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 |
|---|---|---|---|---|---|
| 08.001.035 | Aquatic Therapy | Sep 10, 2024 | Policy Archived | Aquatic therapy is a therapeutic intervention in which the aquatic environment provides flotation increase in... | View |
| 08.001.036 | Hematopoietic Cell Transplantation For Chronic Myeloid Leukemia | Feb 17, 2025 | Feb 20, 2026 | 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 17, 2025 | Feb 20, 2026 | 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 | Approximately 240,000 men in the united states are expected to be diagnosed with prostate cancer in 2016.... | View |
| 08.001.039 | Extracorporeal Membrane Oxygenation For Adult Conditions | Jun 09, 2025 | Jun 20, 2026 | Extracorporeal membrane oxygenation (ecmo) provides extracorporeal circulation and physiologic gas exchange... | View |
| 08.001.040 | Diagnosis And Treatment Of Chronic Cerebrospinal Venous Insufficiency In Multiple Sclerosis | Dec 16, 2019 | Policy Archived | Chronic cerebrospinal venous insufficiency (ccsvi) may be associated with multiple sclerosis (ms), although... | View |
| 08.001.041 | Applicatiion Of Fluoride (Varnish) | Nov 14, 2019 | Policy Archived | Many oral health problems, including dental caries, malocclusion, and fluorosis, begin in childhood and can... | View |
| 08.001.042 | Orthopedic Applications Of Stem Cell Therapy (Including Allografts And Bone Substitutes Used With Autologous Bone Marrow) | Feb 20, 2025 | Feb 20, 2026 | Mesenchymal stem cells (mscs) have the capability to differentiate into a variety of tissue types, including... | View |
| 08.001.043 | Hematopoietic Cell Transplantation For Acute Lymphoblastic Leukemia | Feb 17, 2025 | Feb 20, 2026 | Acute lymphoblastic leukemia (all) is a heterogeneous disease with different genetic variations resulting in... | View |
| 08.001.044 | Treatment Of Hyperhidrosis | Aug 19, 2024 | Aug 20, 2025 | Hyperhidrosis, or excessive sweating, can lead to impairments in psychologic and social functioning. various... | View |
| 08.001.045 | Cranial Electrotherapy Stimulation And Auricular Electrostimulation | Mar 12, 2025 | Mar 20, 2026 | Cranial electrotherapy stimulation (ces), also known as cranial electrical stimulation, transcranial... | View |
| 08.001.046 | Electronic Brachytherapy For Nonmelanoma Skin Cancer | Aug 23, 2024 | Aug 20, 2025 | Electronic brachytherapy is a form of radiotherapy designed to deliver high-dose rate radiation to treat... | View |
| 08.001.047 | Hematopoietic Cell Transplantation For Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma | Feb 13, 2025 | Feb 20, 2026 | Risk stratification of patients with chronic lymphocytic leukemia (cll)/small lymphocytic lymphoma (sll)... | View |
| 08.001.048 | Hematopoietic Cell Transplantation For Non-Hodgkin Lymphomas | Feb 13, 2025 | Feb 20, 2026 | Hematopoietic cell transplantation (hct) refers to a procedure by which hematopoietic stem cells are infused... | View |
| 08.001.049 | Hematopoietic Cell Transplantation For Autoimmune Diseases | Feb 20, 2025 | Feb 20, 2026 | Most patients with autoimmune disorders respond to conventional drug therapies; however, conventional drug... | View |
| 08.001.050 | Hematopoietic Cell Transplantation For Acute Myeloid Leukemia | Feb 20, 2025 | Feb 20, 2026 | Acute myeloid leukemia (aml) refers to leukemias that arise from a myeloid precursor in the bone marrow.... | View |
| 08.001.051 | Hematopoietic Cell Transplantation For Primary Amyloidosis | Feb 18, 2025 | Feb 20, 2026 | Hematopoietic cell transplantation (hct) refers to the infusion of hematopoietic stem cells to restore bone... | View |
| 08.001.052 | Intraoperative Radiotherapy | Aug 09, 2024 | Aug 20, 2025 | Intraoperative radiotherapy (iort) is delivered directly to exposed tissues during surgery and may allow... | View |
| 08.001.053 | Chimeric Antigen Receptor Therapy For Hematologic Malignancies | Jan 20, 2025 | Jan 20, 2026 | Chimeric antigen receptor (car) t-cells are genetically engineered cells that represent a novel class of... | View |
| 08.001.054 | Hematopoietic Cell Transplantation For Waldenstrom | Mar 19, 2021 | Policy Archived | ... | View |
