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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 |
|---|---|---|---|---|---|
| 11.003.004 | Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, and HER2) | Jul 17, 2024 | 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 17, 2024 | Jul 20, 2025 | Cytochrome p450 (cyp450) genotyping for the purpose of aiding in the choice of clopidogrel versus... | View |
| 11.003.009 | Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS) | Jul 22, 2024 | Dec 20, 2024 | Egfr testing analysis of tumor tissue for somatic variants in exons 18 through 21 (eg, g719x, l858r,... | View |
| 11.003.010 | Genetic Testing of CADASIL Syndrome | May 16, 2024 | May 20, 2025 | Genetic testing for a notch3 variant to confirm the diagnosis of cerebral autosomal dominant arteriopathy... | View |
| 11.003.011 | Somatic Genetic Testing to Select Individuals with Melanoma or Glioma for Targeted Therapy (BRAF) | Jul 19, 2024 | Jul 20, 2025 | Testing for braf v600 variants in individuals with unresectable or metastatic melanoma, or with resected... | View |
| 11.003.012 | Genetic Testing for Inherited Thrombophilia | Jun 18, 2024 | Jun 20, 2025 | Genetic testing for inherited thrombophilia, including testing for the factor v leiden variant, prothrombin... | View |
| 11.003.013 | Genetic Testing for Rett Syndrome | Jun 07, 2024 | Jun 20, 2025 | Genetic testing for rett syndrome-associated genes (eg, mecp2, foxg1, or cdkl5) may be considered medically... | View |
| 11.003.014 | Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA | Sep 07, 2023 | Sep 20, 2024 | Noninvasive fetal rhd genotyping using cell-free fetal dna is considered... | View |
| 11.003.015 | Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer | Sep 19, 2023 | Sep 20, 2024 | 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 | Genetic testing for pten may be considered medically necessary to confirm the diagnosis when a patient has... | View |
| 11.003.017 | Genetic Testing for Hereditary Hearing Loss | May 12, 2024 | May 20, 2025 | Genetic testing for hereditary hearing loss genes (gjb2, gjb6, and other hereditary hearing loss–related... | View |
| 11.003.018 | Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss | Sep 19, 2023 | Sep 20, 2024 | Chromosomal microarray testing of fetal tissue may be considered medically necessary for the evaluation of... | View |
| 11.003.020 | Genetic Testing for Lactase Insufficiency | Jun 13, 2024 | Jun 20, 2025 | The use of targeted mcm6 -13910c>t variant analysis for the prediction of lactase insufficiency is considered... | 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 16, 2023 | Aug 20, 2024 | 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 09, 2024 | Jan 20, 2025 | 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 16, 2023 | Nov 20, 2024 | 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 16, 2023 | Nov 20, 2024 | 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 13, 2023 | Sep 20, 2024 | Testing for chek2, atm, and bard1 variants in the assessment of breast cancer risk is considered... | View |
