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 |
|---|---|---|---|---|
| 08.001.029 | Compression Pumps Treatment of lymphedema and Venous Ulcers | Aug 2026 | Compression pumps are proposed as a treatment for patients with lymphedema who have failed conservative... | View |
| 08.001.031 | Chemical Peels | Jan 2026 | A chemical peel is a controlled removal of various layers of the skin with the use of a chemical agent. the... | View |
| 08.001.033 | Hematopoietic Cell Transplantation For Plasma Cell Dyscrasias, Including Multiple Myeloma And Poems Syndrome | Feb 2026 | Multiple myeloma (mm) is a systemic malignancy of plasma cells that represents approximately 10% of all... | View |
| 08.001.034 | Dysphagia Therapy | Aug 2026 | Dysphagia, therapy to swallow, is a medical treatment indicated to improve or restore the functions of... | View |
| 08.001.035 | Aquatic Therapy | Sep 2024 | Aquatic therapy is a therapeutic intervention in which the aquatic environment provides flotation increase in... | View |
| 08.001.039 | Extracorporeal Membrane Oxygenation For Adult Conditions | Jun 2026 | Extracorporeal membrane oxygenation (ecmo) provides extracorporeal circulation and physiologic gas exchange... | View |
| 08.001.041 | Applicatiion Of Fluoride (Varnish) | Nov 2019 | Many oral health problems, including dental caries, malocclusion, and fluorosis, begin in childhood and can... | View |
| 08.001.042 | Orthopedic Applications Of Stem Cell Therapy (Including Allografts And Bone Substitutes Used With Autologous Bone Marrow) | Feb 2026 | Mesenchymal stem cells (mscs) have the capability to differentiate into a variety of tissue types, including... | View |
| 08.001.044 | Treatment Of Hyperhidrosis | Jul 2025 | Hyperhidrosis, or excessive sweating, can lead to impairments in psychologic and social functioning. various... | View |
| 08.001.045 | Cranial Electrotherapy Stimulation And Auricular Electrostimulation | May 2026 | Cranial electrotherapy stimulation (ces), also known as cranial electrical stimulation, transcranial... | View |
| 08.001.046 | Electronic Brachytherapy For Nonmelanoma Skin Cancer | Aug 2026 | Electronic brachytherapy is a form of radiotherapy designed to deliver high-dose rate radiation to treat... | View |
| 08.001.049 | Hematopoietic Cell Transplantation For Autoimmune Diseases | Jun 2026 | Most individuals with autoimmune disorders respond to conventional drug therapies; however, conventional drug... | View |
| 08.001.053 | Chimeric Antigen Receptor Therapy For Hematologic Malignancies | Jan 2026 | Chimeric antigen receptor (car) t-cells are genetically engineered cells that represent a novel class of... | View |
| 08.001.054 | Hematopoietic Cell Transplantation For Waldenstrom | Mar 2021 | ... | View |
| 08.001.055 | Stem Cell Therapy For Peripheral Arterial Disease | Feb 2026 | Peripheral arterial disease (pad) is a common atherosclerotic syndrome associated with significant morbidity... | View |
| 08.001.056 | Intradialytic Parenteral Nutrition | Jul 2024 | Intradialytic parenteral nutrition is the infusion of an intravenous hyperalimentation formula, such as amino... | View |
| 08.001.057 | Baroreflex Stimulation Devices | Sep 2026 | Baroreflex stimulation devices provide electrical stimulation of the baroreceptors in the carotid arteries... | View |
| 08.001.059 | Focal Treatments For Prostate Cancer | Oct 2026 | Prostate cancer is the second most common cancer diagnosis men receive in the u.s., and the behavior of... | View |
| 08.001.060 | Dry Hydrotherapy for chronic pain conditions | Dec 2025 | Dry hydrotherapy, also known as hydromassage or aquamassage, is a massage treatment modality that circulates... | View |
| 08.001.061 | Stationary Ultrasonic Diathermy Devices | Feb 2026 | An ultrasonic diathermy device applies ultrasonic energy to specific body parts at a frequency higher than 20... | View |