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 |
|---|---|---|---|---|---|
| 11.003.083 | 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 | 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 |
| 11.003.087 | Molecular Testing in the Management of Pulmonary Nodules | Jun 19, 2023 | Jun 20, 2024 | Plasma-based proteomic screening, including but not limited to bdx-xl2 (nodify xl2®), in individuals with... | 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 |
| 11.003.089 | Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) | Sep 19, 2023 | Sep 20, 2024 | The use of circulating tumor dna and/or circulating tumor cells is considered investigational for all... | View |
| 11.003.090 | RATIONALE | Apr 15, 2024 | Apr 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 05, 2023 | Jul 20, 2024 | Proteogenomic testing (see policy guidelines section) of patients with cancer (including, but not limited to... | View |
| 11.003.093 | Genetic Testing for Mitochondrial Disorders | Oct 12, 2023 | Oct 20, 2024 | 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 05, 2023 | Jul 20, 2024 | Serum biomarker panel testing with proprietary algorithms and/or index scores for the diagnosis of systemic... | View |
| 11.003.095 | Genotype-Guided Tamoxifen Treatment | Aug 11, 2023 | Aug 20, 2024 | 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 11, 2023 | Aug 20, 2024 | 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 09, 2023 | Jun 20, 2024 | 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 16, 2023 | Nov 20, 2024 | 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 | The use of proteomic testing, including but not limited to the veristrat assay, is considered investigational... | 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 09, 2024 | Feb 20, 2025 | 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 |
