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
PP.002.002 Discontinued Procedures/Reduced Services – Modifiers 73 & 74 Aug 2026 The term "discontinued procedure" designates a surgical or diagnostic procedure provided by a... View
PP.002.004 Split Surgical Package Aug 2026 ... View
PP.002.007 Increased Procedural Services (Modifier 22) May 2026 Description: the term “increased procedural services” designates a service provided by a... View
PP.002.008 Discontinued Procedure May 2026 Description: the term discontinued procedure designates a surgical or diagnostic procedure provided by a... View
PP.002.009 Reduced Services May 2026 As defined in the current procedural terminology (cpt®) book, a reduced service is where a service or... View
PP.002.010 Sleep Studies Jun 2026 This payment policy describes reimbursement guidelines applicable to sleep studies including polysomnography.... View
V5.003.002 Gene Therapies for Sickle Cell Disease Jul 2026 Sickle cell disease is a genetic hemoglobinopathy that results from a genetic variant in the hbb gene... View
V5.003.004 Gene Therapies for Duchenne Muscular Dystrophy Jun 2026 Duchenne muscular dystrophy (dmd) is an inherited disorder that results in progressive muscle weakness and... View