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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 |
|---|---|---|---|---|---|
| 11.003.101 | 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 |
| 11.003.104 | Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment | Dec 28, 2021 | Policy Archived | The use of genetic testing for the lpa rs3798220 allele (lpa-aspirin genotype) is considered investigational... | View |
| 11.003.105 | Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification | Nov 17, 2023 | Nov 20, 2024 | Microarray-based gene expression profile testing for multiple myeloma is considered investigational for all... | View |
| 11.003.106 | Genetic Testing for Heterozygous Familial Hypercholesterolemia | Feb 13, 2024 | Feb 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) | Mar 11, 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, 2023 | Dec 20, 2024 | 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 06, 2023 | Dec 20, 2024 | Hla-dq2 and hla-dq8 testing may be considered medically necessary to rule out celiac disease in: patients... | View |
| 11.003.110 | Genetic Testing for Statin-Induced Myopathy | Dec 07, 2023 | Dec 20, 2024 | Genetic testing for the presence of variants in the slco1b1 gene to identify patients at risk of... | View |
| 11.003.111 | Next Generation Sequencing for the Assessment of Measurable Residual Disease | Jan 09, 2024 | Jan 20, 2025 | Next-generation sequencing (eg clonoseq) to detect measurable residual disease (mrd) at a threshold of... | View |
| 11.003.130 | Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence | Dec 14, 2023 | Dec 20, 2024 | Acupuncture may be considered medically necessary for treatment of episodic migraines and/or tension-type... | View |
| 11.003.131 | Sphenopalatine Ganglion Block for Headache | Dec 07, 2023 | Dec 20, 2024 | Sphenopalatine ganglion blocks are considered investigational for all indications, including but not limited... | View |
| 11.003.133 | Serologic Genetic and molecular Screening for Colorectal Cancer | Aug 17, 2023 | Aug 20, 2024 | Sept9 methylated dna testing (eg, colovantage®, epi procolon®) is considered investigational for colorectal... | View |
| 11.003.134 | Molecular Testing for Germline Variants Associated with Ovarian Cancer (BRIP1, RAD51C, RAD51D, NBN) | Sep 13, 2023 | Sep 20, 2024 | Testing for germline brip1, rad51c, and rad51d variants for ovarian cancer risk assessment in adults may... | View |
| 11.003.135 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Breast Cancer (BRCA1, BRCA2, PIK3CA, Ki-67, RET, BRAF, ESR1) | Jan 17, 2024 | Jan 20, 2024 | Brca1 and brca2 testing genetic testing for brca1 or brca2 germline variants may be... | View |
| 11.003.136 | Tumor-informed Circulating Tumor DNA Testing for Cancer Management | May 12, 2024 | May 20, 2025 | Tumor-informed circulating tumor dna testing (e.g., signatera) is considered investigational for all... | View |
| 11.003.137 | Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1) | Sep 20, 2023 | Sep 20, 2024 | Germline genetic testing for cdh1 variants to identify individuals with or at risk for hereditary diffuse... | View |
| 11.003.138 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations) | Oct 11, 2023 | Oct 20, 2024 | Germline brca1/2 variant analysis for individuals with metastatic castrate-resistant prostate cancer (mcrpc)... | View |
| 11.003.139 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency) | Oct 11, 2023 | Oct 20, 2024 | Germline brca1/2 variant analysis may be considered medically necessary for individuals with advanced... | View |
