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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 |
|---|---|---|---|---|---|
| 11.003.037 | Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease | Jan 20, 2025 | Jan 20, 2026 | Measurement of nontraditional lipid and non-lipid biomarkers (ie, apolipoprotein b, apolipoprotein ai,... | View |
| 11.003.038 | Biomarker Genes for Detection of Lymph Node metastases in Breast Cancer | May 15, 2019 | Policy Archived | Evaluation of biomarker genes is considered investigational for detection of lymph node metastases in... | View |
| 11.003.039 | Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines | Dec 20, 2024 | Dec 20, 2025 | One time genotypic or phenotypic analysis of thiopurine methyltransferase (tpmt) and nudix hydrolase (nudt15)... | View |
| 11.003.040 | Genetic Testing for Alzheimer Disease | Nov 22, 2024 | Nov 20, 2025 | Targeted genetic testing for a known familial variant in the presenilin (psen) genes or amyloid-beta... | View |
| 11.003.042 | Genetic Testing for Cardiac Ion Channelopathies | Feb 13, 2024 | Feb 20, 2025 | Long qt syndrome genetic testing to confirm a diagnosis of congenital long qt syndrome (lqts) may be... | View |
| 11.003.046 | Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) | Nov 26, 2024 | Feb 20, 2025 | Genetic testing for fragile x mental retardation 1 gene (fmr1) variants may be considered medically... | View |
| 11.003.047 | Gene Expression-Based Assays for Cancers of Unknown Primary | Apr 15, 2024 | Apr 20, 2025 | Gene expression profiling is considered investigational to evaluate the site of origin of a tumor of unknown... | View |
| 11.003.048 | Carrier Screening for Genetic Diseases | Oct 10, 2024 | Oct 20, 2025 | Targeted risk-based carrier screening targeted carrier screening for x-linked and autosomal recessive... | View |
| 11.003.049 | Genetic Testing for Diagnosis and Management of Mental Health Conditions | Aug 20, 2024 | Aug 20, 2025 | Genetic testing for diagnosis and management of mental health disorders is considered investigational in... | View |
| 11.003.050 | Genetic Testing for Epilepsy | Mar 11, 2024 | Mar 20, 2025 | Epilepsy is a disorder characterized by unprovoked seizures. it is a heterogeneous condition that encompasses... | View |
| 11.003.051 | Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management | Oct 08, 2024 | Oct 20, 2025 | Use of gene expression analysis and protein biomarkers to guide management of prostate cancer is considered... | View |
| 11.003.052 | Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Managementt | Sep 24, 2024 | Sep 20, 2025 | For individuals who have thyroid nodules without strong clinical or radiologic findings suggestive of... | View |
| 11.003.053 | Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders | Apr 18, 2024 | Apr 20, 2025 | Standard whole exome sequencing, with trio testing when possible (see policy guidelines), may be considered... | View |
| 11.003.056 | Genetic Testing for a Thalassemia | Jul 10, 2024 | Jul 20, 2025 | Genetic testing to confirm a diagnosis of α-thalassemia is considered investigational. genetic testing... | View |
| 11.003.057 | Genetic Testing for Fanconi Anemia | Jan 15, 2025 | Jan 20, 2026 | Genetic testing for the diagnosis of fanconi anemia may be considered medically necessary when the... | View |
| 11.003.059 | Genetic Testing for Hereditary Pancreatitis | Mar 11, 2024 | Mar 20, 2025 | In chronic pancreatitis (cp), recurrent attacks of acute pancreatitis evolve into a chronic inflammatory... | View |
| 11.003.060 | Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia | Feb 20, 2024 | Feb 20, 2025 | Treatment of acute myeloid leukemia (aml) is based on risk stratification, primarily related to patient age... | View |
| 11.003.062 | General Approach to Genetic Testing | Jan 21, 2025 | Jan 20, 2026 | Genetic testing classified in one of the categories below may be considered medically necessary when all... | View |
| 11.003.063 | BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia | Dec 03, 2024 | Nov 20, 2025 | Chronic myelogenous leukemia bcr-abl1 qualitative testing for the presence of the fusion gene may be... | View |
| 11.003.064 | Genetic Cancer Susceptibility Panels Using Next Generation Sequencing | Dec 12, 2024 | Nov 20, 2025 | General genetic cancer susceptibility panel testing is considered investigational; however, when the... | View |
