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 |
|---|---|---|---|---|---|
| 11.001.024 | Laboratory Testing For Hiv Tropism | Jan 19, 2021 | Policy Archived | Hiv tropism testing can determine the predominant coreceptor protein used by hiv to infect target cells.... | View |
| 11.001.026 | Genotipo y Fenotipo en HIV | May 16, 2016 | Policy Archived | ... | View |
| 11.001.027 | Immune Cell Function Assay | Jan 09, 2026 | Jan 20, 2027 | Careful monitoring of lifelong immunosuppression is required to ensure the long-term viability of solid organ... | View |
| 11.001.029 | Prueba fibronectina fetal | May 16, 2016 | Policy Archived | ... | View |
| 11.001.032 | Evaluation of Biomarkers for Alzheimer Disease | Nov 05, 2025 | Nov 20, 2026 | Biochemical changes associated with the pathophysiology of alzheimer disease (ad) are being evaluated to aid... | View |
| 11.001.033 | Bone Turnover Markers For The Diagnosis And Management Of Osteoporosis And Diseases Associated With High Bone Turnover | Jan 09, 2026 | Jan 20, 2027 | Bone turnover markers are biochemical markers of either bone formation or bone resorption. commercially... | View |
| 11.001.034 | Fecal Analysis In The Diagnosis Of Intestinal Dysbiosis | Jan 09, 2026 | Jan 20, 2027 | Intestinal dysbiosis may be defined as a state of disordered microbial ecology that is believed to cause... | 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 19, 2026 | Jan 20, 2027 | Commercial laboratories offer panels of tests evaluating intracellular levels of micronutrients (essential... | View |
| 11.001.038 | Multitarget Polymerase Chain Traction Testing For Diagnosis Of Bacterial Vaginosis | Jan 13, 2026 | Policy Archived | Bacterial vaginosis (bv) is a common medical condition resulting from an imbalance in the normal vaginal... | View |
| 11.001.039 | Nutrient/Nutritional Panel Testing | Jan 13, 2026 | Jan 20, 2027 | Multimarker nutritional panel testing is proposed for patients with certain chronic conditions (eg, mood... | View |
| 11.001.040 | Testing Serum Vitamin D Levels | Jan 13, 2026 | Jan 20, 2027 | Vitamin d, also known as calciferol, is a fat-soluble vitamin that has a variety of physiologic effects, most... | View |
| 11.001.041 | Drug Testing In Pain Management And Substance Use Disorder Treatment | Dec 09, 2025 | Dec 20, 2026 | Individuals in pain management programs and substance use disorder treatment may misuse prescribed opioids... | View |
| 11.001.042 | Fecal Calprotectin Testing | Jan 13, 2026 | Jan 20, 2027 | Calprotectin is a calcium- and zinc-binding protein that is a potential marker of intestinal inflammation.... | View |
| 11.001.044 | Antigen Leukocyte Antibody Test | Nov 12, 2025 | Nov 20, 2026 | 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 20, 2025 | Mar 20, 2026 | Improved accuracy of the identification of pregnant people at risk of preeclampsia and spontaneous preterm... | View |
| 11.001.047 | Multicancer Early Detection Testing | Jul 15, 2025 | Jul 20, 2026 | Many cancers appear to have a better prognosis if diagnosed early in their natural history. this has led to... | View |
| 11.001.048 | Urinary Test for Renal Allograft Rejection | Aug 18, 2025 | Aug 20, 2026 | Clinical assessment, routine monitoring, and noninvasive imaging of allograft function after renal transplant... | View |
| 11.002.001 | Systems Pathology In Prostate Cancer | Dec 10, 2020 | Policy Archived | Systems pathology, an approach that combines cellular and biologic features to standard clinical parameters,... | View |
| 11.002.003 | Molecular Testing For The Management Of Pancreatic Cysts, Barrett Esophagus, And Solid Pancreaticobiliary Lesions | Dec 26, 2024 | Dec 20, 2025 | Tests that integrate microscopic analysis with molecular tissue analysis are generally called topographic... | View |
