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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 |
|---|---|---|---|---|---|
| 11.001.041 | Drug Testing in Pain Management and Substance Use Disorder Treatment | Dec 09, 2024 | Dec 20, 2025 | In outpatient pain management, presumptive (i.e. immunoassay) drug testing may be considered medically... | View |
| 11.001.042 | Fecal Calprotectin Testing | Jan 15, 2025 | Jan 20, 2026 | Fecal calprotectin testing may be considered medically necessary for the evaluation of individuals when the... | View |
| 11.001.044 | Antigen Leukocyte Antibody Test | Nov 15, 2024 | Nov 20, 2025 | The antigen leukocyte antibody test (alcat) is intended to diagnose intolerance to foods and other... | View |
| 11.001.046 | Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes | Mar 19, 2024 | Mar 20, 2025 | The use of maternal serum biomarker tests with or without additional algorithmic analysis for prediction of... | View |
| 11.001.047 | Multicancer Early Detection Testing | Jul 19, 2024 | Jul 20, 2025 | The use of multicancer early detection (mced) tests (e.g., galleri) is considered investigational for cancer... | View |
| 11.002.001 | Systems Pathology in Prostate Cancer | Dec 10, 2020 | Policy Archived | Use of tests utilizing systems pathology that include cellular and biologic features of a tumor is considered... | View |
| 11.002.003 | Molecular Testing for the Management of Pancreatic Cysts and Solid Pancreaticobiliary Lesions | Dec 26, 2024 | Dec 20, 2025 | Molecular testing using the pathfindertg system is considered investigational for all indications including... | View |
| 11.002.004 | Cervical Cancer Screening Technologies With Pap and HPV | Apr 28, 2022 | Policy Archived | The following refers to average-risk asymptomatic women aged 21 to 65: preparation of papanicolaou (pap)... | View |
| 11.003.001 | Laboratory Tests Post Transplant and for Heart Failure | Nov 15, 2024 | Nov 20, 2025 | The use of the presage st2 assay to evaluate the prognosis of individuals diagnosed with chronic heart... | View |
| 11.003.002 | Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy | Apr 15, 2024 | Apr 20, 2025 | Genetic testing for predisposition to hypertrophic cardiomyopathy may be considered medically necessary for... | View |
| 11.003.003 | Multimarker Serum Testing Related to Ovarian Cancer | Jan 20, 2025 | Jan 20, 2026 | All uses of the ova1, overa, and roma tests are investigational, including but not limited to:... | View |
| 11.003.004 | Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, and HER2) | Aug 23, 2024 | Aug 20, 2025 | Kras, nras, braf, ntrk, or her2 testing of tumor tissue may be considered medically necessary for individuals... | View |
| 11.003.006 | PRUEBAS GENETICAS PARA EL TRATAMIENTO HELICOBACTER PYLORI | May 12, 2016 | Policy Archived | La prueba genética para determinar polimorfismo en sistema enzimático citocromo p450 (cyp2c19) no procede... | 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 |
| 11.003.009 | Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, NTRK). | Dec 05, 2024 | Dec 20, 2025 | Egfr testing analysis of tumor tissue for somatic variants in exons 18 through 21 (eg, g719x, l858r,... | View |
| 11.003.010 | Genetic Testing of CADASIL Syndrome | May 16, 2024 | May 20, 2025 | Variants in the notch3 gene have been causally associated with cerebral autosomal dominant arteriopathy with... | View |
| 11.003.011 | Somatic Genetic Testing to Select Individuals with Melanoma or Glioma for Targeted Therapy (BRAF) | Aug 15, 2024 | Jul 20, 2025 | Testing for braf v600 variants in individuals with unresectable or metastatic melanoma, or with resected... | View |
| 11.003.012 | Genetic Testing for Inherited Thrombophilia | Jun 18, 2024 | Jun 20, 2025 | Genetic testing for inherited thrombophilia, including testing for the factor v leiden variant, prothrombin... | 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 |
| 11.003.014 | Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA | Sep 12, 2024 | Sep 20, 2025 | Noninvasive fetal rhd genotyping using cell-free fetal dna is considered investigational.... | View |
