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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 |
|---|---|---|---|---|---|
| 09.003.007 | CONTACT LENSES FOR THE PEDIATRIC POPULATION | Nov 10, 2021 | Policy Archived | Contact lenses are considered for payment for any of the following indications: a. congenital aphakia... | View |
| 09.003.008 | ARCHIVED | Mar 29, 2019 | Policy Archived | Antivascular endothelial growth factor therapies (anti-vegf), ie, pegaptanib (macugen®*), ranibizumab... | View |
| 09.003.009 | Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome | Apr 10, 2024 | Apr 20, 2025 | Eyelid thermal pulsation therapy to treat dry eye syndrome is... | View |
| 09.003.010 | Aqueous Shunts and Stents for Glaucoma | Dec 20, 2024 | Dec 20, 2025 | Insertion of ab externo aqueous shunts approved by the u.s. food and drug administration may be... | View |
| 09.003.011 | NCT: national clinical trial. | Apr 10, 2024 | Apr 20, 2025 | The boston (dohlman-doane) keratoprosthesis (boston kpro) may be considered medically necessary for the... | View |
| 09.003.012 | Orthoptic Training for the Treatment of Vision or Learning Disabilities | May 12, 2024 | Policy Archived | Office-based vergence/accommodative therapy may be considered medically necessary for individuals with... | View |
| 09.003.013 | Retinal Tele-Screening for Diabetic Retinopathy | Apr 15, 2024 | Apr 20, 2025 | Retinal telescreening with digital imaging and manual grading of images may be considered medically necessary... | View |
| 09.003.014 | Corneal Collagen Cross-Linking | Apr 17, 2024 | Apr 20, 2025 | Corneal collagen cross-linking using riboflavin and ultraviolet a may be considered medically necessary as... | View |
| 09.003.026 | Viscocanalostomy and Canaloplasty | Apr 15, 2024 | Apr 20, 2025 | Viscocanalostomy is considered investigational. canaloplasty may be considered medically necessary as a... | View |
| 09.003.030 | Ocriplasmin for Symptomatic Vitreomacular Adhesion | May 20, 2024 | Policy Archived | A single intravitreal injection of ocriplasmin may be considered medically necessary for treatment of an... | View |
| 09.003.031 | Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma | Apr 15, 2024 | Apr 20, 2025 | Analysis of the optic nerve and retinal nerve fiber layer in the diagnosis and evaluation of patients with... | View |
| 10.001.001 | PROCEDIMIENTOS (CIRUGÍA) MULTIPLES, SECUNDARIOS E INCIDENTALES | Aug 22, 2017 | Policy Archived | Procedimientos múltiples: en una sesión operatoria que requiere procedimientos múltiples se pagarán al... | View |
| 10.001.003 | PROCEDIMIENTOS QUIRÚRGICOS EN OFICIS DE LOS MÉDICOS | Jun 30, 2016 | Policy Archived | Se facturan con los modificadores correspondientes. códigos refiérase al manual de política de pago del... | View |
| 10.001.004 | CIRUGÍA AMBULATORIA | Aug 22, 2017 | Policy Archived | Procedimientos que se realizan en lugares de servicio ambulatorios. el participante debe solicitar... | View |
| 10.001.005 | CIRUGÍA INTENTADA | Aug 22, 2017 | Policy Archived | Se requiere que el médico que realice el procedimiento asigne el código cpt que mejor describa el servicio... | View |
| 10.001.006 | PROCEDIMIENTO INDEPENDIENTE (SEPARATE PROCEDURES) | Aug 22, 2017 | Policy Archived | Un procedimiento independiente se considera para pago cuando: es el único código facturado. no se... | View |
| 10.001.007 | “CÓDIGOS U” | May 01, 2015 | Policy Archived | La utilización de códigos u se descontinuó en cumplimiento de las directrices de hipaa. para identificar... | View |
| 10.001.008 | PROCEDIMIENTO CON INFORME (BY REPORT) | May 11, 2016 | Policy Archived | En los casos arriba descritos se envía un informe completo del procedimiento, mecanografiado o en letra de... | View |
| 10.001.009 | PROCEDIMIENTOS CON ASTERISCOS EN LA TARIFA | Aug 22, 2017 | Policy Archived | Este concepto de códigos con asterisco se aplica a los procedimientos identificados en el manual de pago del... | View |
| 10.001.010 | AMBULANCIAS Y SERVICIOS DE TRANSPORTACION MÉDICA | May 11, 2016 | Policy Archived | Transportación terrestre de emergencias médicas, son servicios que se considera para pago cuando se cumplen... | View |
