News
Food as an agent of change
Read more
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 |
|---|---|---|---|---|---|
| 02.001.031 | Biofeedback as a Treatment of Chronic Pain | Dec 09, 2024 | Dec 20, 2025 | Biofeedback as a treatment of chronic pain, including but not limited to low back pain,... | View |
| 02.001.032 | Dynamic Posturography | Mar 14, 2024 | Mar 20, 2025 | Dynamic posturography tests a patient’s balance control in situations intended to isolate factors that... | View |
| 02.001.033 | Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | Nov 19, 2024 | Nov 20, 2025 | Transcranial magnetic stimulation (tms) of the brain using an fda-cleared device and modality, which can... | View |
| 02.001.034 | Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus | Dec 02, 2024 | Dec 20, 2025 | Radiofrequency ablation may be considered medically necessary for the treatment of barrett esophagus with... | View |
| 02.001.036 | RINOMANOMETRIA Y RINOMETRIA ACUSTICA / OPTICA | May 06, 2016 | Policy Archived | Rinimetría y rinomería acústica/óptica no proceden para pago. ningún estudio ha demostrado que el uso de... | View |
| 02.001.037 | Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy | Nov 06, 2024 | Nov 20, 2025 | Sublingual immunotherapy using oralair®, grastek®, or ragwitek® may be considered medically... | View |
| 02.001.038 | EVALUACION CARDIOVASCULAR POR TABLA DE OSCILACION (TILT TABLE) | May 06, 2016 | Policy Archived | La utilización de la prueba de la mesa o tabla de oscilación para el diagnostico de síncope no se... | View |
| 02.001.039 | ANÁLISIS DE LA MARCHA (GAIT ALISYS) | Jun 22, 2016 | Policy Archived | El análisis comprensivo de la marcha se considera para pago como una herramienta en la planificación de la... | View |
| 02.001.041 | Biofeedback for Miscellaneous Indications | Dec 20, 2024 | Dec 20, 2025 | Biofeedback is considered investigational as a treatment of the following miscellaneous conditions:... | View |
| 02.001.042 | HOME OXYGEN THERAPY | Aug 22, 2023 | Policy Archived | Stationary oxygen equipment and home oxygen therapy are covered for payment when the following criteria is... | View |
| 02.001.043 | Interventions for Progressive Scoliosis | May 13, 2024 | May 20, 2025 | A rigid cervical-thoracic-lumbar-sacral or thoracic-lumbar-sacral orthosis may be considered medically... | View |
| 02.001.044 | Biofeedback as a Treatment of Headache | Dec 09, 2024 | Dec 20, 2025 | Biofeedback may be considered medically necessary as part of the overall treatment plan for migraine and... | View |
| 02.001.045 | Light Therapy for Psoriasis | Jan 29, 2021 | Policy Archived | Psoralen plus ultraviolet a for the treatment of severe, disabling psoriasis, which is not responsive to... | View |
| 02.001.046 | Chromoendoscopy as an Adjunct to Colonoscopy | Dec 20, 2024 | Dec 20, 2025 | Chromoendoscopy is considered investigational as an adjunct to diagnostic or surveillance colonoscopy.... | View |
| 02.001.047 | TRATAMIENTO DE VERTIGO PAROXISTICO POSICIOL BENIGNO (BPPV) | Jun 28, 2016 | Policy Archived | La terapia vestibular se considera para pago en el tratamiento del vértigo paroxístico posicional benigno... | View |
| 02.001.048 | Bioimpedance Devices for Detection and Management of Lymphedema | Feb 09, 2024 | Feb 20, 2025 | Devices using bioimpedance (bioelectrical impedance spectroscopy) are considered investigational for use in... | View |
| 02.001.049 | Hypnosis | Apr 05, 2019 | Policy Archived | Hypnosis is considered medically necessary when used to control acute or chronic pain, or as an adjunct to... | View |
| 02.001.050 | Chronic Intermittent Intravenous Insulin Therapy | Mar 18, 2024 | Mar 20, 2025 | Chronic intermittent intravenous insulin therapy is considered... | View |
| 02.001.051 | Orthopedic Applications of Platelet-Rich Plasma | May 17, 2024 | May 20, 2025 | Use of platelet-rich plasma is considered investigational for all orthopedic indications. this includes,... | View |
| 02.001.052 | Noncontact Ultrasound Treatment for Wounds | Feb 12, 2024 | Feb 20, 2025 | Noncontact ultrasound treatment for wounds is... | View |
