20, 2024 | May 20, 2025 | 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 20, 2024 | May 20, 2025 | 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 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 beams consisting of protons or helium ions are a type of particulate radiotherapy. treatment... | View |
| 08.001.013 | Terapia con interferón | Jun 06, 2022 | Policy Archived | Interferon is one of about 20 naturally occurring proteins. three classes of interferons have been... | View |
| 08.001.014 | Chelation Therapy For Off-Label Uses | Mar 19, 2025 | Mar 20, 2026 | Chelation therapy, an established treatment for heavy metal toxicities and transfusional hemosiderosis, has... | View |
| 08.001.015 | Inhaled Nitric Oxide | Jun 11, 2024 | Jun 20, 2025 | Inhaled nitric oxide (ino) is a natural vasodilator and has been studied for a variety of types of... | View |
