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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 |
|---|---|---|---|---|---|
| 11.001.013 | Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance | Jan 21, 2025 | Jan 20, 2026 | The use of urinary tumor markers is considered investigational in the screening, diagnosis of, and... | View |
| 11.001.016 | Serum Biomarker Tests for Multiple Sclerosis | Jun 08, 2020 | Policy Archived | Serum biomarker tests for multiple sclerosis are considered investigational in all... | View |
| 11.001.017 | Pharmacogenetic Testing for Pain Management | Dec 26, 2024 | Dec 20, 2025 | Genetic testing for pain management is considered investigational for all indications (see policy guidelines... | View |
| 11.001.018 | DIAGNÓSTICO SEROLOGICO DE LA ENFERMEDAD CELIACA | Sep 21, 2016 | Policy Archived | La determinación serológica de anticuerpos (hla-dq2 y hla-dq8) de antigliandina y de anticuerpo... | View |
| 11.001.020 | Detection of Circulating Tumor Cells in the Management of Patients With Cancer | May 30, 2019 | May 30, 2020 | Detection and quantification of circulating tumor cells is considered investigational in the management of... | View |
| 11.001.021 | Measurement of Long-Chain Omega-3 Fatty Acids in Red Blood Cell Membranes as a Cardiac Risk Factor | May 22, 2019 | Policy Archived | Measurement of long-chain omega-3 fatty acids in red blood cell membranes, including but not limited to its... | View |
| 11.001.022 | Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disorders | Jan 08, 2025 | Jan 20, 2026 | Measurement of plasma levels of homocysteine is considered investigational in the screening, evaluation,... | View |
| 11.001.023 | PROCALCITONIN AS A MARKER IN THE SYSTEMIC INFLAMMATORY RESPONSE | Nov 10, 2021 | Policy Archived | The use of procalcitonin in the clinical setting is not considered for payment. clinical studies published... | View |
| 11.001.024 | Laboratory Testing for HIV Tropism | Jan 19, 2021 | Policy Archived | Hiv tropism testing (see policy guidelines section for testing methods) may be considered medically necessary... | View |
| 11.001.026 | GENOTIPO Y FENOTIPO EN HIV | May 16, 2016 | Policy Archived | Identificación de genotipo o fenotipo se considera para pago en pacientes que no han respondido a terapia... | View |
| 11.001.027 | Immune Cell Function Assay | Jan 08, 2025 | Jan 20, 2026 | Use of the immune cell function assay to monitor and predict immune function after solid organ... | View |
| 11.001.029 | PRUEBA FIBRONECTI FETAL (fFN) | May 16, 2016 | Policy Archived | El uso de la prueba de fibronectina fetal (ffn), se considera para pago en mujeres con embarazos sencillos o... | View |
| 11.001.032 | Evaluation of Biomarkers for Alzheimer Disease | Dec 10, 2024 | Nov 20, 2025 | Cerebrospinal fluid biomarker testing, including but not limited to amyloid beta peptides, tau protein, or... | View |
| 11.001.033 | Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover | Feb 05, 2025 | Feb 20, 2026 | Measurement of bone turnover markers is considered investigational to determine fracture risk in patients... | View |
| 11.001.034 | Fecal Analysis in the Diagnosis of Intestinal Dysbiosis | Jan 08, 2025 | Jan 20, 2026 | Fecal analysis of the following components is considered investigational as a diagnostic test for the... | View |
| 11.001.036 | Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 | Jan 19, 2021 | Policy Archived | Novel assays that quantitatively measure total human epidermal growth factor receptor 2 (her2) protein... | View |
| 11.001.037 | Intracellular Micronutrient Analysis | Jan 08, 2025 | Jan 20, 2026 | Intracellular micronutrient panel testing is... | View |
| 11.001.038 | Summary | Jan 15, 2025 | Policy Archived | Multitarget polymerase chain reaction testing for the diagnosis of bacterial vaginosis is... | View |
| 11.001.039 | Nutrient/Nutritional Panel Testing | Jan 15, 2025 | Jan 20, 2026 | Nutrient/nutritional panel testing is considered investigational for all indications including but not... | View |
| 11.001.040 | Testing Serum Vitamin D Levels | Jan 15, 2025 | Jan 20, 2026 | Testing vitamin d levels in individuals with signs and/or symptoms of vitamin d deficiency or toxicity (see... | View |
