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 |
|---|---|---|---|---|---|
| 11.002.004 | Cervical Cancer Screening Technologies With Pap And Hpv | Sep 24, 2025 | 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 18, 2025 | Nov 20, 2026 | 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 19, 2026 | Jan 20, 2027 | 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 18, 2025 | Aug 20, 2026 | The epidermal growth factor receptor (egfr) is overexpressed in colorectal cancer (crc). egfr-targeted... | 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 23, 2025 | Jul 20, 2026 | 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 19, 2025 | Dec 20, 2026 | Over half of patients with non-small-cell lung cancer (nsclc) present with advanced and therefore incurable... | View |
| 11.003.010 | Genetic Testing Of Cadasil Syndrome | Jun 16, 2025 | Policy Archived | Variants in the notch3 gene have been causally associated with cerebral autosomal dominant arteriopathy with... | View |
| 11.003.011 | Genetic Testing To Select Melanoma Or Glioma Patients For Targeted Therapy | Jul 16, 2025 | Jul 20, 2026 | The identification of specific, targetable oncogenic “driver mutations” in a subset of melanomas... | View |
| 11.003.012 | Genetic Testing For Inherited Thrombophilia | Jun 10, 2025 | Jun 20, 2026 | Inherited thrombophilias are a group of disorders that predispose individuals to thrombosis. genetic testing... | View |
| 11.003.013 | Genetic Testing For Rett Syndrome | Jul 17, 2024 | Policy Archived | Rett syndrome (rtt), a neurodevelopmental disorder, is usually caused by pathogenic variants in the... | View |
| 11.003.014 | Noninvasive Fetal Rhd Genotyping Using Cell-Free Fetal Dna | Sep 05, 2025 | Sep 20, 2026 | Rhesus d (rhd)-negative women who are exposed to rhd-positive red blood cells can develop anti-rhd... | View |
| 11.003.015 | Gene Expression Profile Testing And Circulating Tumor Dna Testing For Predicting Recurrence In Colon Cancer | Sep 18, 2024 | Sep 20, 2025 | Gene expression profile (gep) and circulating tumor dna (ctdna) tests have been developed for use as... | View |
| 11.003.016 | Genetic Testing For Pten Hamartoma Tumor Syndrome | Mar 10, 2025 | Mar 20, 2026 | The pten hamartoma tumor syndrome (phts) includes several syndromes with heterogeneous clinical symptoms,... | View |
| 11.003.017 | Genetic Testing For Hereditary Hearing Loss | May 09, 2025 | May 20, 2026 | Hearing loss is a common birth defect. approximately 1 in 500 newborns in developed countries is affected by... | View |
| 11.003.018 | Chromosomal Microarray Testing For The Evaluation Of Pregnancy Loss | Sep 19, 2025 | Sep 20, 2026 | Chromosomal microarray (cma) testing of fetal tissue or placental tissue derived from the fetal genotype has... | View |
| 11.003.020 | Genetic Testing For Lactase Insufficiency | Jul 17, 2024 | Policy Archived | Genetic testing of adults with suspected lactase insufficiency is proposed as an alternative to current... | View |
| 11.003.021 | Gene Expression Testing In The Evaluation Of Patients With Stable Ischemic Heart Disease | Apr 20, 2021 | Policy Archived | Expression levels of various genes in circulating white blood cells or whole blood samples have been reported... | View |
| 11.003.022 | Genetic Testing For Li-Fraumeni Syndrome | Aug 18, 2025 | Aug 20, 2026 | Li-fraumeni syndrome (lfs) is a cancer predisposition syndrome associated with the development of several... | View |
