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 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 | Dec 05, 2024 | Nov 20, 2025 | Summary multiple myeloma is a genetically complex-and invariably fatal-disease. a host of well-characterized... | View |
| 11.003.106 | Genetic Testing For Heterozygous Familial Hypercholesterolemia | Nov 12, 2024 | Nov 20, 2025 | 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 20, 2024 | Dec 20, 2025 | Biologic agents used to treat autoimmune diseases include infliximab, adalimumab, vedolizumab, and... | View |
| 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 18, 2025 | Aug 20, 2026 | 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 | 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, 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 | Sep 25, 2025 | Sep 20, 2026 | 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 22, 2025 | Sep 20, 2026 | 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 |
