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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 |
|---|---|---|---|---|---|
| 11.003.109 | Human Leukocyte Antigen Testing For Celiac Disease | Dec 09, 2024 | Dec 20, 2025 | 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 09, 2024 | Dec 20, 2025 | 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 22, 2025 | Jan 20, 2026 | 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 16, 2024 | Dec 20, 2025 | 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 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 Variants Associated With Hereditary Ovarian Cancer | Dec 16, 2024 | Sep 20, 2025 | 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, 2025 | Jan 20, 2026 | Multiple biomarkers are being evaluated to predict response to targeted treatments for patients with advanced... | View |
| 11.003.136 | Tumor-informed Circulating Tumor DNA Testing for Cancer Management | Oct 15, 2024 | Oct 20, 2025 | This evidence review addresses the use of tumor-informed circulating tumor dna (ctdna) testing for cancer... | View |
| 11.003.137 | Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1) | Sep 20, 2024 | Sep 20, 2025 | Hereditary diffuse gastric cancer (hdgc, sometimes called signet ring gastric cancer) is an autosomal... | 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, Microsatellite Instability/Mismatch Repair, Tumor Mutational Burden) | 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 and Immunotherapy in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, Tumor Mutational Burden, Microsatellite Instability/Mismatch Repair) | Oct 16, 2024 | Oct 20, 2025 | Biomarker-targeted therapy has shown a clear survival benefit in patients with ovarian cancer. more recently,... | 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 | There are numerous commercially available genetic and molecular diagnostic, prognostic, and therapeutic tests... | View |
| 11.003.142 | Circulating Tumor-Tissue-Modified Viral DNA Testing | Apr 14, 2025 | Apr 20, 2026 | This evidence review addresses the use of circulating tumor-tissue-viral modified (ttmv) human papillomavirus... | View |
| 12.002.001 | Regional Anesthesia In Vaginal Birth | Mar 31, 2019 | Policy Archived | Regional anesthesia is one that is selectively applied to a specific region of the body. under the term of... | View |
| 13.001.001 | Restorative Single Crowns, Inlays And Onlays | Oct 26, 2023 | Policy Archived | A crown, inlay or onlay is the prosthetic construction that is placed fixed in a previously prepared tooth... | View |
| 13.002.001 | Removable Prostheses; Complete And Partial Removable Dentures | Oct 26, 2023 | Policy Archived | It is an artificial removable device designed to restore the anatomy of one, several or all the teeth,... | View |
| 13.002.002 | Fixed Prosthesis | Oct 24, 2024 | Policy Archived | Fixed partial denture is a series of crowns that replace one or more of the edentulous spaces. retainers or... | View |
| 13.002.003 | Other Fixed Partial Dentures Services | Oct 26, 2023 | Policy Archived | They are components that help with the construction of fixed partial dentures when the condition or position... | View |
