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 |
|---|---|---|---|---|---|
| 02.001.006 | Prolotherapy | Dec 11, 2023 | Dec 20, 2024 | Prolotherapy is considered investigational as a treatment of musculoskeletal... | View |
| 02.001.007 | ANTIBIOTICOS EN AEROSOL COMO TRATAMIENTO DE LA SINUSITIS CRONICA | Jun 28, 2016 | Policy Archived | Tratamiento de la sinusitis crónica o exacerbaciones agudas de la sinusitis crónica con antibióticos en... | View |
| 02.001.008 | MONITOREO DEL FLUJO SANGUÍNEO CEREBRAL REGIOL USANDO U SONDA TERMICA | May 06, 2016 | Policy Archived | Monitoreo de la circulación cerebral usando electrodos termales no se considera para pago. no hay datos... | View |
| 02.001.009 | SUSPENSION DE LA VEJIGA URIRIA USANDO RADIOFRECUENCIA TRANSVAGIL Y TRANSURETAL PARA INCONTINENCIA URIRIA AL ESFUERZO | Aug 08, 2016 | Policy Archived | El tratamiento transvaginal por radiofrecuencia para incontinencia urinaria del esfuerzo no se considera para... | View |
| 02.001.010 | Nonpharmacologic Treatment of Rosacea | Jan 22, 2024 | Jan 20, 2025 | Nonpharmacologic treatment of rosacea, including but not limited to laser and light therapy, dermabrasion,... | View |
| 02.001.011 | Hyperbaric Oxygen Therapy | Jul 19, 2023 | Policy Archived | Topical hyperbaric oxygen therapy is considered investigational. systemic hyperbaric oxygen pressurization... | View |
| 02.001.012 | Continuous Glucose Monitoring | Aug 18, 2023 | Aug 20, 2024 | Individuals with type 1 diabetes long-term continuous glucose monitoring (cgm) device monitoring of... | View |
| 02.001.013 | STENT PROSTATICO TEMPORERO | May 05, 2016 | Policy Archived | El uso de un stent prostático no se considera para pago en ninguna de las condiciones enumeradas en la... | View |
| 02.001.014 | VENDAJE DE CALOR RADIANTE PARA EL TRATAMIENTO DE HERIDAS | Jun 28, 2016 | Policy Archived | El uso del vendaje de calor radiante no se considera para pago. no existe literatura médica que valide el... | View |
| 02.001.015 | Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain | Jul 06, 2023 | Jul 20, 2024 | Paraspinal surface electromyography is considered investigational as a technique to diagnose or monitor back... | View |
| 02.001.016 | TERAPIA CON POTENCIACION CON INSULI | May 06, 2016 | Policy Archived | La terapia de potenciación con insulina no se considera para pago. estudios recientes tienden a sugerir que... | View |
| 02.001.017 | Laser Treatment of Active Acne | Mar 23, 2020 | Policy Archived | The treatment of active acne by means of laser therapy is not considered for payment. the pilot studies are... | View |
| 02.001.018 | Electrostimulation and Electromagnetic Therapy for Treating Wounds | Feb 05, 2024 | Feb 20, 2025 | Electrical stimulation for the treatment of wounds, including but not limited to low-intensity direct... | View |
| 02.001.019 | ESTIMULACION SENSORIAL EN PACIENTES COMATOSOS | May 06, 2016 | Policy Archived | La estimulación sensorial para pacientes en coma no se considera para pago, ya que la evidencia científica... | View |
| 02.001.020 | Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) | May 04, 2023 | May 20, 2024 | Intracranial stent placement may be considered medically necessary as part of the endovascular treatment of... | View |
| 02.001.022 | Quantitative Sensory Testing | Jul 06, 2023 | Jul 20, 2024 | Quantitative sensory testing, including but not limited to current perception threshold testing,... | View |
| 02.001.024 | ONDA DE CHOQUE EXTRACORPOREA EN EL TRATAMIENTO DE LA ENFERMEDAD DE PEYRONIE | May 06, 2016 | Policy Archived | El uso de la onda de choque extracorpórea en el tratamiento de la enfermedad de peyronie no se considera... | View |
| 02.001.025 | HIGH INTENSITY LASER THERAPY | Nov 09, 2022 | Policy Archived | High intensity laser therapy in cases of osteoarthritis, trauma and back pain is not considered for payment.... | View |
| 02.001.026 | Electromyography and Nerve Conduction Studies | Jul 19, 2023 | Jul 20, 2024 | Electrodiagnostic assessment, consisting of electromyography, nerve conduction study, and related measures,... | 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 percutaneous treatment of fracture non-unions of bone defects with the use of bone marrow aspirate with... | View |
