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.
Medical Policies table
| ID | Title | Review | Description | Access |
|---|---|---|---|---|
| 08.001.062 | Electrotherapy as a treatment modality for Bell’s Palsy | Aug 2026 | An idiopathic facial nerve palsy, or unilateral facial nerve paresis/paralysis, commonly referred to as... | View |
| 08.002.001 | Lipid Apheresis | Jul 2025 | This use of low-density lipoprotein (ldl) apheresis has been proposed to treat various types of familial... | View |
| 08.003.001 | Treatment Of Tinnitus | Mar 2026 | Various nonpharmacologic treatments are being evaluated to improve the symptoms of tinnitus. these approaches... | View |
| 08.003.002 | Outpatient Pulmonary Rehabilitation | Apr 2026 | Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life... | View |
| 08.003.003 | Cognitive Rehabilitation | Nov 2025 | Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central... | View |
| 08.003.004 | Sensory Integration Therapy and Auditory Therapy | Aug 2026 | Sensory integration therapy has been proposed as a treatment of developmental disorders in patients with... | View |
| 08.003.006 | Cardiac Rehabilitation In The Outpatient Setting | Apr 2026 | Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that... | View |
| 08.003.012 | Hippotherapy | May 2024 | Hippotherapy, also referred to as equine-assisted therapy, describes a treatment strategy that uses equine... | View |
| 08.003.013 | Functional Neuromuscular Electrical Stimulation | Apr 2026 | Functional electrical stimulation (fes) involves the use of an orthotic device or exercise equipment with... | View |
| 09.001.002 | Hospice Services At Home | Nov 2020 | ... | View |
| 09.001.004 | Endothelial Keratoplasty | May 2025 | Endothelial keratoplasty also referred to as posterior lamellar keratoplasty, is a form of corneal... | View |
| 09.003.001 | Corneal Topography/Computer-Assisted Corneal Topography/ Photokeratoscopy | May 2024 | Computer-assisted corneal topography (also called photokeratoscopy or videokeratography) provides a... | View |
| 09.003.002 | Retinal Prosthesis | May 2024 | A retinal prosthesis replaces lost photoreceptor function by transmitting external images to an array of... | View |
| 09.003.003 | Fotocoagulación del drusen macular | Sep 2016 | ... | View |
| 09.003.004 | Intraocular Radiotherapy For Age-Related Macular Degeneration | Apr 2026 | Intraocular radiation, including brachytherapy, proton beam therapy, and stereotactic radiotherapy, are being... | View |
| 09.003.005 | Intravitreal And Punctum Corticosteroid Implants | Aug 2026 | An intravitreal implant is a drug delivery system, injected or surgically implanted in the vitreous of the... | View |
| 09.003.006 | Intravitreal Angiogenesis Inhibitors For Retinal Vascular Conditions | Feb 2026 | ... | View |
| 09.003.008 | Intravitreal Angiogenesis Inhibitors For Choroidal Vascular Conditions | Feb 2026 | Angiogenesis inhibitors (eg, ranibizumab, bevacizumab, pegaptanib, aflibercept) are being evaluated for the... | View |
| 09.003.009 | Eyelid Thermal Pulsation For The Treatment Of Dry Eye Syndrome | Apr 2026 | Thermal pulsation is a treatment option for meibomian gland dysfunction. meibomian gland dysfunction is... | View |
| 09.003.010 | Aqueous Shunts And Stents For Glaucoma | Dec 2025 | Glaucoma surgery is intended to reduce intraocular pressure (iop) when the target iop cannot be reached using... | View |