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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 |
|---|---|---|---|---|---|
| 11.003.089 | Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) | Sep 20, 2024 | Sep 20, 2025 | The use of circulating tumor dna and/or circulating tumor cells is considered investigational for all... | View |
| 11.003.090 | RATIONALE | Mar 15, 2024 | Mar 20, 2025 | Gene expression profiling for uveal melanoma with decisiondx-um is medically necessary for patients with... | View |
| 11.003.092 | Proteogenomic Testing for Patients With Cancer | Jul 08, 2024 | Jul 20, 2025 | Proteogenomic testing (see policy guidelines section) of individuals with cancer (including, but not limited... | View |
| 11.003.093 | Genetic Testing for Mitochondrial Disorders | Oct 08, 2024 | Oct 20, 2025 | Genetic testing to establish a genetic diagnosis of a mitochondrial disorder may be considered medically... | View |
| 11.003.094 | Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases | Jul 08, 2024 | Jul 20, 2025 | Serum biomarker panel testing with proprietary algorithms and/or index scores for the diagnosis of systemic... | View |
| 11.003.095 | Genotype-Guided Tamoxifen Treatment | Sep 13, 2024 | Sep 20, 2025 | Genotyping to determine cytochrome p450 2d6 (cyp2d6) variants is considered investigational for the purpose... | View |
| 11.003.096 | Miscellaneous Genetic and Molecular Diagnostic Tests | Aug 12, 2024 | Aug 20, 2025 | All tests listed in this policy are considered investigational and grouped according to the categories of... | View |
| 11.003.097 | Gene Expression Profiling for Cutaneous Melanoma | Jun 07, 2024 | Jun 20, 2025 | Gene expression testing, including but not limited to the pigmented lesion assay, in the evaluation of... | View |
| 11.003.098 | Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer | Nov 15, 2024 | Nov 20, 2025 | Testing for 1 or more single nucleotide variants to predict an individual’s risk of breast cancer is... | View |
| 11.003.099 | Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy) | Dec 10, 2021 | Policy Archived | Proteomic testing has been proposed as a way to predict survival outcomes, as well as the response to and... | View |
| 11.003.100 | DNA-Based Testing for Adolescent Idiopathic Scoliosis | Mar 05, 2021 | Policy Archived | Dna-based prognostic testing for adolescent idiopathic scoliosis is... | View |
| 11.003.101 | Genetic Testing for Alpha 1 – Antitrypsin Deficiency | Feb 13, 2024 | Feb 20, 2025 | Genetic testing for alpha1-antitrypsin deficiency may be considered medically necessary when either of the... | View |
| 11.003.102 | Genetic Testing for Neurofibromatosis | Feb 05, 2025 | Feb 20, 2026 | Genetic testing for neurofibromatosis type 1 (nf1) or neurofibromatosis type 2 (nf2) pathogenic variants... | View |
| 11.003.103 | Gene Therapy for Inherited Retinal Dystrophy | Feb 13, 2024 | Feb 20, 2025 | Adeno-associated virus vector-based gene therapy via subretinal injection with voretigene neparvovec is... | View |
| 11.003.104 | Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment | Dec 28, 2021 | Policy Archived | Lipoprotein(a) (lpa) is a lipid-rich particle similar to low-density lipoprotein and has been determined to... | View |
| 11.003.105 | Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification | Dec 05, 2024 | Nov 20, 2025 | Microarray-based gene expression profile testing for multiple myeloma is considered investigational for all... | View |
| 11.003.106 | Genetic Testing for Heterozygous Familial Hypercholesterolemia | Nov 12, 2024 | Nov 20, 2025 | Genetic testing to confirm a diagnosis of familial hypercholesterolemia (fh) may be considered medically... | View |
| 11.003.107 | Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes (ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, and TP53) | Dec 16, 2024 | Mar 20, 2025 | Genetic testing for brca1, brca2, and palb2 variants to guide selection for treatment with platinum-based... | View |
| 11.003.108 | Measurement of Serum Antibodies to Selected Biologic Agent | Dec 20, 2024 | Dec 20, 2025 | Measurement of antidrug antibodies in an individual receiving treatment with a biologic agent, either alone... | View |
| 11.003.109 | Human Leukocyte Antigen Testing for Celiac Disease | Dec 09, 2024 | Dec 20, 2025 | Hla-dq2 and hla-dq8 testing may be considered medically necessary to rule out celiac disease in: patients... | View |
