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 |
|---|---|---|---|---|---|
| 08.001.028 | Lysis Of Epidural Adhesions | Dec 29, 2020 | Policy Archived | Lysis of epidural adhesions involves passing a catheter, either endoscopically or percutaneously, under... | View |
| 08.001.029 | Compression Pumps Treatment of lymphedema and Venous Ulcers | Aug 18, 2025 | NA | Compression pumps are proposed as a treatment for patients with lymphedema who have failed conservative... | View |
| 08.001.030 | Occupational Therapy | Jan 29, 2020 | Policy Archived | Occupational therapy is defined as that therapy which promotes the restoration of the ability of a person... | View |
| 08.001.031 | Chemical Peels | Jan 13, 2026 | Jan 20, 2027 | A chemical peel is a controlled removal of various layers of the skin with the use of a chemical agent. the... | View |
| 08.001.033 | Hematopoietic Cell Transplantation For Plasma Cell Dyscrasias, Including Multiple Myeloma And Poems Syndrome | Feb 05, 2025 | Feb 20, 2026 | Multiple myeloma (mm) is a systemic malignancy of plasma cells that represents approximately 10% of all... | View |
| 08.001.034 | Dysphagia Therapy | Sep 25, 2025 | Sep 20, 2026 | Dysphagia, therapy to swallow, is a medical treatment indicated to improve or restore the functions of... | View |
| 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) | Oct 17, 2025 | Oct 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 | Jul 11, 2025 | Policy Archived | 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 18, 2025 | Aug 20, 2026 | 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 |
