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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 |
|---|---|---|---|---|---|
| 13.004.002 | Periodontal non-Surgical Services | Oct 24, 2024 | Policy Archived | All periodontal treatments need predetermination of benefits and the treatment plan for evaluation, should be... | View |
| 13.005.001 | Dental Implants | Oct 24, 2024 | Oct 20, 2025 | 1. there must be bone integration of the implant, to be able move to the prosthesis phase of crowns,... | View |
| 13.005.002 | Implant Services; Crowns, bridges (retainers and Pontics) and Prostheses Supported by Implants | Oct 24, 2024 | Oct 20, 2025 | 1. crowns should be predetermined and are subject to the corresponding coinsurances and caps. 2. the... | View |
| 13.006.001 | Visit to Ambulatory Surgical Center and / or Hospital | Nov 11, 2020 | Policy Archived | Code d9420 requires predeterminationand the required documents are; (a) patient’s diagnostic (b)... | View |
| 13.007.001 | Maxillofacial Prosthesis | Oct 24, 2024 | Policy Archived | The maxillofacial prosthesis services require predetermination. 1. the maxillofacial prosthesis services... | View |
| 13.008.001 | Frenectomy | Oct 26, 2023 | Policy Archived | 1.requires predetermination. 2.the predetermination must be accompanied by the evaluation and... | View |
| 13.009.001 | Maxillary Obturators | Aug 22, 2023 | Policy Archived | These services are covered for all patients that have a palatal or nasopharyngeal defect that impairs the... | View |
| 13.009.002 | Oral Surgical Splint, Impression and Preparation | Nov 11, 2020 | Policy Archived | This service is considered as surgical guidance and stabilization for orthognathic surgery (surgical... | View |
| 13.009.003 | Orthognathic Surgery | Oct 24, 2024 | Oct 20, 2025 | These surgeries may be recognized for payment as long as one of the following criteria is met:... | View |
| 13.009.004 | Temporomandibular Joint Disorder | Mar 05, 2024 | Mar 20, 2025 | Diagnostic procedures the following diagnostic procedures may be considered medically necessary in the... | View |
| 13.010.001 | Orthodontic Services | Oct 24, 2024 | Policy Archived | 1. that sufficient functional disability be present as a result of disease, trauma, congenital anomalies... | View |
| 7.001.168 | Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation | Sep 07, 2022 | Sep 07, 2023 | The use of surgical left atrial appendage occlusion devices, including the atriclip device, for stroke... | View |
| M3.001.001 | Therapeutic Radiopharmaceuticals for Prostate Cancer | Aug 22, 2024 | Aug 20, 2025 | Therapeutic radiopharmaceuticals for prostate cancer using lutetium (lu) 177 vipivotide tetraxetan... | View |
| M5.001.001 | Viscosupplementation Therapy For Knee | May 10, 2024 | May 20, 2025 | Viscosupplementation therapy is part of the therapy used in the treatment of osteoarthritis of the knee.... | View |
| M5.001.002 | Rituximab | May 10, 2024 | May 20, 2025 | Rituximab is a genetically engineered chimeric murine/human monoclonal igg1 kappa antibody directed against... | View |
| M5.001.003 | Trastuzumab – Trastuzumab Biologics | May 10, 2024 | May 20, 2025 | Trastuzumab is a monoclonal antibody, one of a group of drugs designed to attack specific cancer cells.... | View |
| M5.001.005 | Bevacizumab – Bevacizumab Biologics for Oncologic Uses | May 10, 2024 | May 20, 2025 | Bevacizumab is a humanized monoclonal antibody directed against vascular endothelial growth factor a... | View |
| M5.001.006 | CSF Hematopoietic Colony Stimulating Factors | May 10, 2024 | May 20, 2025 | White blood cell growth factors, also known as granulocyte colony stimulating factors (g-csf), are... | View |
| M5.001.007 | Somatuline® Depot; Lanreotide | May 10, 2024 | May 20, 2025 | Somatuline® depot; lanreotide may be considered medically necessary in patients 18 years of age or older... | View |
| M5.001.008 | Simponi ARIA® (golimumab) | May 10, 2024 | May 20, 2025 | Simponi aria® (golimumab) may be considered medically necessary in patients is at least 18 years of... | View |
