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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 |
|---|---|---|---|---|---|
| 08.001.052 | Intraoperative Radiotherapy | Aug 09, 2023 | Aug 20, 2024 | 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 08, 2024 | Jan 20, 2025 | Tisagenlecleucel for b-cell acute lymphoblastic leukemia tisagenlecleucel is considered medically... | 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 |
| 08.001.056 | Intradialytic Parenteral Nutrition | Jun 12, 2024 | Jun 20, 2025 | Intradialytic parenteral nutrition as an adjunct to hemodialysis may be considered medically necessary when... | 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 19, 2023 | Oct 20, 2024 | Use of any focal therapy modality to treat individuals with localized prostate cancer... | View |
| 08.001.060 | Dry Hydrotherapy for Chronic Pain Conditions | Jul 16, 2024 | Dec 20, 2024 | 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 | Apr 15, 2024 | Oct 20, 2024 | Sensory integration therapy and auditory integration therapy are considered investigational except for the... | View |
| 08.003.005 | Endobronchial Brachytherapy | Aug 15, 2023 | Aug 20, 2024 | 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 is considered investigational.... | 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 (descemet stripping endothelial keratoplasty, descemet stripping automated... | View |
