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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 |
|---|---|---|---|---|---|
| 08.001.016 | Extracorporeal Photopheresis | Nov 15, 2024 | Nov 20, 2025 | 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 19, 2024 | Aug 20, 2025 | 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 22, 2024 | Oct 20, 2025 | 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, 2024 | Aug 20, 2025 | 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 12, 2024 | Nov 20, 2025 | 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 23, 2024 | Aug 20, 2025 | 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 |
| 08.001.031 | Chemical Peels | Jan 15, 2025 | Jan 20, 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 05, 2025 | Feb 20, 2026 | Multiple myeloma a single or second (salvage) autologous hematopoietic cell transplantation may be... | View |
| 08.001.034 | DYSPHAGIA THERAPY | Oct 24, 2024 | Oct 20, 2025 | Therapy for the treatment of dysphagia is considered medically necessary and proceeds for payment when any... | View |
| 08.001.035 | Aquatic Therapy | Sep 10, 2024 | Policy Archived | Aquatic therapy to improve or restore physical function after illness, trauma or physical damage or loss of... | View |
| 08.001.036 | Allogeneic Hematopoietic Cell Transplantation | Feb 12, 2024 | Feb 20, 2025 | Chronic myeloid leukemia (cml) is a hematopoietic stem cell disorder characterized by the presence of a... | View |
| 08.001.037 | Hematopoietic Cell Transplantation for Hodgkin Lymphoma | Feb 12, 2024 | Feb 20, 2025 | Hodgkin lymphoma (hl) results from a clonal expansion of a b-cell lineage, characterized by the presence of... | View |
| 08.001.038 | Radio 223 Injection (Xofigo) | Nov 10, 2021 | Policy Archived | The radium 223 injection (xofigo) is considered for payment when all of the following criteria for prostate... | View |
