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 |
|---|---|---|---|---|
| 08.001.036 | Hematopoietic Cell Transplantation For Chronic Myeloid Leukemia | Feb 2025 | Chronic myeloid leukemia (cml) is a hematopoietic stem cell disorder characterized by the presence of a... | View |
| 08.001.037 | Hematopoietic Cell Transplantation For Hodgkin Lymphoma | Feb 2025 | Hodgkin lymphoma (hl) results from a clonal expansion of a b-cell lineage, characterized by the presence of... | View |
| 08.001.038 | Radio 223 Injection (Xofigo) | Nov 2021 | Approximately 240,000 men in the united states are expected to be diagnosed with prostate cancer in 2016.... | View |
| 08.001.039 | Extracorporeal Membrane Oxygenation For Adult Conditions | Jun 2025 | Extracorporeal membrane oxygenation (ecmo) provides extracorporeal circulation and physiologic gas exchange... | View |
| 08.001.040 | Diagnosis And Treatment Of Chronic Cerebrospinal Venous Insufficiency In Multiple Sclerosis | Dec 2019 | Chronic cerebrospinal venous insufficiency (ccsvi) may be associated with multiple sclerosis (ms), although... | View |
| 08.001.041 | Applicatiion Of Fluoride (Varnish) | Nov 2019 | Many oral health problems, including dental caries, malocclusion, and fluorosis, begin in childhood and can... | View |
| 08.001.042 | Orthopedic Applications Of Stem Cell Therapy (Including Allografts And Bone Substitutes Used With Autologous Bone Marrow) | Feb 2026 | Mesenchymal stem cells (mscs) have the capability to differentiate into a variety of tissue types, including... | View |
| 08.001.043 | Hematopoietic Cell Transplantation For Acute Lymphoblastic Leukemia | Feb 2025 | Acute lymphoblastic leukemia (all) is a heterogeneous disease with different genetic variations resulting in... | View |
| 08.001.044 | Treatment Of Hyperhidrosis | Jul 2025 | Hyperhidrosis, or excessive sweating, can lead to impairments in psychologic and social functioning. various... | View |
| 08.001.045 | Cranial Electrotherapy Stimulation And Auricular Electrostimulation | May 2026 | Cranial electrotherapy stimulation (ces), also known as cranial electrical stimulation, transcranial... | View |
| 08.001.046 | Electronic Brachytherapy For Nonmelanoma Skin Cancer | Feb 2026 | Electronic brachytherapy is a form of radiotherapy designed to deliver high-dose rate radiation to treat... | View |
| 08.001.047 | Hematopoietic Cell Transplantation For Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma | Feb 2025 | Risk stratification of patients with chronic lymphocytic leukemia (cll)/small lymphocytic lymphoma (sll)... | View |
| 08.001.048 | Hematopoietic Cell Transplantation For Non-Hodgkin Lymphomas | Feb 2025 | Hematopoietic cell transplantation (hct) refers to a procedure by which hematopoietic stem cells are infused... | View |
| 08.001.049 | Hematopoietic Cell Transplantation For Autoimmune Diseases | Feb 2026 | Most individuals with autoimmune disorders respond to conventional drug therapies; however, conventional drug... | View |
| 08.001.051 | Hematopoietic Cell Transplantation For Primary Amyloidosis | Feb 2025 | Hematopoietic cell transplantation (hct) refers to the infusion of hematopoietic stem cells to restore bone... | View |
| 08.001.052 | Intraoperative Radiotherapy | Aug 2024 | Intraoperative radiotherapy (iort) is delivered directly to exposed tissues during surgery and may allow... | View |
| 08.001.053 | Chimeric Antigen Receptor Therapy For Hematologic Malignancies | Jan 2026 | Chimeric antigen receptor (car) t-cells are genetically engineered cells that represent a novel class of... | View |
| 08.001.054 | Hematopoietic Cell Transplantation For Waldenstrom | Mar 2021 | ... | View |
| 08.001.055 | Stem Cell Therapy For Peripheral Arterial Disease | Feb 2026 | Peripheral arterial disease (pad) is a common atherosclerotic syndrome associated with significant morbidity... | View |
| 08.001.056 | Intradialytic Parenteral Nutrition | Jul 2024 | Intradialytic parenteral nutrition is the infusion of an intravenous hyperalimentation formula, such as amino... | View |