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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 |
|---|---|---|---|---|---|
| 08.001.060 | Dry Hydrotherapy for Chronic Pain Conditions | Dec 12, 2024 | Dec 20, 2025 | The use of dry hydrotherapy massagers for the treatment of chronic pain conditions is... | View |
| 08.001.061 | Stationary Ultrasonic Diathermy Devices | Feb 12, 2024 | Feb 20, 2025 | Ultrasonic diathermy devices for the treatment of musculoskeletal pain are considered... | View |
| 08.002.001 | Lipid Apheresis | Jul 29, 2021 | Policy Archived | Low-density lipoprotein (ldl) apheresis may be considered medically necessary in patients with homozygous... | View |
| 08.003.001 | Treatment of Tinnitus | Mar 19, 2024 | Mar 20, 2025 | Psychological coping therapy including cognitive-behavioral therapy, self-help cognitive-behavioral therapy,... | View |
| 08.003.002 | Outpatient Pulmonary Rehabilitation | Apr 08, 2024 | Apr 20, 2025 | A single course of pulmonary rehabilitation in the outpatient ambulatory care setting may be... | View |
| 08.003.003 | Cognitive Rehabilitation | Nov 09, 2022 | Policy Archived | Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) may be... | View |
| 08.003.004 | Sensory Integration Therapy and Auditory Therapy | Oct 24, 2024 | Oct 20, 2025 | Sensory integration therapy has been proposed as a treatment of developmental disorders in patients with... | View |
| 08.003.005 | Endobronchial Brachytherapy | Aug 23, 2024 | Aug 20, 2025 | Endobronchial brachytherapy may be considered medically necessary in the following clinical situations:... | View |
| 08.003.006 | Cardiac Rehabilitation in the Outpatient Setting | Apr 09, 2024 | Apr 20, 2025 | Outpatient cardiac rehabilitation programs may be considered medically necessary for individuals with a... | View |
| 08.003.012 | Hippotherapy | May 20, 2024 | Policy Archived | Hippotherapy, also referred to as equine-assisted therapy, describes a treatment strategy that uses equine... | View |
| 08.003.013 | Functional Neuromuscular Electrical Stimulation | Apr 08, 2024 | Apr 20, 2025 | Neuromuscular stimulation is considered investigational as a technique to restore function following nerve... | View |
| 09.001.001 | CONSULTAS | Aug 22, 2017 | Policy Archived | El médico consultor puede iniciar servicios diagnósticos y/o terapéuticos. la necesidad de consulta por... | View |
| 09.001.002 | Hospice Services at Home | Nov 11, 2020 | Policy Archived | Hospice services are considered for payment if they meet the following criteria: 1. physician... | View |
| 09.001.004 | Endothelial Keratoplasty | Apr 17, 2024 | Apr 20, 2025 | Endothelial keratoplasty also referred to as posterior lamellar keratoplasty, is a form of corneal... | View |
| 09.003.001 | Corneal Topography/Computer-Assisted Corneal Topography/ Photokeratoscopy | May 16, 2024 | Policy Archived | Non-computer-assisted corneal topography is considered part of the evaluation and management services of... | View |
| 09.003.002 | Retinal Prosthesis | May 20, 2024 | Policy Archived | Retinal prostheses are considered... | View |
| 09.003.003 | FOTOCOAGULACIÓN DEL DRUSEN MACULAR | Sep 21, 2016 | Policy Archived | Terapia con láser para la destrucción de drusen macular no se considera para pago, ya que no hay evidencia... | View |
| 09.003.004 | Intraocular Radiotherapy for Age-Related Macular Degeneration | Apr 12, 2024 | Apr 20, 2025 | Intraocular placement of a radiation source (brachytherapy) for the treatment of choroidal neovascularization... | View |
| 09.003.005 | Intravitreal and Punctum Corticosteroid Implants | Oct 24, 2024 | Oct 20, 2025 | A fluocinolone acetonide intravitreal implant 0.59 mg (retisert®) may be considered medically necessary for... | View |
| 09.003.006 | Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions | Mar 29, 2019 | Policy Archived | Intravitreal injection of ranibizumab, bevacizumab, or aflibercept may be considered medically necessary for... | View |
