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 |
|---|---|---|---|---|---|
| 08.001.035 | Aquatic Therapy | Sep 10, 2024 | Policy Archived | Aquatic therapy is a therapeutic intervention in which the aquatic environment provides flotation increase in... | View |
| 08.001.050 | Hematopoietic Cell Transplantation For Acute Myeloid Leukemia | Feb 20, 2025 | Feb 20, 2026 | Acute myeloid leukemia (aml) refers to leukemias that arise from a myeloid precursor in the bone marrow.... | View |
| 08.001.053 | Chimeric Antigen Receptor Therapy For Hematologic Malignancies | Jan 20, 2025 | Jan 20, 2026 | Chimeric antigen receptor (car) t-cells are genetically engineered cells that represent a novel class of... | View |
| 10.002.001 | Chiropractic Services | Sep 11, 2024 | Policy Archived | The primary mode of chiropractic treatment is manual or instrument-assisted manipulation or adjustment.... | View |
| 10.002.006 | Osteopathy Doctors’ Services | Jul 13, 2022 | Policy Archived | The osteopath is a health professional whose studies are equivalent to a doctorate. his training emphasizes... | View |
| 10.002.010 | Acupuncture | Apr 20, 2022 | Policy Archived | Acupuncture is the practice of piercing the skin with needles at specific body sites to induce anesthesia, to... | View |
| 11.001.001 | Autologous Blood Transfusion (Cell Saver) | Sep 10, 2024 | Policy Archived | Surgical blood conservation techniques are used to reduce patient exposure to allogeneic blood during and... | View |
| 11.001.007 | Identification Of Microorganisms Using Nucleic Acid Probes | Jul 16, 2024 | Jul 20, 2025 | Nucleic acid probes are available for the identification of a wide variety of microorganisms. nucleic acid... | View |
| 11.003.008 | Cytochrome P450 Genotype-Guided Treatment Strategy | Jul 17, 2024 | Jul 20, 2025 | The cytochrome p450 (cyp450) family is involved in the metabolism of many currently administered drugs, and... | View |
| 11.003.013 | Genetic Testing For Rett Syndrome | Jul 17, 2024 | Policy Archived | Rett syndrome (rtt), a neurodevelopmental disorder, is usually caused by pathogenic variants in the... | 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 (cma) testing has been proposed for the detection of genetic imbalances in infants or... | View |
| 11.003.028 | Genetic Testing For Lynch Syndrome And Other Inherited Colon Cancer Syndromes | Dec 05, 2024 | Oct 20, 2025 | Genetic testing is available for both those with and those at risk for various types of hereditary cancer.... | View |
| 11.003.034 | Genetic And Protein Biomarkers For The Diagnosis And Cancer Risk Assessment Of Prostate Cancer | Dec 20, 2024 | Dec 20, 2025 | Various genetic and protein biomarkers are associated with prostate cancer. these tests have the potential to... | 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 | Laboratory tests have been developed to detect the expression, via messenger rna, of different genes in... | View |
| 11.003.047 | Gene Expression-Based Assays For Cancers Of Unknown Primary | May 09, 2025 | May 20, 2026 | Cancers of unknown primary represent 3% to 4% of cancers diagnosed in the united states. these cancers are... | View |
| 11.003.051 | Gene Expression Profiling And Protein Biomarkers For Prostate Cancer Management | May 05, 2025 | May 20, 2026 | Gene expression profile analysis and protein biomarkers have been proposed as a means to risk-stratify... | View |
| 11.003.066 | Genetic Testing For Duchenne And Becker Muscular Dystrophy | Apr 10, 2025 | Apr 20, 2026 | Variants in the duchenne muscular dystrophy (dmd) gene, which encodes the protein dystrophin, may result in a... | View |
| 11.003.072 | Genetic Testing For Marfan Syndrome, Thoracic Aortic Aneurysms And Dissections, And Related Disorders | Mar 20, 2025 | Mar 20, 2026 | 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 | Invasive prenatal (fetal) diagnostic testing may be used to identify pathogenic genetic alterations in... | View |
| 11.003.130 | Acupuncture For Pain Management, Nausea And Vomiting, And Opioid Dependence | Dec 16, 2024 | Dec 20, 2025 | Acupuncture describes a group of procedures intended to stimulate anatomical points with the goal of... | View |
