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 |
|---|---|---|---|---|---|
| 11.003.010 | 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 | Aug 15, 2024 | Jul 20, 2025 | 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 12, 2024 | Sep 20, 2025 | 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, 2024 | Sep 20, 2025 | 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 20, 2024 | Aug 20, 2025 | Li-fraumeni syndrome (lfs) is a cancer predisposition syndrome associated with the development of several... | View |
| 11.003.023 | General Approach To Evaluating The Utility Of Genetic Panels | Jan 21, 2025 | Jan 20, 2026 | Genetic panel testing offers potential advantages and disadvantages compared with direct sequence analysis.... | 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 (cma) testing has been proposed for the detection of genetic imbalances in infants or... | View |
| 11.003.026 | Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies | Mar 20, 2025 | Nov 20, 2025 | Comprehensive genomic profiling offers the potential to evaluate a large number of genetic markers at a... | View |
| 11.003.027 | Gene Variants Associated With Breast Cancer In Individuals At High Breast Cancer Risk. | Sep 12, 2024 | Sep 20, 2025 | It is estimated that 3% to 5% of women presenting for assessment for hereditary breast/ovarian cancer risk... | View |
| 11.003.028 | Genetic Testing For Lynch Syndrome And Other Inherited Colon Cancer Syndromes | Dec 05, 2024 | Oct 20, 2025 | Genetic testing is available for both those with and those at risk for various types of hereditary cancer.... | View |
| 11.003.029 | Epithelial Cell Cytology In Breast Cancer Risk Assesment And High-Risk Patient Management (Ductal Labage And Suction Collection Systems) | May 20, 2019 | Policy Archived | In summary, the available literature regarding ductal lavage and suction collection systems for breast cancer... | View |
| 11.003.030 | Genetic Testing For Brca1 Or Brca2 For Hereditary Breast/Ovarian Cancer Syndrome And Other High-Risk Cancers | Feb 10, 2025 | Sep 20, 2025 | Hereditary breast and ovarian cancer syndrome describe the familial cancer syndromes related to variants in... | View |
| 11.003.031 | Genetic Testing For Hereditary Hemochromatosis | Jun 10, 2025 | Policy Archived | Hereditary hemochromatosis (hh), a common genetic disorder of iron metabolism, can lead to inappropriate iron... | View |
