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
11.003.006 Pruebas Genéticas para el Tratamiento Helico Bacter Pylori May 2026 Helicobacter pylori is a bacterium associated with a number of gastrointestinal problems, such as peptic... View
11.003.008 Cytochrome P450 Genotype-Guided Treatment Strategy Jul 2025 The cytochrome p450 (cyp450) family is involved in the metabolism of many currently administered drugs, and... View
11.003.009 Molecular Analysis For Targeted Therapy Of Non-Small-Cell Lung Cancer Dec 2025 Over half of patients with non-small-cell lung cancer (nsclc) present with advanced and therefore incurable... View
11.003.010 Genetic Testing Of Cadasil Syndrome Jun 2025 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 Jul 2025 The identification of specific, targetable oncogenic “driver mutations” in a subset of melanomas... View
11.003.012 Genetic Testing For Inherited Thrombophilia May 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 2024 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 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 2024 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 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 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 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 2024 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 2021 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 Feb 2026 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 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 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 Nov 2025 Comprehensive genetic 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. Feb 2026 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 Oct 2025 Genetic testing is available for both those with and those at risk for various types of hereditary cancer.... View