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 |
|---|---|---|---|---|---|
| 11.003.097 | 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 12, 2025 | Nov 20, 2026 | 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 |
| 11.003.105 | Microarray-Based Gene Expression Profile Testing For Multiple Myeloma Risk Stratification | Nov 10, 2025 | Nov 20, 2026 | Multiple myeloma is a genetically complex and invariably fatal disease. a host of well-characterized factors... | View |
| 11.003.106 | Genetic Testing For Heterozygous Familial Hypercholesterolemia | Nov 05, 2025 | Nov 20, 2026 | Complete appendix to guidelines available at http://journals.aace.com. endocr pract. apr 02 2017; 23(4):... | View |
| 11.003.107 | Genetic Testing For Hereditary Pancreatic Cancer | Mar 03, 2025 | Mar 20, 2026 | Pancreatic cancer is the fourth leading cause of cancer death in the united states, accounting for 8.3% of... | View |
| 11.003.108 | Measurement Of Serum Antibodies To Selected Biologic Agent | Dec 18, 2025 | Dec 20, 2026 | Biologic agents used to treat autoimmune diseases include infliximab, adalimumab, vedolizumab, and... | View |
| 11.003.109 | Human Leukocyte Antigen Testing For Celiac Disease | Dec 05, 2025 | Dec 20, 2026 | Celiac disease (cd) is currently diagnosed by serology, medical history, and response to a gluten-free diet,... | View |
| 11.003.110 | Genetic Testing For Statin-Induced Myopathy | Dec 05, 2025 | Dec 20, 2026 | Hmg-coa reductase inhibitors, or statins, which are widely used to treat hypercholesterolemia, can cause... | View |
| 11.003.111 | Next Generation Sequencing For The Assessment Of Measurable Residual Disease | Jan 14, 2026 | Jan 20, 2027 | Measurable residual disease (mrd), also known as minimal residual disease, refers to residual clonal cells in... | View |
| 11.003.130 | Acupuncture For Pain Management, Nausea And Vomiting, And Opioid Dependence | Dec 09, 2025 | Dec 20, 2026 | Acupuncture describes a group of procedures intended to stimulate anatomical points with the goal of... | View |
| 11.003.131 | Sphenopalatine Ganglion Block For Headache | Dec 05, 2025 | Dec 20, 2026 | 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 | Jan 20, 2026 | Jan 20, 2027 | ... | View |
| 11.003.134 | Molecular Testing For Variants Associated With Hereditary Ovarian Cancer | Sep 02, 2025 | Sep 20, 2026 | It is estimated that approximately 20% of women presenting for assessment for hereditary ovarian cancer (oc)... | View |
| 11.003.135 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer | Jan 20, 2026 | Jan 20, 2027 | Multiple biomarkers are being evaluated to select treatment with an fda-approved targeted treatments for... | View |
