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 |
|---|---|---|---|---|---|
| 13.001.001 | 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 |
| 13.003.001 | Endodontic Retreatment | Nov 11, 2020 | Policy Archived | It is remaking of a contaminated endodontic, in a tooth with a previously root canal treatment. <a... | View |
| 13.004.001 | Periodontal Surgical Services | Oct 24, 2024 | Oct 20, 2025 | The main objective of the periodontal surgical procedures is to be able to preserve the periodontal tissues... | View |
| 13.004.002 | Periodontal Non-Surgical Services | Oct 24, 2024 | Policy Archived | Periodontal non- surgical services include all post-operative care. they are a range of therapeutic... | View |
| 13.005.001 | Dental Implants | Oct 24, 2024 | Oct 20, 2025 | Dental implants are attachments that replace the root function of a tooth that are placed in the edentulous... | View |
| 13.005.002 | Implant Services; Crowns, Bridges (Retainers And Pontics) And Prostheses Supported By Implants | Oct 24, 2024 | Oct 20, 2025 | The crown on implants is a fixed prosthesis that is placed on an osseointegrated implant. retainers of... | View |
| 13.006.001 | Visit To Ambulatory Surgical Center And / Or Hospital | Nov 11, 2020 | Policy Archived | When a participating dentist leaves his office to perform dental services in an ambulatory surgical center or... | View |
| 13.007.001 | Maxillofacial Prosthesis | Oct 24, 2024 | Policy Archived | These are specialized and extensive prosthesis services to replace the loss of a great part of the facial and... | View |
| 13.008.001 | Frenectomy | Oct 26, 2023 | Policy Archived | It is the surgical procedure of the extirpation, dissection or muscular liberation of the frenulum that... | View |
| 13.009.001 | Maxillary Obturators | Aug 22, 2023 | Policy Archived | Maxillary obturators are considered a maxillofacial prosthesis. maxillary prosthetic devices are generally... | View |
| 13.009.002 | Oral Surgical Splint, Impression And Preparation | Nov 11, 2020 | Policy Archived | The oral splints are molds manufactured by the oral and maxillofacial surgeon prior to surgery. these molds... | View |
| 13.009.003 | Orthognathic Surgery | Oct 24, 2024 | Oct 20, 2025 | Are procedures that include surgical manipulation of the maxilla and /or the mandible to restore the correct... | View |
| 13.009.004 | Temporomandibular Joint Disorder | Mar 03, 2025 | Mar 20, 2026 | Temporomandibular joint disorder (tmjd) refers to a group of disorders characterized by pain in the... | View |
| 13.010.001 | Orthodontic Services | Oct 24, 2024 | Policy Archived | The branch of dentistry that is responsible for the study, prevention, diagnosis and treatment of anomalies... | View |
| 7.001.168 | Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation | Sep 07, 2022 | Sep 07, 2023 | Atrial fibrillation (af) is the most common type of cardiac arrhythmia. stroke associated with af is... | View |
| M3.001.001 | Therapeutic Radiopharmaceuticals for Prostate Cancer | Aug 22, 2024 | Aug 20, 2025 | Radiopharmaceuticals are composed of a radioisotope (ie, a radioactive particle) bond to an organic molecule... | View |
| M3.001.002 | Radio 223 Injection (Xofigo) | May 06, 2025 | May 20, 2026 | Approximately 240,000 men in the united states are expected to be diagnosed with prostate cancer in 2016.... | View |
