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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 |
|---|---|---|---|---|---|
| 08.001.031 | 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 |
| 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 12, 2024 | Jun 20, 2025 | 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 19, 2024 | Jul 20, 2025 | 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 |
