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
08.001.057 Baroreflex Stimulation Devices Jan 2026 Baroreflex stimulation devices provide electrical stimulation of the baroreceptors in the carotid arteries... View
08.001.059 Focal Treatments For Prostate Cancer Mar 2026 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 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 2026 An ultrasonic diathermy device applies ultrasonic energy to specific body parts at a frequency higher than 20... View
08.001.062 Electrotherapy Sep 2025 An idiopathic facial nerve palsy, or unilateral facial nerve paresis/paralysis, commonly referred to as... View
08.002.001 Lipid Apheresis Jul 2025 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 2026 Various nonpharmacologic treatments are being evaluated to improve the symptoms of tinnitus. these approaches... View
08.003.002 Outpatient Pulmonary Rehabilitation Apr 2026 Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life... View
08.003.003 Cognitive Rehabilitation Nov 2025 Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central... View
08.003.004 Sensory Integration Therapy and Auditory Therapy Apr 2026 Sensory integration therapy has been proposed as a treatment of developmental disorders in patients with... View
08.003.005 Endobronchial Brachytherapy Aug 2024 Endobronchial brachytherapy is the delivery of radiotherapy directly to endobronchial lesions, either... View
08.003.006 Cardiac Rehabilitation In The Outpatient Setting Apr 2026 Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that... View
08.003.012 Hippotherapy May 2024 Hippotherapy, also referred to as equine-assisted therapy, describes a treatment strategy that uses equine... View
08.003.013 Functional Neuromuscular Electrical Stimulation Apr 2026 Functional electrical stimulation (fes) involves the use of an orthotic device or exercise equipment with... View
09.001.001 Consultas Aug 2017 ... View
09.001.002 Hospice Services At Home Nov 2020 ... View
09.001.003 Tratamiento de la degeneracion macular con colocacion de retaane en area yuxtoes Sep 2016 ... View
09.001.004 Endothelial Keratoplasty May 2025 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 2024 Computer-assisted corneal topography (also called photokeratoscopy or videokeratography) provides a... View
09.003.002 Retinal Prosthesis May 2024 A retinal prosthesis replaces lost photoreceptor function by transmitting external images to an array of... View