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 |
|---|---|---|---|---|---|
| 11.001.035 | Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk | Feb 09, 2024 | Retired | Measurement of lipoprotein-associated phospholipase a2 is... | View |
| 11.001.036 | Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 | Jan 19, 2021 | Policy Archived | The assessment of human epidermal growth factor receptor 2 (her2) status by quantitative total her2 protein... | View |
| 11.001.037 | Intracellular Micronutrient Analysis | Jan 19, 2024 | Jan 20, 2025 | Intracellular micronutrient panel testing is... | View |
| 11.001.038 | Summary | Jan 04, 2024 | Policy Archived | Multitarget polymerase chain reaction testing for the diagnosis of bacterial vaginosis is... | View |
| 11.001.039 | Nutrient/Nutritional Panel Testing | Jan 08, 2024 | Jan 20, 2025 | Nutrient/nutritional panel testing is considered investigational for all indications including but not... | View |
| 11.001.040 | Testing Serum Vitamin D Levels | Jan 15, 2024 | Jan 20, 2025 | Testing vitamin d levels in individuals with signs and/or symptoms of vitamin d deficiency or toxicity (see... | View |
| 11.001.041 | Drug Testing in Pain Management and Substance Use Disorder Treatment | Dec 11, 2023 | Dec 20, 2024 | In outpatient pain management, presumptive (i.e. immunoassay) drug testing may be considered medically... | View |
| 11.001.042 | Fecal Calprotectin Testing | Jan 04, 2024 | Jan 20, 2025 | 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, 2023 | Nov 20, 2024 | The antigen leukocyte antibody test is considered investigational for all... | 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 18, 2023 | Policy Archived | 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, Barrett Esophagus, and Solid Pancreaticobiliary Lesions | Aug 16, 2023 | Aug 20, 2024 | 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 16, 2023 | Nov 20, 2024 | 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 19, 2024 | Jan 20, 2025 | 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 17, 2023 | Aug 20, 2024 | Kras, nras, braf, or her2 testing of tumor tissue may be considered medically necessary for individuals with... | 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 11, 2023 | Jul 20, 2024 | Cytochrome p450 (cyp450) genotyping for the purpose of aiding in the choice of clopidogrel versus... | View |
