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 |
|---|---|---|---|---|---|
| 11.003.063 | 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 | Nov 16, 2023 | Nov 20, 2024 | General genetic cancer susceptibility panel testing is considered investigational; however, when the coverage... | View |
| 11.003.066 | Genetic Testing for Duchenne and Becker Muscular Dystrophy | Apr 14, 2023 | Apr 20, 2024 | Genetic testing for dmd gene variants may be considered medically necessary under the following conditions:... | View |
| 11.003.067 | Genotype-Guided Warfarin Dosing | Jul 05, 2023 | Jul 20, 2024 | 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 20, 2023 | Apr 20, 2024 | 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 13, 2023 | Apr 20, 2024 | 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 18, 2023 | Jul 20, 2024 | 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 | Sep 11, 2023 | Sep 20, 2024 | 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 07, 2023 | Sep 20, 2024 | Chromosomal microarray testing in patients who are undergoing invasive diagnostic prenatal (fetal)... | View |
| 11.003.081 | Genetic Testing for Macular Degeneration | Apr 19, 2023 | Apr 20, 2024 | Genetic testing for macular degeneration is considered... | View |
| 11.003.082 | Genetic Testing for Facioscapulohumeral Muscular Dystrophy | Mar 19, 2023 | Mar 19, 2024 | Genetic testing for facioscapulohumeral muscular dystrophy may be considered medically necessary to confirm... | View |
| 11.003.083 | Genetic Testing for CHARGE Syndrome | Mar 19, 2023 | Mar 19, 2024 | 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 19, 2023 | Mar 19, 2024 | 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 | May 22, 2023 | May 20, 2024 | Genetic testing for genes associated with limb-girdle muscular dystrophy to confirm a diagnosis of... | 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 |
