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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 |
|---|---|---|---|---|---|
| 08.001.039 | 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 | Aug 19, 2024 | Aug 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 23, 2024 | Aug 20, 2025 | 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 | Summary risk stratification of patients with chronic lymphocytic leukemia (cll)/small 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, 2024 | Aug 20, 2025 | 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 20, 2025 | Jan 20, 2026 | For all therapies, basic criteria include: have adequate organ function with no significant deterioration... | 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 |
| 08.001.055 | Stem Cell Therapy for Peripheral Arterial Disease | Feb 20, 2024 | Feb 20, 2025 | Treatment of peripheral arterial disease, including critical limb ischemia, with injection or infusion of... | View |
| 08.001.056 | Intradialytic Parenteral Nutrition | Jul 16, 2024 | Policy Archived | Policy statements intradialytic parenteral nutrition as an adjunct to hemodialysis may be... | View |
| 08.001.057 | Baroreflex Stimulation Devices | Jun 18, 2024 | Jun 20, 2025 | Use of baroreflex stimulation implanted devices is considered investigational in all situations, including... | View |
| 08.001.059 | Focal Treatments for Prostate Cancer | Oct 22, 2024 | Oct 20, 2025 | Use of any focal therapy modality to treat individuals with localized prostate cancer... | View |
