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 |
|---|---|---|---|---|---|
| 08.001.055 | Stem Cell Therapy For Peripheral Arterial Disease | Feb 20, 2025 | Feb 20, 2026 | Peripheral arterial disease is a common atherosclerotic syndrome associated with significant morbidity and... | View |
| 08.001.056 | Intradialytic Parenteral Nutrition | Jul 16, 2024 | Policy Archived | Intradialytic parenteral nutrition is the infusion of an intravenous hyperalimentation formula, such as amino... | View |
| 08.001.057 | Baroreflex Stimulation Devices | Jun 20, 2025 | Jun 20, 2026 | Baroreflex stimulation devices provide electrical stimulation of the baroreceptors in the carotid arteries... | View |
| 08.001.059 | Focal Treatments For Prostate Cancer | Oct 22, 2024 | Oct 20, 2025 | Prostate cancer is the second most common cancer diagnosis men receive in the u.s., and the behavior of... | View |
| 08.001.060 | Dry Hydrotherapy for chronic pain conditions | Dec 12, 2024 | Dec 20, 2025 | Dry hydrotherapy, also known as hydromassage or aquamassage, is a massage treatment modality that circulates... | View |
| 08.001.061 | Stationary Ultrasonic Diathermy Devices | Feb 17, 2025 | Feb 20, 2026 | An ultrasonic diathermy device applies ultrasonic energy to specific body parts at a frequency higher than 20... | View |
| 08.002.001 | Lipid Apheresis | Jul 29, 2021 | Policy Archived | This use of low-density lipoprotein (ldl) apheresis has been proposed to treat various types of familial... | View |
| 08.003.001 | Treatment Of Tinnitus | Mar 19, 2025 | Mar 20, 2026 | Various nonpharmacologic treatments are being evaluated to improve the symptoms of tinnitus. these approaches... | View |
| 08.003.002 | Outpatient Pulmonary Rehabilitation | Apr 14, 2025 | Apr 20, 2026 | Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life... | View |
| 08.003.003 | Cognitive Rehabilitation | Nov 09, 2022 | Policy Archived | Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central... | View |
| 08.003.004 | Sensory Integration Therapy And Auditory Integration 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 is the delivery of radiotherapy directly to endobronchial lesions, either... | View |
| 08.003.006 | Cardiac Rehabilitation In The Outpatient Setting | Apr 18, 2025 | Apr 20, 2026 | Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that... | 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 22, 2025 | Apr 20, 2026 | Functional electrical stimulation (fes) involves the use of an orthotic device or exercise equipment with... | View |
| 09.001.001 | Consultas | Aug 22, 2017 | Policy Archived | ... | View |
| 09.001.002 | Hospice Services At Home | Nov 11, 2020 | Policy Archived | ... | View |
| 09.001.004 | Endothelial Keratoplasty | May 19, 2025 | Policy Archived | 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 | Computer-assisted corneal topography (also called photokeratoscopy or videokeratography) provides a... | View |
| 09.003.002 | Retinal Prosthesis | May 20, 2024 | Policy Archived | A retinal prosthesis replaces lost photoreceptor function by transmitting external images to an array of... | View |
