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 |
|---|---|---|---|---|---|
| 13.003.001 | 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 15, 2023 | Mar 15, 2024 | 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 |
| 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 |
| M5.001.001 | Viscosupplementation Therapy For Knee | Oct 26, 2023 | Oct 20, 2024 | Viscosupplementation therapy is part of the therapy used in the treatment of osteoarthritis of the knee.... | View |
| M5.001.002 | Rituximab | Oct 26, 2023 | Oct 20, 2024 | Rituximab is a genetically engineered chimeric murine/human monoclonal igg1 kappa antibody directed against... | View |
| M5.001.003 | Trastuzumab – Trastuzumab Biologics | Oct 26, 2023 | Oct 20, 2024 | Trastuzumab is a monoclonal antibody, one of a group of drugs designed to attack specific cancer cells.... | View |
| M5.001.004 | Pegfilgrastim | Sep 20, 2023 | Oct 26, 2023 | Pegfilgrastim is a colony stimulating factor (csf) that acts on hematopoietic cells by binding to specific... | View |
| M5.001.005 | Bevacizumab – Bevacizumab Biologics for Oncologic Uses | Oct 26, 2023 | Oct 20, 2024 | Bevacizumab is a humanized monoclonal antibody directed against vascular endothelial growth factor a... | View |
| M5.001.006 | CSF Hematopoietic Colony Stimulating Factors | Oct 26, 2023 | Oct 20, 2024 | G-csf is classified as a recombinant hematopoietic stimulant. this is not a cancer chemotherapy agent. it is... | View |
