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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 |
|---|---|---|---|---|---|
| 10.001.013 | Clinical Trials | Nov 14, 2018 | Policy Archived | Triple-s covers for payment all medically necessary and routine services provided in a clinical trial... | View |
| 10.001.014 | TELEMEDICINE | Oct 24, 2024 | Oct 20, 2025 | Numerous states have enacted laws regarding coverage of health care services delivered through telemedicine... | View |
| 10.001.026 | GLUCOMETERS AND SUPPLIES | Nov 14, 2018 | Policy Archived | To be eligible for coverage of related supplies and accessories, and blood glucose monitors, the member must... | View |
| 10.002.001 | CHIROPRACTIC SERVICES | Sep 11, 2024 | Policy Archived | Chiropractic services may be considered medically necessary when all of the following criteria are met:... | View |
| 10.002.002 | SERVICIOS DE SICOLOGOS CLINICOS | Dec 29, 2017 | Policy Archived | Triple-s considera para pago servicios ambulatorios e intrahospitalarios, diagnósticos y terapéuticos, que... | View |
| 10.002.003 | SERVICIOS DE OPTOMETRIA | Aug 22, 2017 | Policy Archived | Se consideran para pago los servicios por optómetras para aquellas pólizas que así lo estipulen. estos... | View |
| 10.002.006 | OSTEOPATHY DOCTORS’ SERVICES | Jul 13, 2022 | Policy Archived | The doctor in osteopathy is authorized to practice osteopathy by the medical licensing and discipline board... | View |
| 10.002.007 | Social Work Services | 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 |
| 10.002.009 | SERVICIOS DE AUDIOLOGIA | May 11, 2016 | Policy Archived | Triple-s cubrirá las pruebas de audiología ambulatoria en niños y adultos cuando éstas sean requeridas y... | View |
| 10.002.010 | Acupuncture | Apr 20, 2022 | Policy Archived | Acupuncture may be considered medically necessary for treatment of the following conditions: 1. chronic... | View |
| 11.001.001 | Autologous blood transfusion (Cell Saver) | Sep 10, 2024 | Policy Archived | Policy statements the self-transfusion "cell savers" is considered for payment in the following surgeries:... | View |
| 11.001.003 | Anti-CCP Testing for Rheumatiod Arthritis | May 26, 2023 | Policy Archived | Measurement of anti-ccp may be considered medically necessary when used as part of the diagnostic workup for... | View |
| 11.001.004 | MARCADORES DE TUMORES SERICOS PARA CANCER DE MAMA Y GASTROINTESTIL | Sep 21, 2016 | Policy Archived | Determinaciones de marcadores de tumor ca72-4, ca19-9 y ca27.29 no se consideran para pago como una técnica... | View |
| 11.001.005 | In Vitro Chemoresistance and Chemosensitivity Assays | Sep 09, 2021 | Policy Archived | In vitro chemoresistance and chemosensitivity assays have been developed to provide information about the... | View |
| 11.001.006 | Testing for Helicobacter Pylori Infection | Feb 10, 2025 | Policy Archived | Urea breath testing or fecal antigen testing may be considered medically necessary as part of the workup of... | View |
| 11.001.007 | Identification of Microorganisms Using Nucleic Acid Probes | Jul 16, 2024 | Jul 20, 2025 | The use of nucleic acid testing using a direct or amplified probe technique (without quantification of viral... | View |
| 11.001.009 | Noninvasine Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease | Dec 12, 2024 | Dec 20, 2025 | A single fibrosure multianalyte assay may be considered medically necessary for the evaluation of... | View |
| 11.001.010 | ALFA-FETOPROTEI EN LA DETECCION DE CANCER HEPATOCELULAR | May 12, 2016 | Policy Archived | El alfa-fetoproteína para detección de cáncer hepatocelular no se considera para... | View |
| 11.001.011 | Serum Biomarker Human Epididymis Protein 4 | Jan 21, 2025 | Jan 20, 2026 | Human epididymis protein 4 (he4) is a novel biomarker that has been cleared by the u.s. food and drug... | View |
| 11.001.012 | JAK2, MPL, and CALR, Testing for Myeloproliferative Neoplasms | Sep 23, 2024 | Sep 20, 2025 | Jak2 testing may be considered medically necessary in the diagnosis of individuals presenting with... | View |
