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 |
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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 06, 2023 | Jun 20, 2024 | 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 05, 2023 | Jul 20, 2024 | 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 |
08.001.031 | Chemical Peels | Jan 12, 2024 | Jan 20, 2025 | Dermal chemical peels used to treat individuals with numerous (>10) actinic keratoses or other premalignant... | View |
08.001.033 | Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome | Feb 08, 2024 | Feb 20, 2025 | Multiple myeloma a single or second (salvage) autologous hematopoietic cell transplantation may be... | View |
08.001.034 | DYSPHAGIA THERAPY | Feb 14, 2024 | Oct 20, 2024 | Therapy for the treatment of dysphagia is considered medically necessary and proceeds for payment when any... | View |
08.001.035 | Aquatic Therapy | Nov 11, 2020 | Policy Archived | Aquatic therapy to improve or restore physical function after illness, trauma or physical damage or loss of... | View |