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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
08.001.036 Allogeneic Hematopoietic Cell Transplantation Feb 12, 2024 Feb 20, 2025 Allogeneic hematopoietic cell transplantation (hct) using a myeloablative conditioning regimen may be... View
08.001.037 Hematopoietic Cell Transplantation for Hodgkin Lymphoma Feb 12, 2024 Feb 20, 2025 Autologous hematopoietic cell transplantation (hct) may be considered medically necessary in patients with... View
08.001.038 Radio 223 Injection (Xofigo) Nov 10, 2021 Policy Archived The radium 223 injection (xofigo) is considered for payment when all of the following criteria for prostate... View
08.001.039 Extracorporeal Membrane Oxygenation for Adult Conditions Jun 06, 2023 Jun 20, 2024 The use of extracorporeal membrane oxygenation (ecmo) may be considered medically necessary for the... View
08.001.040 Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis Dec 16, 2019 Policy Archived The identification and subsequent treatment of chronic cerebrospinal venous insufficiency in patients with... View
08.001.041 Application Of Fluoride (Varnish) Nov 14, 2019 Policy Archived Fluoride varnish is considered medically necessary to help reduce the risk of decayed, missing, or filled... View
08.001.042 Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow) Feb 20, 2024 Feb 20, 2025 Mesenchymal stem cell therapy is considered investigational for all orthopedic applications, including use in... View
08.001.043 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia Feb 12, 2024 Feb 20, 2025 Childhood acute lymphoblastic leukemia autologous or allogeneic hematopoietic cell transplantation... View
08.001.044 Treatment of Hyperhidrosis Jul 18, 2023 Jul 20, 2024 Treatment of primary focal hyperhidrosis using aluminum chloride 20% solution, botulinum toxin for severe... View
08.001.045 Cranial Electrotherapy Stimulation and Auricular Electrostimulation Mar 15, 2024 Mar 20, 2025 Cranial electrotherapy stimulation (also known as cranial electrostimulation therapy) is investigational in... View
08.001.046 Electronic Brachytherapy for Nonmelanoma Skin Cancer Aug 15, 2023 Aug 20, 2024 Electronic brachytherapy for the treatment of nonmelanoma skin cancer is... View
08.001.047 Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Feb 12, 2024 Feb 20, 2025 Allogeneic hematopoietic cell transplantation is considered medically necessary to treat chronic lymphocytic... View
08.001.048 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Feb 12, 2024 Feb 20, 2025 For individuals with non-hodgkin lymphoma (nhl) b-cell subtypes considered aggressive (except mantle cell... View
08.001.049 Hematopoietic Cell Transplantation for Autoimmune Diseases Feb 20, 2024 Feb 20, 2025 Autologous or allogeneic hematopoietic cell transplantation (hct) is considered investigational as a... View
08.001.050 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia Feb 20, 2024 Feb 20, 2025 Allogeneic hematopoietic cell transplantation (hct) using a myeloablative conditioning regimen may be... View
08.001.051 Hematopoietic cell Transplantation for Primary Amyloidosis Feb 13, 2024 Feb 20, 2025 Autologous hematopoietic cell transplantation may be considered medically necessary to treat primary... View
08.001.052 Intraoperative Radiotherapy Aug 09, 2023 Aug 20, 2024 Use of intraoperative radiotherapy may be considered medically necessary in the following situation:... View
08.001.053 Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma Jan 08, 2024 Jan 20, 2025 Tisagenlecleucel for b-cell acute lymphoblastic leukemia tisagenlecleucel is considered medically... View
08.001.054 Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia Mar 19, 2021 Policy Archived Autologous hematopoietic cell transplantation may be considered medically necessary as salvage therapy of... View
08.001.056 Intradialytic Parenteral Nutrition Jun 12, 2023 Jun 20, 2024 Intradialytic parenteral nutrition as an adjunct to hemodialysis may be considered medically necessary when... View
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