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 |
|---|---|---|---|---|---|
| 11.003.108 | 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 | Oct 19, 2023 | May 20, 2024 | 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 |
| 11.003.140 | Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB) | May 24, 2023 | May 20, 2024 | Braf v600 variant testing braf v600 variant testing of tumor tissue to select individuals for immune... | View |
| 11.003.141 | Laboratory Testing Investigational Services | Nov 17, 2023 | 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 26, 2023 | Oct 20, 2024 | 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 |
