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.

Medical Policies table

ID Title Review Description Access
11.003.095 Genotype-Guided Tamoxifen Treatment Sep 2024 Tamoxifen is prescribed as a component of adjuvant endocrine therapy to prevent endocrine receptor-positive... View
11.003.096 Miscellaneous Genetic And Molecular Diagnostic Tests Aug 2024 There are numerous commercially available genetic and molecular diagnostic, prognostic, and therapeutic tests... View
11.003.097 Gene Expression Profiling For Cutaneous Melanoma Jun 2026 Laboratory tests have been developed that detect the expression of different genes in pigmented lesions or... View
11.003.098 Use Of Common Genetic Variants (Single Nucleotide Variants) To Predict Risk Of Nonfamilial Breast Cancer Nov 2025 Several single nucleotide variants (snvs), which are single base-pair variations in the dna sequence of the... View
11.003.099 Circulating Tumor Dna For Management Of Non-Small-Cell Lung Cancer (Liquid Biopsy) Dec 2021 ... View
11.003.100 Dna-Based Testing For Adolescent Idiopathic Scoliosis Mar 2021 Adolescent idiopathic scoliosis (ais) is a disease of unknown etiology that causes mild-to-severe spinal... View
11.003.101 Genetic Testing For Alpha 1 – Antitrypsin Deficiency Feb 2026 Alpha1-antitrypsin deficiency (aatd) is an autosomal recessive genetic disorder that results in decreased... View
11.003.102 Genetic Testing For Neurofibromatosis Feb 2026 Neurofibromatoses are autosomal dominant genetic disorders associated with tumors of the peripheral and... View
11.003.103 Gene Therapy For Inherited Retinal Dystrophy Feb 2025 Inherited retinal dystrophy can be caused by recessive variants in the rpe65 gene. patients with biallelic... View
11.003.104 Genetic Testing For Lipoprotein(A) Variant(S) As A Decision Aid For Aspirin Treatment Dec 2021 Lipoprotein(a) (lpa) is a lipid-rich particle similar to low-density lipoprotein and has been determined to... View
11.003.105 Microarray-Based Gene Expression Profile Testing For Multiple Myeloma Risk Stratification Nov 2025 Multiple myeloma is a genetically complex and invariably fatal disease. a host of well-characterized factors... View
11.003.106 Genetic Testing For Heterozygous Familial Hypercholesterolemia Nov 2025 Complete appendix to guidelines available at http://journals.aace.com. endocr pract. apr 02 2017; 23(4):... View
11.003.107 Genetic Testing For Hereditary Pancreatic Cancer Mar 2026 Pancreatic cancer is the fourth leading cause of cancer death in the united states, accounting for 8.3% of... View
11.003.108 Measurement Of Serum Antibodies To Selected Biologic Agent Dec 2025 Biologic agents used to treat autoimmune diseases include infliximab, adalimumab, vedolizumab, and... View
11.003.109 Human Leukocyte Antigen Testing For Celiac Disease Dec 2025 Celiac disease (cd) is currently diagnosed by serology, medical history, and response to a gluten-free diet,... View
11.003.110 Genetic Testing For Statin-Induced Myopathy Dec 2025 Hmg-coa reductase inhibitors, or statins, which are widely used to treat hypercholesterolemia, can cause... View
11.003.111 Next Generation Sequencing For The Assessment Of Measurable Residual Disease Jan 2026 Measurable residual disease (mrd), also known as minimal residual disease, refers to residual clonal cells in... View
11.003.130 Acupuncture For Pain Management, Nausea And Vomiting, And Opioid Dependence Dec 2025 Acupuncture describes a group of procedures intended to stimulate anatomical points with the goal of... View
11.003.131 Sphenopalatine Ganglion Block For Headache Dec 2025 Chronic migraine and severe headaches are common conditions and the available treatments are not universally... View
11.003.133 Serologic Genetic And Molecular Screening For Colorectal Cancer Jan 2026 ... View