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 |
|---|---|---|---|---|---|
| 11.003.013 | Genetic testing for Rett Syndrome | Jun 09, 2023 | Jun 20, 2024 | Genetic testing for rett syndrome-associated genes (eg, mecp2, foxg1, or cdkl5) may be... | 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 14, 2023 | Mar 20, 2024 | 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 23, 2023 | May 20, 2024 | 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 12, 2023 | Jun 20, 2024 | 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 |
| 11.003.028 | Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes | Oct 11, 2023 | Oct 20, 2024 | 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) | Sep 19, 2023 | Sep 20, 2024 | 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 | Jun 08, 2023 | Jun 20, 2024 | Genetic testing for human hemochromatosis (hfe) gene variants may be considered medically necessary in an... | View |
| 11.003.032 | Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening | Dec 20, 2023 | Dec 20, 2024 | Dna analysis of stool samples can be considered medically necessary as a screening technique for colorectal... | 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, 2023 | Dec 20, 2024 | The following genetic and protein biomarkers for the diagnosis of prostate cancer are... | View |
