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 |
|---|---|---|---|---|---|
| 11.003.084 | Genetic Testing For Idiopathic Dilated Cardiomyopathy | Mar 12, 2025 | Mar 20, 2026 | Dilated cardiomyopathy (dcm) is characterized by progressive left ventricular enlargement and systolic... | View |
| 11.003.085 | Genetic Testing For Limb-Girdle Muscular Dystrophies | Jun 18, 2024 | Policy Archived | ... | View |
| 11.003.086 | Kif6 Genotyping For Predicting Cardiovascular Risk | Aug 20, 2021 | Policy Archived | Genetic testing to determine kinesin-like protein 6 (kif6) trp719arg variant status is being evaluated as a... | View |
| 11.003.087 | Molecular Testing In The Management Of Pulmonary Nodules | Jun 18, 2024 | Jun 20, 2025 | Plasma-based proteomic screening and gene expression profiling of bronchial brushing are molecular tests... | View |
| 11.003.088 | Molecular Testing For Chronic Heart Failure And Heart Transplant | Jun 17, 2021 | Policy Archived | Clinical assessment and noninvasive imaging of chronic heart failure can be limited in accurately diagnosing... | View |
| 11.003.089 | Circulating Tumor Dna And Circulating Tumor Cells For Cancer Management (Liquid Biopsy) | Sep 20, 2024 | Sep 20, 2025 | Circulating tumor dna (ctdna) and circulating tumor cells (ctcs) in peripheral blood, referred to as... | View |
| 11.003.090 | Gene Expression Profiling For Uveal Melanoma | Mar 12, 2025 | Mar 20, 2026 | Uveal melanoma is associated with a high rate of metastatic disease, and survival after the development of... | View |
| 11.003.092 | Proteogenomic Testing For Patients With Cancer | Jul 08, 2024 | Jul 20, 2025 | Proteogenomics refers to the integration of genomic information with proteomic and transcriptomic information... | View |
| 11.003.093 | Genetic Testing For Mitochondrial Disorders | Oct 08, 2024 | Oct 20, 2025 | Mitochondrial diseases are multisystem diseases that arise from dysfunction in the mitochondrial protein... | View |
| 11.003.094 | Serum Biomarket Panel Testing For Systemic Lupus Erythematosus And Other Connective Tissue Deseases | Jul 08, 2024 | Jul 20, 2025 | Systemic lupus erythematosus (sle) is an autoimmune connective tissue disease (ctd) that can be difficult to... | View |
| 11.003.095 | Genotype-Guided Tamoxifen Treatment | Sep 13, 2024 | Sep 20, 2025 | Tamoxifen is prescribed as a component of adjuvant endocrine therapy to prevent endocrine receptor-positive... | View |
| 11.003.096 | Miscellaneous Genetic And Molecular Diagnostic Tests | Aug 12, 2024 | Aug 20, 2025 | There are numerous commercially available genetic and molecular diagnostic, prognostic, and therapeutic tests... | View |
| 11.003.097 | Gene Expression Profiling For Cutaneous Melanoma | Jun 09, 2025 | Jun 20, 2026 | Laboratory tests have been developed that detect the expression of different genes in pigmented lesions or... | 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 | Several single nucleotide variants (snvs), which are single base-pair variations in the dna sequence of the... | View |
| 11.003.099 | Circulating Tumor Dna For Management Of Non-Small-Cell Lung Cancer (Liquid Biopsy) | Dec 10, 2021 | Policy Archived | ... | View |
| 11.003.100 | Dna-Based Testing For Adolescent Idiopathic Scoliosis | Mar 05, 2021 | Policy Archived | Adolescent idiopathic scoliosis (ais) is a disease of unknown etiology that causes mild-to-severe spinal... | View |
| 11.003.101 | Genetic Testing For Alpha 1 – Antitrypsin Deficiency | Feb 19, 2025 | Feb 20, 2026 | Alpha1-antitrypsin deficiency (aatd) is an autosomal recessive genetic disorder that results in decreased... | View |
| 11.003.102 | Genetic Testing For Neurofibromatosis | Feb 05, 2025 | Feb 20, 2026 | Neurofibromatoses are autosomal dominant genetic disorders associated with tumors of the peripheral and... | View |
| 11.003.103 | Gene Therapy For Inherited Retinal Dystrophy | Feb 19, 2025 | Feb 20, 2026 | Inherited retinal dystrophy can be caused by recessive variants in the rpe65 gene. patients with biallelic... | 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 |
