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 |
|---|---|---|---|---|---|
| 09.003.003 | Fotocoagulación del drusen macular | Sep 21, 2016 | Policy Archived | ... | View |
| 09.003.004 | Intraocular Radiotherapy For Age-Related Macular Degeneration | Apr 14, 2025 | Apr 20, 2026 | Intraocular radiation, including brachytherapy, proton beam therapy, and stereotactic radiotherapy, are being... | View |
| 09.003.005 | Intravitreal And Punctum Corticosteroid Implants | Oct 24, 2024 | Oct 20, 2025 | An intravitreal implant is a drug delivery system, injected or surgically implanted in the vitreous of the... | View |
| 09.003.006 | Intravitreal Angiogenesis Inhibitors For Retinal Vascular Conditions | Mar 29, 2019 | Policy Archived | ... | View |
| 09.003.007 | Contact Lenses For The Pediatric Population | Nov 10, 2021 | Policy Archived | It is estimated that 40.9 million people over the age of 18 in the united states (one in six adults) wear... | View |
| 09.003.008 | Intravitreal Angiogenesis Inhibitors For Choroidal Vascular Conditions | Mar 29, 2019 | Policy Archived | Angiogenesis inhibitors (eg, ranibizumab, bevacizumab, pegaptanib, aflibercept) are being evaluated for the... | View |
| 09.003.009 | Eyelid Thermal Pulsation For The Treatment Of Dry Eye Syndrome | Apr 18, 2025 | Apr 20, 2026 | Thermal pulsation is a treatment option for meibomian gland dysfunction. meibomian gland dysfunction is... | View |
| 09.003.010 | Aqueous Shunts And Stents For Glaucoma | Dec 20, 2024 | Dec 20, 2025 | Glaucoma surgery is intended to reduce intraocular pressure (iop) when the target iop cannot be reached using... | View |
| 09.003.011 | Keratoprosthesis | Apr 18, 2025 | Apr 20, 2026 | A keratoprosthesis, consisting of a central optic held in a cylindrical frame, is an artificial cornea... | View |
| 09.003.012 | Orthoptic Training For The Treatment Of Vision Or Learning | May 12, 2024 | Policy Archived | Orthoptic training refers to techniques designed to correct accommodative and convergence insufficiency (or... | View |
| 09.003.013 | Retinal Telescreening For Diabetic Retinopathy | May 09, 2025 | Policy Archived | Retinopathy telescreening and risk assessment with digital imaging systems are proposed as an alternative to... | View |
| 09.003.014 | Corneal Collagen Cross-Linking | Apr 10, 2025 | Apr 20, 2026 | Corneal collagen cross-linking is a photochemical procedure approved by the u.s. food and drug administration... | View |
| 09.003.026 | Viscocanalostomy And Canaloplasty | Apr 18, 2025 | Apr 20, 2026 | Glaucoma surgery is intended to reduce intraocular pressure when the target intraocular pressure cannot be... | View |
| 09.003.030 | Ocriplasmin For Symptomatic Vitreomacular Adhesion | May 20, 2024 | Policy Archived | Ocriplasmin is a recombinant truncated form of human plasmin, a proteolytic enzyme that breaks down protein... | View |
| 09.003.031 | Ophthalmologic Techniques That Evaluate The Posterior Segment For Glaucoma | Apr 14, 2025 | Apr 20, 2026 | Several techniques have been developed to measure the thickness of the optic nerve and retinal nerve fiber... | View |
| 09.003.032 | Fundus Photography and Extended Ophthalmoscopy | Jun 03, 2025 | Oct 20, 2025 | Fundus photography fundus photography is the practice of using a retinal camera to record anomalies in the... | View |
| 10.001.001 | Procedimientos multiples, secundarios e incidentales | Aug 22, 2017 | Policy Archived | ... | View |
| 10.001.003 | Procedimeintos quirúrgicos en oficinas con uso de los modificadores OS y OB | Jun 30, 2016 | Policy Archived | ... | View |
| 10.001.004 | Cirugía ambulatoria | Aug 22, 2017 | Policy Archived | ... | View |
| 10.001.005 | Cirugía intentada | Aug 22, 2017 | Policy Archived | ... | View |
