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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 |
|---|---|---|---|---|---|
| 11.003.140 | Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB) | May 12, 2024 | May 20, 2025 | 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 |
| 13.003.001 | Endodontic Retreatment | Nov 11, 2020 | Policy Archived | If it is necessary to make a retreatment before 5 years, a predetermination is required and this must be... | View |
| 13.004.001 | Periodontal Surgical Services | Oct 26, 2023 | Oct 20, 2024 | 1.a history of a surgical code will limit for payment the approval of a second surgical code in a same... | View |
| 13.004.002 | Periodontal non-Surgical Services | Oct 26, 2023 | Oct 20, 2024 | All periodontal treatments need predetermination of benefits and the treatment plan for evaluation, should be... | View |
| 13.005.001 | Dental Implants | Oct 26, 2023 | Oct 20, 2024 | 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 26, 2023 | Oct 20, 2024 | 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 26, 2023 | Oct 20, 2024 | 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 26, 2023 | Oct 20, 2024 | 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 26, 2023 | Oct 20, 2024 | 1. that sufficient functional disability be present as a result of disease, trauma, congenital anomalies... | View |
