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
11.003.134 Molecular Testing For Variants Associated With Hereditary Ovarian Cancer Sep 2025 It is estimated that approximately 20% of women presenting for assessment for hereditary ovarian cancer (oc)... View
11.003.135 Genetic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer Jul 2026 Multiple biomarkers are being evaluated to select treatment with an fda-approved targeted treatments for... View
11.003.136 Tumor-informed Circulating Tumor DNA Testing for Cancer Management Aug 2026 This evidence review addresses the use of tumor-informed circulating tumor dna (ctdna) testing for cancer... View
11.003.137 Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1) Sep 2025 Hereditary diffuse gastric cancer (hdgc, sometimes called signet ring gastric cancer) is an autosomal... View
11.003.138 Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, Microsatellite Instability/Mismatch Repair, Tumor Mutational Burden) Oct 2025 Biomarker-targeted therapy has shown a clear survival benefit in individuals with metastatic prostate cancer.... View
11.003.139 Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, Tumor Mutational Burden, Microsatellite Instability/Mismatch Repair) Oct 2025 Biomarker-targeted therapy has shown a clear survival benefit in patients with ovarian cancer. typically, the... View
11.003.140 Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB) Aug 2026 Multiple biomarkers are being evaluated to predict response to immunotherapy for individuals with cancer.... View
11.003.141 Laboratory Testing Investigational Services Mar 2026 There are numerous commercially available genetic and molecular diagnostic, prognostic, and therapeutic tests... View
11.003.142 Circulating Tumor-Tissue-Modified Viral DNA Testing Apr 2026 This evidence review addresses the use of circulating tumor-tissue-viral modified (ttmv) human papillomavirus... View
12.002.001 Regional Anesthesia In Vaginal Birth Mar 2019 Regional anesthesia is one that is selectively applied to a specific region of the body. under the term of... View
13.001.001 Restorative Single Crowns, Inlays And Onlays Oct 2023 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 2023 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 2024 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 2023 They are components that help with the construction of fixed partial dentures when the condition or position... View
13.003.001 Endodontic Retreatment Nov 2020 It is remaking of a contaminated endodontic, in a tooth with a previously root canal treatment. <a... View
13.004.001 Periodontal Surgical Services Aug 2026 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 2024 Periodontal non- surgical services include all post-operative care. they are a range of therapeutic... View
13.005.001 Dental Implants Aug 2026 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 Aug 2026 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 2020 When a participating dentist leaves his office to perform dental services in an ambulatory surgical center or... View