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 |
|---|---|---|---|---|---|
| 11.003.035 | 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 12, 2023 | Apr 20, 2024 | 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 | Jan 19, 2024 | Jan 20, 2025 | For testing performed as a panel, see evidence review 11.001.015. genetic counseling experts recommend... | View |
| 11.003.038.html | 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 13, 2023 | Apr 20, 2024 | Gene expression profiling is considered investigational to evaluate the site of origin of a tumor of... | 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 |
| 11.003.052 | Molecular Markers in Fine Needle Aspirates of the Thyroid | Sep 11, 2023 | Sep 20, 2024 | 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 19, 2023 | Apr 20, 2024 | 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 05, 2023 | Jul 20, 2024 | Genetic testing to confirm a diagnosis of α-thalassemia is considered investigational. genetic testing... | View |
| 11.003.057 | Genetic Testing for Fanconi Anemia | Jan 08, 2024 | Jan 20, 2025 | 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 14, 2023 | Mar 20, 2024 | Genetic testing for hereditary pancreatitis may be considered medically necessary for patients aged 18 years... | View |
| 11.003.060 | Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia | Feb 20, 2024 | Feb 20, 2025 | Genetic testing for flt3 internal tandem duplication (flt3-itd), npm1, andcebpa variants may be considered... | View |
| 11.003.062 | General Approach to Genetic Testing | Jan 09, 2024 | Jan 20, 2025 | Genetic testing classified in one of the categories below may be considered medically necessary when all... | View |
