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 |
|---|---|---|---|---|---|
| 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 18, 2025 | Aug 20, 2026 | Photodynamic therapy (pdt; also called phototherapy, photoradiotherapy, photosensitizing therapy, or... | View |
| 08.001.009 | Low-Level Laser Therapy | Jul 15, 2025 | Jul 20, 2026 | Low-level laser therapy (lllt), also called photobiomodulation, is being evaluated to treat various... | View |
| 08.001.010 | High-Dose Rate Temporary Prostate Brachytherapy | Jan 14, 2026 | Jan 20, 2027 | 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 |
| 08.001.012 | Charged-Particle (Proton Or Helium Ion) Radiotherapy For Neoplastic Conditions | Jun 06, 2025 | Jun 20, 2026 | Charged-particle beams consisting of protons or helium ions are a type of particulate radiotherapy. treatment... | View |
| 08.001.013 | Terapia con interferón | Jul 23, 2025 | 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 | Jul 23, 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 09, 2025 | Jun 20, 2026 | Inhaled nitric oxide (ino) is a natural vasodilator and has been studied for a variety of types of... | View |
| 08.001.016 | Extracorporeal Photopheresis | Nov 11, 2025 | Nov 20, 2026 | Extracorporeal photopheresis (ecp) is a leukapheresis-based immunomodulatory procedure that involves the... | View |
| 08.001.017 | Accelerated Breast Irradiation And Brachytherapy Boost After Breast-Conserving Surgery For Early-Stage Breast Cancer | Aug 18, 2025 | Aug 20, 2025 | Radiotherapy is the standard of care for patients with breast cancer undergoing breast-conserving surgery... | View |
| 08.001.019 | Measurement Of Exhaled Nitric Oxide And Exhaled Breath Condensate In The Diagnosis And Management Of Respiratory Disorders | Nov 05, 2025 | Nov 20, 2026 | Evaluation of exhaled nitric oxide (no) and exhaled breath condensate (ebc) are proposed as techniques to... | View |
| 08.001.020 | Neutron Beam Radiotherapy | May 10, 2019 | Policy Archived | Neutron beam therapy is a form of radiotherapy that is used primarily for the treatment of unresectable or... | View |
| 08.001.021 | Scintimammography And Gamma Imaging Of The Breast And Axilla | Oct 17, 2025 | Oct 20, 2026 | Scintimammography, breast-specific gamma imaging (bsgi), and molecular breast imaging (mbi) use radiotracers... | View |
| 08.001.022 | Intracavitary Balloon Catheter Brain Brachytherapy For Malignant Gliomas Or Metastasis To The Brain | Sep 05, 2025 | Policy Archived | Intracavitary balloon catheter brain brachytherapy is an approach to localized radiotherapy using liquid... | View |
| 08.001.023 | Erwinaze | Nov 10, 2021 | Policy Archived | Asparagine is an amino acid essential for cell growth. it occurs in most cells. the neoplastic cells present... | View |
| 08.001.024 | Correcion de los Trastornos de la refracción | May 22, 2017 | Policy Archived | ... | View |
| 08.001.025 | Adoptive Immunotherapy | Oct 16, 2025 | Oct 20, 2026 | The spontaneous regression of certain cancers (eg, renal cell carcinoma, melanoma) supports the idea that a... | View |
| 08.001.027 | Cellular Immunotherapy For Prostate Cancer | Aug 18, 2025 | Aug 20, 2026 | Sipuleucel-t (provenge) is a therapeutic agent used to treat asymptomatic or minimally symptomatic,... | View |
