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.

Medical Policies table

ID Title Review Description Access
11.001.033 Bone Turnover Markers For The Diagnosis And Management Of Osteoporosis And Diseases Associated With High Bone Turnover Jan 2026 Bone turnover markers are biochemical markers of either bone formation or bone resorption. commercially... View
11.001.034 Fecal Analysis In The Diagnosis Of Intestinal Dysbiosis Jan 2026 Intestinal dysbiosis may be defined as a state of disordered microbial ecology that is believed to cause... View
11.001.036 Quantitative Assay For Measurement Of Her2 Total Protein Expression And Her2 Jan 2021 Novel assays that quantitatively measure total human epidermal growth factor receptor 2 (her2) protein... View
11.001.037 Intracellular Micronutrient Analysis Jan 2026 Commercial laboratories offer panels of tests evaluating intracellular levels of micronutrients (essential... View
11.001.038 Multitarget Polymerase Chain Traction Testing For Diagnosis Of Bacterial Vaginosis Jan 2026 Bacterial vaginosis (bv) is a common medical condition resulting from an imbalance in the normal vaginal... View
11.001.039 Nutrient/Nutritional Panel Testing Jan 2026 Multimarker nutritional panel testing is proposed for patients with certain chronic conditions (eg, mood... View
11.001.040 Testing Serum Vitamin D Levels Jan 2026 Vitamin d, also known as calciferol, is a fat-soluble vitamin that has a variety of physiologic effects, most... View
11.001.041 Drug Testing In Pain Management And Substance Use Disorder Treatment Dec 2025 Individuals in pain management programs and substance use disorder treatment may misuse prescribed opioids... View
11.001.042 Fecal Calprotectin Testing Jan 2026 Calprotectin is a calcium- and zinc-binding protein that is a potential marker of intestinal inflammation.... View
11.001.044 Antigen Leukocyte Antibody Test Nov 2025 The antigen leukocyte antibody test (alcat) is intended to diagnose intolerance to foods and other... View
11.001.046 Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes Mar 2026 Improved accuracy of the identification of pregnant people at risk of preeclampsia and spontaneous preterm... View
11.001.047 Multicancer Early Detection Testing Jul 2025 Many cancers appear to have a better prognosis if diagnosed early in their natural history. this has led to... View
11.001.048 Urinary Test for Renal Allograft Rejection Aug 2025 Clinical assessment, routine monitoring, and noninvasive imaging of allograft function after renal transplant... View
11.002.001 Systems Pathology In Prostate Cancer Dec 2020 Systems pathology, an approach that combines cellular and biologic features to standard clinical parameters,... View
11.002.003 Molecular Testing For The Management Of Pancreatic Cysts, Barrett Esophagus, And Solid Pancreaticobiliary Lesions Dec 2024 Tests that integrate microscopic analysis with molecular tissue analysis are generally called topographic... View
11.002.004 Cervical Cancer Screening Technologies With Pap And Hpv Sep 2025 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 Feb 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 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 2026 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 2025 The epidermal growth factor receptor (egfr) is overexpressed in colorectal cancer (crc). egfr-targeted... View