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 |
|---|---|---|---|---|---|
| 08.001.012 | 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 | 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 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 15, 2024 | Nov 20, 2025 | 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 19, 2024 | 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 | Jul 16, 2024 | Jul 20, 2025 | 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 22, 2024 | Oct 20, 2025 | 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 | Aug 09, 2024 | Aug 20, 2025 | 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 | 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 (provenge) is a class of therapeutic agent used to treat asymptomatic-or minimally... | View |
| 08.001.028 | Lysis Of Epidural Adhesions | Dec 29, 2020 | Policy Archived | Lysis of epidural adhesions involves passing a catheter, either endoscopically or percutaneously, under... | View |
| 08.001.029 | Pneumatic Compression Pumps Treatment Of Lymphedema And Venous Ulcers | Feb 19, 2025 | Feb 20, 2026 | Pneumatic compression pumps are proposed as a treatment for patients with lymphedema who have failed... | View |
| 08.001.030 | Occupational Therapy | Jan 29, 2020 | Policy Archived | Occupational therapy is defined as that therapy which promotes the restoration of the ability of a person... | 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 (mm) is a systemic malignancy of plasma cells that represents approximately 10% of all... | View |
| 08.001.034 | Dysphagia Therapy | Jun 03, 2025 | Oct 20, 2025 | Dysphagia, therapy to swallow, is a medical treatment indicated to improve or restore the functions of... | View |
