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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 |
|---|---|---|---|---|---|
| 02.001.009 | Suspensión de la vegija urinaria usando radiofrecuencia transvaginal para incont | Aug 08, 2017 | Policy Archived | ... | View |
| 02.001.010 | Nonpharmacologic Treatment Of Rosacea | Jan 20, 2025 | Jan 20, 2026 | Rosacea is a chronic, inflammatory skin condition without a known cure; the goal of treatment is symptom... | View |
| 02.001.011 | Hyperbaric Oxygen Therapy | Jul 19, 2023 | Policy Archived | Hyperbaric oxygen therapy (hbot) involves breathing 100% oxygen at pressures between 1.5 and 3.0 atmospheres.... | View |
| 02.001.012 | Continuous Or Intermittent Monitoring Of Glucose In Interstitial Fluid | Aug 05, 2024 | Aug 20, 2025 | ... | View |
| 02.001.013 | Stent prostático temporero | May 05, 2016 | Policy Archived | ... | View |
| 02.001.014 | Vendaje de calor radiante para el tratamiento de heridas | Jun 28, 2016 | Policy Archived | ... | View |
| 02.001.015 | Paraspinal Surface Electromyography To Evaluate And Monitor Back Pain | Jul 15, 2024 | Jul 20, 2025 | A noninvasive procedure that records the summation of muscle electrical activity, paraspinal surface... | View |
| 02.001.016 | Terapia con potenciacion con insulina | May 06, 2016 | Policy Archived | ... | View |
| 02.001.017 | Laser Treatment Of Active Acne | Mar 23, 2020 | Policy Archived | Acne is a condition of the pilosebaceous follicular glands that affects mainly adolescents and young adults... | View |
| 02.001.018 | Electrostimulation And Electromagnetic Therapy For Treating Wounds | Feb 04, 2025 | Feb 20, 2026 | Electrostimulation (electrical stimulation) refers to the application of electrical current through... | View |
| 02.001.019 | Estimulación sensorial en pacientes comatosos | May 06, 2016 | Policy Archived | ... | View |
| 02.001.020 | Endovascular Procedures For Intracranial Arterial Disease (Atherosclerosis And Aneurysms) | May 13, 2024 | May 20, 2025 | Intracranial arterial disease includes thromboembolic events, vascular stenoses, and aneurysms. endovascular... | View |
| 02.001.022 | Quantitative Sensory Testing | Jul 15, 2024 | Jul 20, 2025 | Quantitative sensory testing (qst) systems are used for the noninvasive assessment and quantification of... | View |
| 02.001.024 | Onda de choque extracorporea en el tratamiento de la enfermedad de peyronie | May 06, 2016 | Policy Archived | ... | View |
| 02.001.025 | High Intensity Laser Therapy | Nov 09, 2022 | Policy Archived | Conventional laser therapy has been used in europe for more than 25 years. up to this moment, this therapy... | View |
| 02.001.026 | Electromyography And Nerve Conduction Studies | Sep 09, 2024 | Jul 20, 2025 | Electromyography (emg) and nerve conduction studies (ncs), also collectively known as an electrodiagnostic... | View |
| 02.001.027 | Percutaneous Treatment Of Fracture Non-Unions Or Bone Defects With Autologous Bone Marrow With Demineralized Bone Matrix (Dbm) | Apr 02, 2019 | Policy Archived | The standard treatment of problem fractures or osseous defects has been an autologous cancellous bone graft... | View |
| 02.001.028 | Psoralens con luz ultravioleta A (PUVA) | May 10, 2016 | Policy Archived | ... | View |
| 02.001.029 | MIRINGOTOMÍA Y TIMPANOSTOMÍA ASISTIDAS CON LASER | May 06, 2016 | Policy Archived | ... | View |
| 02.001.030 | Actigraphy | Aug 06, 2024 | Jul 20, 2025 | Actigraphy refers to the assessment of body movement activity patterns using devices, typically placed on the... | View |
