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
11.001.037 Intracellular Micronutrient Analysis Jan 2026 Commercial laboratories offer panels of tests evaluating intracellular levels of micronutrients (essential... View
11.001.038 Multitarget Polymerase Chain Traction Testing For Diagnosis Of Bacterial Vaginosis Jan 2026 Bacterial vaginosis (bv) is a common medical condition resulting from an imbalance in the normal vaginal... View
11.001.039 Nutrient/Nutritional Panel Testing Jan 2026 Multimarker nutritional panel testing is proposed for patients with certain chronic conditions (eg, mood... View
11.001.040 Testing Serum Vitamin D Levels Jan 2026 Vitamin d, also known as calciferol, is a fat-soluble vitamin that has a variety of physiologic effects, most... View
11.001.041 Drug Testing In Pain Management And Substance Use Disorder Treatment Dec 2025 Individuals in pain management programs and substance use disorder treatment may misuse prescribed opioids... View
11.001.042 Fecal Calprotectin Testing Jan 2026 Calprotectin is a calcium- and zinc-binding protein that is a potential marker of intestinal inflammation.... View
11.001.044 Antigen Leukocyte Antibody Test Nov 2025 The antigen leukocyte antibody test (alcat) is intended to diagnose intolerance to foods and other... View
11.001.046 Maternal Serum Testing for Prediction of Adverse Obstetric Outcomes Jun 2026 ... View
11.001.047 Multicancer Early Detection Testing Jul 2026 Many cancers appear to have a better prognosis if diagnosed early in their natural history. this has led to... View
11.001.048 Urinary Test for Renal Allograft Rejection Aug 2026 Clinical assessment, routine monitoring, and noninvasive imaging of allograft function after renal transplant... View
11.003.001 Laboratory Tests For Heart And Kidney Transplant Rejection Aug 2026 Clinical assessment and noninvasive imaging of chronic heart failure can be limited in accurately diagnosing... View
11.003.002 Genetic Testing For Predisposition To Inherited Hypertrophic Cardiomyopathy Apr 2026 Familial hypertrophic cardiomyopathy is an inherited condition caused by a disease associated variant in 1 or... View
11.003.003 Multimarker Serum Testing Related To Ovarian Cancer Jan 2026 A variety of serum biomarkers have been studied for their association with ovarian cancer. of particular... View
11.003.004 Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, MMR/MSI, HER2, and TMB) Aug 2026 The epidermal growth factor receptor (egfr) is overexpressed in colorectal cancer (crc). egfr-targeted... View
11.003.006 Pruebas Genéticas para el Tratamiento Helico Bacter Pylori May 2026 Helicobacter pylori is a bacterium associated with a number of gastrointestinal problems, such as peptic... View
11.003.008 Cytochrome P450 Genotype-Guided Treatment Strategy Jul 2026 The cytochrome p450 (cyp450) family is involved in the metabolism of many currently administered drugs, and... View
11.003.009 Molecular Analysis For Targeted Therapy Of Non-Small-Cell Lung Cancer Dec 2025 Over half of patients with non-small-cell lung cancer (nsclc) present with advanced and therefore incurable... View
11.003.010 Genetic Testing Of Cadasil Syndrome Jun 2025 Variants in the notch3 gene have been causally associated with cerebral autosomal dominant arteriopathy with... View
11.003.012 Genetic Testing For Inherited Thrombophilia Jun 2026 Inherited thrombophilias are a group of disorders that predispose individuals to thrombosis. genetic testing... View
11.003.013 Genetic Testing For Rett Syndrome Jul 2024 Rett syndrome (rtt), a neurodevelopmental disorder, is usually caused by pathogenic variants in the... View