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
02.002.037 Leadless Cardiac Pacemakers Jul 2026 Pacemakers are intended to be used as a substitute for the heart’s intrinsic pacing system to correct... View
02.003.021 Tumor-Infiltrating Lymphocytes for Advanced Melanoma Sep 2026 The spontaneous regression of certain cancers (eg, melanoma) supports the idea that an affected... View
02.004.002 Wireless Capsule Endoscopy To Diagnose Disorders Of The Small Bowel, Esophagus, And Colon Sep 2026 The wireless capsule endoscopy (ce) uses a noninvasive device to visualize segments of the gastrointestinal... View
02.005.009 Non-Invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease Apr 2026 Respiratory failure is characterized by low arterial blood oxygen (hypoxemia, pao2) and/or high arterial... View
02.005.010 Medical Management of Obstructive Sleep Apnea Syndrome Jul 2026 Obstructive sleep apnea (osa) syndrome is characterized by repetitive episodes of upper airway obstruction... View
02.007.012 Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions Sep 2026 Peripheral nerve stimulation (pns) is a percutaneous system consisting of leads, electrodes, and a pulse... View
04.001.009 Laparoscopic And Percutaneous Techniques For The Myolysis Of Uterine Fibroids Mar 2026 Various minimally invasive treatments for uterine fibroids have been proposed as alternatives to surgery.... View
04.001.011 Ovarian And Internal Iliac Vein Endovascular Occlusion As A Treatment Of Pelvic Congestion Syndrome Sep 2026 Pelvic congestion syndrome is characterized by chronic pelvic pain that is often aggravated by standing;... View
05.001.028 Treatment For Spinal Muscular Atrophy Sep 2026 Spinal muscular atrophy is an inherited disorder caused by homozygous deletions or variants in the smn1 gene.... View
05.001.033 Treatment Of Hereditary Transthyretin-Mediated Amyloidosis In Adult Patients Jul 2026 Hereditary transthyretin-mediated amyloidosis (hattr) is a rare, progressive, and fatal autosomal dominant... View
05.001.041 Injectable Clostridial Collagenase For Fibroproliferative Disorders Apr 2026 Clostridial collagenase is a bacterial collagenase, derived from clostridium histolyticum, which has been... View
05.001.046 Monoclonal Antibodies for Treatment of Alzheimer Disease Mar 2026 Alzheimer disease (ad) is a neurodegenerative disorder leading to progressive, irreversible destruction of... View
05.001.048 Biological Treatments for Refractory Myasthenia Gravis Jul 2026 Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness... View
05.001.054 Denosumab Products and its biosimilars May 2026 Denosumab is a fully human monoclonal antibody against receptor activator of nuclear factor κ-β... View
05.001.057 Foscarbidopa-Foslevodopa (Vyalev) Sep 2026 Parkinson’s disease is a progressive neurodegenerative condition caused by a loss of dopaminergic... View
05.002.001 Chimeric Antigen Receptor Therapy for Multiple Myeloma Mar 2026 Multiple myeloma is a hematologic malignancy characterized by abnormal growth of plasma cells with production... View
05.003.001 Gene Therapies for Thalassemia Apr 2026 Beta (β)-thalassemia is a genetic hemoglobinopathy that results from defects in β-globin synthesis... View
05.003.002 Gene Therapies for Sickle Cell Disease Apr 2026 Sickle cell disease is a genetic hemoglobinopathy that results from a genetic variant in the hbb gene... View
05.003.003 Gene Therapies for Metachromatic Leukodystrophy Jul 2026 Metachromatic leukodystrophy (mld) is a rare autosomal recessive lysosomal storage disorder caused by... View
05.003.007 Gene Therapies for Aromatic L-amino Acid Decarboxylase Deficiency Sep 2026 Aromatic l-amino acid decarboxylase (aadc) deficiency is a rare autosomal recessive neurodevelopmental... View