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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 |
|---|---|---|---|---|---|
| 11.003.028 | 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 | Jul 10, 2024 | Policy Archived | 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 |
| 11.003.035 | Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer | Dec 06, 2023 | Dec 20, 2024 | The use of the 21-gene reverse transcriptase-polymerase chain reaction (rt-pcr) assay (ie, oncotype dx),... | View |
| 11.003.036 | Genetic Testing for Familial Cutaneous Malignant Melanoma | Apr 15, 2024 | Apr 20, 2025 | Genetic testing for genes associated with familial cutaneous malignant melanoma or associated with... | View |
| 11.003.037 | Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease | Mar 19, 2024 | Mar 20, 2025 | 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, 2023 | Dec 20, 2024 | One time genotypic or phenotypic analysis of thiopurine methyltransferase (tpmt) and nudix hydrolase (nudt15)... | View |
| 11.003.040 | Genetic Testing for Alzheimer Disease | Nov 16, 2023 | Nov 20, 2024 | 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 X Syndrome) | Feb 13, 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 18, 2023 | Oct 20, 2024 | 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 17, 2023 | Aug 20, 2024 | Genetic testing for diagnosis and management of mental health disorders is considered investigational in... | View |
| 11.003.050 | Genetic Testing for Epilepsy | Mar 14, 2023 | Mar 20, 2024 | Genetic testing for genes associated with infantile- and early-childhood onset epilepsy syndromes in... | View |
| 11.003.051 | Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management | Dec 06, 2023 | Dec 20, 2024 | Use of gene expression analysis and protein biomarkers to guide management of prostate cancer is considered... | View |
