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 |
|---|---|---|---|---|---|
| 11.001.036 | 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 | 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 15, 2025 | 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 15, 2025 | Jan 20, 2026 | Multimarker nutritional panel testing is proposed for patients with certain chronic conditions (eg, mood... | View |
| 11.001.040 | Testing Serum Vitamin D Levels | Jan 15, 2025 | Jan 20, 2026 | 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, 2024 | Dec 20, 2025 | Patients in pain management programs and substance use disorder treatment may misuse prescribed opioids... | View |
| 11.001.042 | Fecal Calprotectin Testing | Jun 13, 2025 | Jan 20, 2026 | 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 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 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 19, 2024 | Jul 20, 2025 | Many cancers appear to have a better prognosis if diagnosed early in their natural history. this has led to... | 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 |
| 11.002.004 | Cervical Cancer Screening Technologies With Pap And Hpv | Apr 28, 2022 | Policy Archived | Data suggest that cytologic screening for cervical cancer reduces the incidence of cervical cancer by up to... | View |
| 11.003.001 | Laboratory Tests For Heart And Kidney Transplant Rejection | Nov 15, 2024 | Nov 20, 2025 | Clinical assessment and noninvasive imaging of chronic heart failure can be limited in accurately diagnosing... | View |
| 11.003.002 | Genetic Testing For Predisposition To Inherited Hypertrophic Cardiomyopathy | Apr 18, 2025 | Apr 20, 2026 | Familial hypertrophic cardiomyopathy is an inherited condition caused by a disease associated variant in 1 or... | View |
| 11.003.003 | Multimarker Serum Testing Related To Ovarian Cancer | Jan 20, 2025 | Jan 20, 2026 | A variety of serum biomarkers have been studied for their association with ovarian cancer. of particular... | View |
| 11.003.004 | Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, MMR/MSI, HER2, and TMB) | Aug 23, 2024 | Aug 20, 2025 | Summary the epidermal growth factor receptor (egfr) is overexpressed in colorectal cancer (crc).... | View |
| 11.003.006 | Pruebas Genéticas para el Tratamiento Helico Bacter Pylori | May 12, 2016 | Policy Archived | ... | 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 |
| 11.003.009 | Molecular Analysis For Targeted Therapy Of Non-Small-Cell Lung Cancer | Dec 05, 2024 | Dec 20, 2025 | Over half of patients with non-small-cell lung cancer (nsclc) present with advanced and therefore incurable... | View |
