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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 |
|---|---|---|---|---|---|
| 08.001.030 | OCCUPATIONAL THERAPY | Jan 29, 2020 | Policy Archived | Occupational therapy services are considered for payment when they are performed to address the need of a... | View |
| 08.001.035 | Aquatic Therapy | Sep 10, 2024 | Policy Archived | Aquatic therapy to improve or restore physical function after illness, trauma or physical damage or loss of... | View |
| 08.001.050 | Hematopoietic Cell Transplantation for Acute Myeloid Leukemia | Feb 20, 2024 | Feb 20, 2025 | Allogeneic hematopoietic cell transplantation (hct) using a myeloablative conditioning regimen may be... | View |
| 08.001.053 | Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma | Jan 20, 2025 | Jan 20, 2026 | For all therapies, basic criteria include: have adequate organ function with no significant deterioration... | 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 |
| 10.002.006 | 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 10, 2024 | Policy Archived | Policy statements the self-transfusion "cell savers" is considered for payment in the following surgeries:... | 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 |
| 11.003.008 | Cytochrome P450 Genotype-Guided Treatment Strategy | Jul 17, 2024 | Jul 20, 2025 | Cytochrome p450 (cyp450) genotyping for the purpose of aiding in the choice of clopidogrel versus... | View |
| 11.003.013 | Genetic Testing for Rett Syndrome | Jul 17, 2024 | Policy Archived | 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 22, 2024 | Nov 20, 2025 | 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 | Dec 05, 2024 | Oct 20, 2025 | 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, 2024 | Dec 20, 2025 | 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, 2024 | Dec 20, 2025 | 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... | View |
| 11.003.072 | Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders | Mar 19, 2024 | Mar 20, 2025 | Marfan syndrome (mfs) is a systemic connective tissue disease (ctd) with a high degree of clinical... | View |
| 11.003.079 | Invasive Prenatal (Fetal) Diagnostic Testing | Sep 13, 2024 | Sep 20, 2025 | 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 16, 2024 | Dec 20, 2025 | 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 | May 20, 2025 | Viscosupplementation therapy is part of the therapy used in the treatment of osteoarthritis of the knee.... | View |
