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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 |
|---|---|---|---|---|---|
| 11.003.015 | Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer | Sep 18, 2024 | Sep 20, 2025 | Gene expression assays for determining the prognosis of stage ii or iii colon cancer following surgery are... | View |
| 11.003.016 | Genetic Testing for PTEN Hamartoma Tumor Syndrome | Mar 08, 2024 | Mar 20, 2025 | The pten hamartoma tumor syndrome (phts) includes several syndromes with heterogeneous clinical symptoms,... | View |
| 11.003.017 | Genetic Testing for Hereditary Hearing Loss | May 12, 2024 | May 20, 2025 | 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, 2024 | Sep 20, 2025 | Chromosomal microarray testing of fetal tissue may be considered medically necessary for the evaluation of... | 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 | Gene expression testing in the evaluation of patients with stable ischemic heart disease is... | View |
| 11.003.022 | Genetic Testing for Li-Fraumeni Syndrome | Aug 20, 2024 | Aug 20, 2025 | Genetic testing for tp53 may be considered medically necessary to confirm a diagnosis of li-fraumeni syndrome... | View |
| 11.003.023 | General Approach to Evaluating the Utility of Genetic Panels | Jan 21, 2025 | Jan 20, 2026 | Genetic panels that use next-generation sequencing or chromosomal microarray analysis, and are classified in... | View |
| 11.003.025 | Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies | Nov 22, 2024 | Nov 20, 2025 | Chromosomal microarray analysis may be considered medically necessary as first-line testing in the initial... | View |
| 11.003.026 | Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies | Nov 22, 2024 | Nov 20, 2025 | The use of comprehensive genomic profiling for selecting targeted cancer treatment is considered... | View |
| 11.003.027 | Germline Genetic Testing for Gene Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk (CHEK2, ATM, and BARD1) | Sep 12, 2024 | Sep 20, 2025 | Testing for chek2, atm, and bard1 variants in the assessment of breast cancer risk is considered... | View |
| 11.003.028 | Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes | Dec 05, 2024 | Oct 20, 2025 | Apc testing genetic testing of the apc gene may be considered medically necessary in the following... | View |
| 11.003.029 | Epithelial Cell Cytology in Breast Cancer Risk Assesment and High-Risk Patient Management (Ductal Lavage and Suction Collection Systems) | May 20, 2019 | Policy Archived | Cytologic analysis of epithelial cells from nipple aspirations as a technique to assess breast cancer risk... | View |
| 11.003.030 | Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) | Feb 10, 2025 | Sep 20, 2025 | Genetic testing should be performed in a setting that has suitably trained health care providers who can give... | View |
| 11.003.031 | Genetic Testing for Hereditary Hemochromatosis | Jul 10, 2024 | Policy Archived | Genetic testing for human hemochromatosis (hfe) gene variants may be considered medically necessary in an... | View |
| 11.003.032 | Analysis of Human DNA or RNA in Stool Samples as a Technique for Colorectal Cancer Screening | Jan 20, 2025 | Jan 20, 2026 | Dna or rna analysis of stool samples can be considered medically necessary as a screening technique for... | View |
| 11.003.033 | ALISIS DE LOS PATRONES PROTEOMICOS PARA IDENTIFICACION TEMPRA DEL CÁNCER DE OVARIO | May 12, 2016 | Policy Archived | El análisis de patrones proteómicos en el suero como cernimiento y detección de cáncer de ovario no se... | View |
| 11.003.034 | Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer | Dec 20, 2024 | Dec 20, 2025 | The following genetic and protein biomarkers for the diagnosis of prostate cancer are... | View |
| 11.003.035 | Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer | Dec 06, 2024 | Dec 20, 2025 | The use of the 21-gene reverse transcriptase-polymerase chain reaction (rt-pcr) assay (ie, oncotype dx),... | View |
| 11.003.036 | Genetic Testing for Familial Cutaneous Malignant Melanoma | Apr 15, 2024 | Apr 20, 2025 | Genetic testing for genes associated with familial cutaneous malignant melanoma or associated with... | View |
