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 |
|---|---|---|---|---|---|
| 10.002.001 | CHIROPRACTIC SERVICES | Feb 25, 2022 | Policy Archived | Chiropractic services may be considered medically necessary when all of the following criteria are met:... | 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 |
| 10.002.010 | 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 29, 2022 | Policy Archived | The self-transfusion "cell savers" is considered for payment in the following surgeries: a. general... | View |
| 11.001.007 | Identification of Microorganisms Using Nucleic Acid Probes | Jul 10, 2023 | Jul 20, 2024 | The use of nucleic acid testing using a direct or amplified probe technique (without quantification of viral... | View |
| 11.003.008 | Cytochrome P450 Genotype-Guided Treatment Strategy | Jul 11, 2023 | Jul 20, 2024 | Cytochrome p450 (cyp450) genotyping for the purpose of aiding in the choice of clopidogrel versus... | View |
| 11.003.013 | Genetic Testing for Rett Syndrome | Jun 07, 2024 | Jun 20, 2025 | Genetic testing for rett syndrome-associated genes (eg, mecp2, foxg1, or cdkl5) may be considered medically... | View |
| 11.003.025 | Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies | Nov 16, 2023 | Nov 20, 2024 | Chromosomal microarray analysis may be considered medically necessary as first-line testing in the initial... | View |
| 11.003.028 | Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes | Oct 11, 2023 | Oct 20, 2024 | Apc testing genetic testing of the apc gene may be considered medically necessary in the following... | View |
| 11.003.034 | Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer | Dec 20, 2023 | Dec 20, 2024 | The following genetic and protein biomarkers for the diagnosis of prostate cancer are... | View |
| 11.003.035 | Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer | Dec 06, 2023 | Dec 20, 2024 | The use of the 21-gene reverse transcriptase-polymerase chain reaction (rt-pcr) assay (ie, oncotype dx),... | View |
| 11.003.066 | Genetic Testing for Duchenne and Becker Muscular Dystrophy | Apr 17, 2024 | Apr 20, 2025 | Genetic testing for dmd gene variants may be considered medically necessary under the following conditions:... | View |
| 11.003.072 | Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders | Apr 19, 2024 | Apr 20, 2025 | Individual genetic testing for the diagnosis of marfan syndrome, ehlers-danlos syndrome type iv, other... | View |
| 11.003.079 | Invasive Prenatal (Fetal) Diagnostic Testing | Sep 07, 2023 | Sep 20, 2024 | Chromosomal microarray testing in patients who are undergoing invasive diagnostic prenatal (fetal)... | View |
| 11.003.130 | Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence | Dec 14, 2023 | Dec 20, 2024 | Acupuncture may be considered medically necessary for treatment of episodic migraines and/or tension-type... | View |
| M5.001.001 | Viscosupplementation Therapy For Knee | May 10, 2024 | Oct 20, 2024 | Viscosupplementation therapy is part of the therapy used in the treatment of osteoarthritis of the knee.... | View |
| M5.001.002 | Rituximab | May 10, 2024 | Oct 20, 2024 | Rituximab is a genetically engineered chimeric murine/human monoclonal igg1 kappa antibody directed against... | View |
| M5.001.003 | Trastuzumab – Trastuzumab Biologics | May 10, 2024 | Oct 20, 2024 | Trastuzumab is a monoclonal antibody, one of a group of drugs designed to attack specific cancer cells.... | View |
| M5.001.004 | Pegfilgrastim | Oct 26, 2023 | Retired | Pegfilgrastim is a colony stimulating factor (csf) that acts on hematopoietic cells by binding to specific... | View |
| M5.001.005 | Bevacizumab – Bevacizumab Biologics for Oncologic Uses | May 10, 2024 | Oct 20, 2024 | Bevacizumab is a humanized monoclonal antibody directed against vascular endothelial growth factor a... | View |
