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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 |
|---|---|---|---|---|---|
| 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 14, 2023 | Aug 20, 2024 | 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 | Spinal manipulation and manipulation of other joints performed during the procedure (eg, hip joint) with the... | 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 |
| 08.001.016 | Extracorporeal Photopheresis | Nov 15, 2023 | Nov 20, 2024 | Organ rejection after solid organ transplant extracorporeal photopheresis may be considered medically... | View |
| 08.001.017 | Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer | Aug 16, 2023 | Aug 20, 2024 | When using radiotherapy after breast-conserving surgery for early-stage breast cancer: accelerated... | View |
| 08.001.019 | Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders | Jul 16, 2024 | Jul 20, 2025 | Measurement of exhaled nitric oxide is considered investigational in the diagnosis and management of... | View |
| 08.001.020 | Neutron Beam Radiotherapy | May 10, 2019 | Policy Archived | Neutron beam radiotherapy of advanced salivary gland tumors and soft tissue sarcomas is considered medically... | View |
| 08.001.021 | Scintimammography and Gamma Imaging of the Breast and Axilla | Oct 19, 2023 | Oct 20, 2024 | Scintimammography, breast-specific gamma imaging, and molecular breast imaging are... | View |
| 08.001.022 | Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain | Aug 09, 2023 | Aug 20, 2024 | Intracavitary balloon catheter brain brachytherapy is considered investigational,alone or as part of a... | View |
| 08.001.023 | ERWINAZE | Nov 10, 2021 | Policy Archived | Erwinaze is considered for payment in the treatment of acute lymphocytic leukemia and acute myeloid leukemia... | View |
| 08.001.024 | CORRECCION DE LOS TRASTORNOS DE LA REFRACCION | May 22, 2017 | Policy Archived | Corrección de trastornos de la visión no proceden para pago irrespectivo de la técnica o modalidad... | View |
| 08.001.025 | Adoptive Immunotherapy | Nov 13, 2023 | Nov 20, 2024 | All adoptive immunotherapy techniques intended to enhance autoimmune effects are... | View |
| 08.001.027 | Cellular Immunotherapy for Prostate Cancer | Aug 15, 2023 | Aug 20, 2024 | Sipuleucel-t therapy may be considered medically necessary in the treatment of asymptomatic or minimally... | View |
| 08.001.028 | Lysis of Epidural Adhesions | Dec 29, 2020 | Dec 29, 2021 | Catheter-based techniques for lysis of epidural adhesions, with or without endoscopic guidance, are... | View |
| 08.001.029 | Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers | Apr 09, 2024 | Apr 20, 2025 | Single-compartment or multichamber nonprogrammable lymphedema pumps applied to the limb may be... | View |
| 08.001.030 | OCCUPATIONAL THERAPY | Jan 29, 2020 | Policy Archived | Occupational therapy services are considered for payment when they are performed to address the need of a... | View |
