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
07.003.010 Small Bowel/Liver And Multivisceral Transplant Oct 2025 This evidence review addresses transplantation and retransplantation of an intestinal allograft in... View
07.003.011 Islet Transplantation Oct 2025 Performed in conjunction with pancreatectomy for chronic pancreatitis, autologous islet transplantation is... View
07.003.012 Amniotic Membrane And Amniotic Fluid May 2026 Several commercially available forms of human amniotic membrane (ham) and amniotic fluid can be administered... View
07.003.013 Composite Tissue Allotransplantation Of The Hand And Face Oct 2025 Composite tissue allotransplantation (also referred to as vascularized composite allotransplantation) is... View
07.003.014 Kidney Transplant Sep 2025 Kidney transplant, a treatment option for end-stage renal disease, involves the surgical removal of a kidney... View
07.004.001 Implantation Of Intrastromal Corneal Ring Segments Archived May 2021 Intrastromal corneal ring segments (icrs) are composed of microthin soft plastic inserts of variable... View
07.004.002 Vascular Endothelial Growth Factor Inhibitors for the Treatment of Ophthalmological Diseases Sep 2025 Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular... View
07.004.003 Vascular Endothelial Growth Factor Inhibitors for Sickle Cell Retinopathy Apr 2026 Sickle cell retinopathy is a known complication of sickle cell disease. sickle cell retinopathy is... View
08.001.001 Physical Therapy In The Home Apr 2025 Physical therapy is the treatment of an illness or injury with the use of therapeutic exercises or... View
08.001.002 Physical Therapy Services Jul 2025 Physical therapy is the treatment of illness or physical damage through the use of therapeutic exercise,... View
08.001.003 Home Based Occupational Therapy Nov 2020 ... View
08.001.004 Speech Therapy Aug 2025 Developmental language disorder is the most common developmental disability of childhood, occurring in 5 to... View
08.001.005 Photodynamic Therapy For Choroidal Neovascularization Apr 2026 Verteporfin photodynamic therapy is a treatment modality designed to selectively occlude ocular choroidal... View
08.001.006 Vertebral Axial Decompression May 2026 Vertebral axial decompression applies traction to the vertebral column to reduce intradiscal pressure and, in... View
08.001.007 Dry Needling Of Myofascial Trigger Points May 2026 Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that... View
08.001.008 Oncologic Applications Of Photodynamic Therapy, Including Barrett Esophagus Aug 2025 Photodynamic therapy (pdt; also called phototherapy, photoradiotherapy, photosensitizing therapy, or... View
08.001.009 Low-Level Laser Therapy Feb 2026 Low-level laser therapy (lllt), also called photobiomodulation, is being evaluated to treat various... View
08.001.010 High-Dose Rate Temporary Prostate Brachytherapy Jan 2026 High-dose rate (hdr) temporary prostate brachytherapy is a technique for delivering a high-intensity... View
08.001.011 Manipulation Under Anesthesia May 2026 Manipulation under anesthesia consists of a series of mobilization, stretching, and traction procedures... View
08.001.012 Charged-Particle (Proton Or Helium Ion) Radiotherapy For Neoplastic Conditions Jun 2025 Charged-particle beams consisting of protons or helium ions are a type of particulate radiotherapy. treatment... View