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 |
|---|---|---|---|---|---|
| 09.003.030 | 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 | Jan 28, 2026 | Sep 20, 2026 | 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 |
| 10.001.006 | Procedimientos independientes | Aug 22, 2017 | Policy Archived | ... | View |
| 10.001.007 | Códigos U | May 01, 2015 | Policy Archived | ... | View |
| 10.001.008 | Procedimiento con informe (by report) | May 11, 2016 | Policy Archived | ... | View |
| 10.001.009 | Procedimientos con asteriscos en la tarifa | Aug 22, 2017 | Policy Archived | ... | View |
| 10.001.010 | Ambulancias y servicios de transportación médica | May 11, 2016 | Policy Archived | ... | View |
| 10.001.013 | Clinical Trials | Nov 14, 2018 | Policy Archived | A clinical trial is a research study that is used in the medical field to find new avenues to improve health.... | View |
| 10.001.014 | TELEMEDICINE | Sep 25, 2025 | Sep 20, 2026 | Telemedicine is the remote exchange of medical information through secure electronic communication to support... | View |
| 10.001.026 | Glucometers And Supplies | Nov 14, 2018 | Policy Archived | A blood glucose monitor (glucometer) is a portable, battery-operated device used to determine the blood... | View |
| 10.002.001 | Chiropractic Services | Sep 11, 2024 | Policy Archived | The primary mode of chiropractic treatment is manual or instrument-assisted manipulation or adjustment.... | View |
| 10.002.002 | Servicios de Sicólogos Clínicos | Jul 03, 2025 | Policy Archived | A clinical psychologist refers to a person or health professional who holds a master's or doctoral... | View |
| 10.002.003 | Servicios de Optometría | Aug 22, 2017 | Policy Archived | ... | View |
| 10.002.006 | Osteopathy Doctors’ Services | Jul 13, 2022 | Policy Archived | The osteopath is a health professional whose studies are equivalent to a doctorate. his training emphasizes... | View |
| 10.002.007 | Servicios de Trabajador Social Clínico | Nov 26, 2024 | Policy Archived | A social worker is a person trained to help people manage, prevent or cope with everyday problems. they are... | View |
