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.
Medical Policies table
| ID | Title | Review | Description | Access |
|---|---|---|---|---|
| 08.001.013 | Terapia con interferón | Jul 2025 | Interferon is one of about 20 naturally occurring proteins. three classes of interferons have been... | View |
| 08.001.014 | Chelation Therapy For Off-Label Uses | Mar 2026 | Chelation therapy, an established treatment for heavy metal toxicities and transfusional hemosiderosis, has... | View |
| 08.001.015 | Inhaled Nitric Oxide | Jun 2025 | Inhaled nitric oxide (ino) is a natural vasodilator and has been studied for a variety of types of... | View |
| 08.001.016 | Extracorporeal Photopheresis | Feb 2026 | Extracorporeal photopheresis (ecp) is a leukapheresis-based immunomodulatory procedure that involves the... | View |
| 08.001.017 | Accelerated Breast Irradiation And Brachytherapy Boost After Breast-Conserving Surgery For Early-Stage Breast Cancer | Aug 2025 | Radiotherapy is the standard of care for patients with breast cancer undergoing breast-conserving surgery... | View |
| 08.001.019 | Measurement Of Exhaled Nitric Oxide And Exhaled Breath Condensate In The Diagnosis And Management Of Respiratory Disorders | Nov 2025 | Evaluation of exhaled nitric oxide (no) and exhaled breath condensate (ebc) are proposed as techniques to... | View |
| 08.001.020 | Neutron Beam Radiotherapy | May 2019 | Neutron beam therapy is a form of radiotherapy that is used primarily for the treatment of unresectable or... | View |
| 08.001.021 | Scintimammography And Gamma Imaging Of The Breast And Axilla | Oct 2025 | Scintimammography, breast-specific gamma imaging (bsgi), and molecular breast imaging (mbi) use radiotracers... | View |
| 08.001.022 | Intracavitary Balloon Catheter Brain Brachytherapy For Malignant Gliomas Or Metastasis To The Brain | Sep 2025 | Intracavitary balloon catheter brain brachytherapy is an approach to localized radiotherapy using liquid... | View |
| 08.001.023 | Erwinaze | Nov 2021 | Asparagine is an amino acid essential for cell growth. it occurs in most cells. the neoplastic cells present... | View |
| 08.001.024 | Correcion de los Trastornos de la refracción | May 2017 | ... | View |
| 08.001.025 | Adoptive Immunotherapy | Oct 2025 | The spontaneous regression of certain cancers (eg, renal cell carcinoma, melanoma) supports the idea that a... | View |
| 08.001.027 | Cellular Immunotherapy For Prostate Cancer | Aug 2025 | Sipuleucel-t (provenge) is a therapeutic agent used to treat asymptomatic or minimally symptomatic,... | View |
| 08.001.028 | Lysis Of Epidural Adhesions | Dec 2020 | 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 2025 | Compression pumps are proposed as a treatment for patients with lymphedema who have failed conservative... | View |
| 08.001.030 | Occupational Therapy | Jan 2020 | Occupational therapy is defined as that therapy which promotes the restoration of the ability of a person... | View |
| 08.001.031 | Chemical Peels | Jan 2026 | 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 2026 | Multiple myeloma (mm) is a systemic malignancy of plasma cells that represents approximately 10% of all... | View |
| 08.001.034 | Dysphagia Therapy | Feb 2026 | Dysphagia, therapy to swallow, is a medical treatment indicated to improve or restore the functions of... | View |
| 08.001.035 | Aquatic Therapy | Sep 2024 | Aquatic therapy is a therapeutic intervention in which the aquatic environment provides flotation increase in... | View |