News
Food as an agent of change
Read more
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 |
|---|---|---|---|---|---|
| 11.003.066 | 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... | 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 | Dec 16, 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 | Dec 06, 2024 | Sep 20, 2025 | 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 | Mar 19, 2024 | Mar 20, 2025 | Marfan syndrome (mfs) is a systemic connective tissue disease (ctd) with a high degree of clinical... | 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, 2024 | Dec 20, 2025 | 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 | Feb 03, 2025 | Sep 20, 2025 | Nucleic acid sequencing-based testing of maternal plasma to screen for trisomy 21, 18, and 13 may be... | View |
| 11.003.079 | Invasive Prenatal (Fetal) Diagnostic Testing | Sep 13, 2024 | Sep 20, 2025 | Chromosomal microarray testing in patients who are undergoing invasive diagnostic prenatal (fetal)... | View |
| 11.003.081 | Genetic Testing for Macular Degeneration | Apr 18, 2024 | Apr 20, 2025 | Genetic testing for macular degeneration is considered... | View |
| 11.003.082 | Genetic Testing for Facioscapulohumeral Muscular Dystrophy | Mar 15, 2024 | Mar 20, 2025 | Genetic testing for facioscapulohumeral muscular dystrophy may be considered medically necessary to confirm... | View |
| 11.003.083 | Genetic Testing for CHARGE Syndrome | Mar 15, 2024 | Mar 20, 2025 | Genetic testing for charge syndrome may be considered medically necessary to confirm a diagnosis in a... | View |
| 11.003.084 | Genetic Testing for Idiopathic Dilated Cardiomyopathy | Mar 15, 2024 | Mar 20, 2025 | Comprehensive genetic testing for individuals with signs or symptoms of dilated cardiomyopathy, which is... | View |
| 11.003.085 | Genetic Testing for Limb-Girdle Muscular Dystrophies | Jun 18, 2024 | Policy Archived | The limb-girdle muscular dystrophies are a genetically heterogeneous group of muscular dystrophies... | View |
| 11.003.086 | KIF6 Genotyping for Predicting Cardiovascular Risk | Aug 20, 2021 | Policy Archived | Kif6 genotyping is considered investigational for predicting cardiovascular risk and/or the effectiveness of... | View |
| 11.003.087 | Molecular Testing in the Management of Pulmonary Nodules | Jun 18, 2024 | Jun 20, 2025 | Plasma-based proteomic screening, including but not limited to nodify xl2® (bdx-xl2), nodify cdt®, and... | View |
| 11.003.088 | Molecular Testing for Chronic Heart Failure and Heart Transplant | Jun 17, 2021 | Policy Archived | The use of the presage st2 assay to evaluate the prognosis of patients diagnosed with chronic heart failure... | View |
