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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 |
|---|---|---|---|---|---|
| 11.001.006 | Testing for Helicobacter pylori Infection | Feb 21, 2023 | Policy Archived | Urea breath testing or fecal antigen testing may be considered medically necessary as part of the workup of... | 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 |
| 11.001.009 | Noninvasine Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease | Dec 13, 2023 | Dec 20, 2024 | A single fibrosure multianalyte assay may be considered medically necessary for the evaluation of patients... | View |
| 11.001.010 | ALFA-FETOPROTEI EN LA DETECCION DE CANCER HEPATOCELULAR | May 12, 2016 | Policy Archived | El alfa-fetoproteína para detección de cáncer hepatocelular no se considera para... | View |
| 11.001.011 | Serum Biomarker Human Epididymis Protein 4 | Jan 19, 2024 | Jan 20, 2025 | Measurement of human epididymis protein 4 is investigational for all indications.... | View |
| 11.001.012 | JAK2, MPL, and CALR, Testing for Myeloproliferative Neoplasms | Sep 12, 2023 | Sep 20, 2024 | Jak2 testing may be considered medically necessary in the diagnosis of individuals presenting with... | View |
| 11.001.013 | Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance | Jan 09, 2024 | Jan 20, 2025 | The use of urinary tumor markers is considered investigational in the screening, diagnosis of, and... | View |
| 11.001.015 | Cardiovascular Risk Panels | Feb 09, 2024 | Retired | Cardiovascular disease risk panels, consisting of multiple individual biomarkers intended to assess cardiac... | 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 20, 2023 | Dec 20, 2024 | 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 |
| 11.001.019 | Rapid Flu Tests in the Outpatient Setting | Apr 30, 2019 | Policy Archived | In the outpatient setting rapid flu tests may be considered medically necessary as a technique to guide... | 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 04, 2024 | Jan 20, 2025 | 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 03, 2024 | Jan 20, 2025 | 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 |
