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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 |
|---|---|---|---|---|---|
| 11.003.110 | Genetic Testing for Statin-Induced Myopathy | Dec 09, 2024 | Dec 20, 2025 | 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 22, 2025 | Jan 20, 2026 | 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 16, 2024 | Dec 20, 2025 | 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 09, 2024 | Dec 20, 2025 | Chronic migraine and severe headaches are common conditions and the available treatments are not universally... | View |
| 11.003.133 | Serologic Genetic and molecular Screening for Colorectal Cancer | Aug 20, 2024 | Aug 20, 2025 | It is well established that early detection of colorectal cancer (crc) reduces disease-related mortality. for... | View |
| 11.003.134 | Molecular Testing for Germline Variants Associated with Ovarian Cancer (BRIP1, RAD51C, RAD51D, NBN) | Dec 16, 2024 | Sep 20, 2025 | 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, NTRK) | Jan 20, 2025 | Jan 20, 2026 | 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 | Oct 15, 2024 | Oct 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, 2024 | Sep 20, 2025 | 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, NTRK Gene Fusion) | Oct 08, 2024 | Oct 20, 2025 | Biomarker-targeted therapy has shown a clear survival benefit in individuals with metastatic prostate cancer.... | View |
| 11.003.139 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, NTRK) | Oct 16, 2024 | Oct 20, 2025 | Germline brca1/2 variant analysis may be considered medically necessary for individuals with advanced... | View |
| 11.003.140 | Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB) | May 12, 2024 | May 20, 2025 | Multiple biomarkers are being evaluated to predict response to immunotherapy for individuals with cancer.... | View |
| 11.003.141 | Laboratory Testing Investigational Services | Dec 05, 2024 | Nov 20, 2024 | All tests listed in this policy are considered investigational as there is insufficient evidence to determine... | View |
| 12.002.001 | Regional Anesthesia in Vaginal Birth | Mar 31, 2019 | Policy Archived | Local infiltration and pudendal blockade are considered part of the management of labor and are included in... | View |
| 13.001.001 | Restorative Single Crowns, Inlays and Onlays | Oct 26, 2023 | Policy Archived | Single crowns, inlays or onlays require predetermination and must be accompanied by periapical radiographic... | View |
| 13.002.001 | Removable Prostheses; Complete and Partial Removable Dentures | Oct 26, 2023 | Policy Archived | All removable dentures; complete or partial, require predetermination in the line of buisiness advantage... | View |
| 13.002.002 | Fixed Prosthesis | Oct 24, 2024 | Policy Archived | All fixed bridges require predetermination. please refer to the section of predetermination of benefits for... | View |
| 13.002.003 | Other Fixed Partial Dentures Services | Oct 26, 2023 | Policy Archived | Rules and limitations for other fixed partial dentures services: 1. code d6940 stress breaker and... | View |
| 13.003.001 | Endodontic Retreatment | Nov 11, 2020 | Policy Archived | If it is necessary to make a retreatment before 5 years, a predetermination is required and this must be... | View |
| 13.004.001 | Periodontal Surgical Services | Oct 24, 2024 | Oct 20, 2025 | 1.a history of a surgical code will limit for payment the approval of a second surgical code in a same... | View |
