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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 |
|---|---|---|---|---|---|
| 11.003.052 | Molecular Markers in Fine Needle Aspirates of the Thyroid | Jul 19, 2024 | 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 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 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 |
| 11.003.063 | BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia | Nov 15, 2023 | Nov 20, 2024 | 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 | Jul 17, 2024 | Nov 20, 2024 | The human genome variation society nomenclature is used to report information on variants found in dna and... | View |
| 11.003.066 | Genetic Testing for Duchenne and Becker Muscular Dystrophy | Apr 17, 2024 | Apr 20, 2025 | Genetic testing for dmd gene variants may be considered medically necessary under the following conditions:... | View |
| 11.003.067 | Genotype-Guided Warfarin Dosing | Jul 08, 2024 | Jul 20, 2025 | Genotyping to determine cytochrome p450 2c9 (cyp2c9), p450 4f2 (cyp4f2), and vitamin k epoxide reductase... | View |
| 11.003.068 | Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies | Feb 13, 2024 | Feb 20, 2025 | Genetic testing is considered medically necessary when the diagnosis of an inherited peripheral motor or... | View |
| 11.003.069 | Analysis of MGMT Promoter Methylation in Malignant Gliomas | Jun 13, 2019 | Policy Archived | Methylation analysis of the o6-methylguanine dna methyltransferase (mgmt) gene promoter from glioma tumor... | View |
| 11.003.070 | Preimplantation Genetic Testing | Sep 07, 2023 | Sep 20, 2024 | Preimplantation genetic diagnosis may be considered medically necessary as an adjunct to in vitro... | View |
| 11.003.072 | Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders | Apr 19, 2024 | Apr 20, 2025 | Individual genetic testing for the diagnosis of marfan syndrome, ehlers-danlos syndrome type iv, other... | View |
| 11.003.073 | Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer | Apr 15, 2024 | Apr 20, 2025 | Assay testing for determining 5-fluorouracil area under the curve in order to adjust 5-fluorouracil dose for... | View |
| 11.003.075 | Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer | Dec 06, 2023 | Dec 20, 2024 | The use of proteomic testing, including but not limited to the veristrat assay, is considered investigational... | View |
| 11.003.076 | Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis | Jul 19, 2024 | Jul 20, 2025 | The use of a multibiomarker disease activity score for rheumatoid arthritis (eg, vectra score) is... | View |
| 11.003.077 | LOS ENSAYOS DE VARIOS ALITOS CON EL ALISIS ALGORITMICO PARA PREDECIR EL RIESGO DE DABETES TIPO 2 | Oct 11, 2016 | Policy Archived | El uso de paneles de varios analitos con el análisis algorítmico (masa) para la predicción de la diabetes... | View |
| 11.003.078 | Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders and Twin Zygosity Using Cell-Free Fetal DNA | Apr 15, 2024 | Apr 20, 2025 | Nucleic acid sequencing-based testing of maternal plasma to screen for trisomy 21, 18, and 13 may be... | View |
