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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 is a technique intended to teach patients self-regulation of certain physiologic processes not... | View |
| 02.001.032 | Dynamic Posturography | Mar 12, 2025 | Mar 20, 2026 | Dynamic posturography tests an individual's balance control in situations intended to isolate factors... | 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) is a noninvasive method of delivering electrical stimulation to the... | View |
| 02.001.034 | Endoscopic Radiofrequency Ablation Or Cryoablation For Barrett Esophagus | Dec 02, 2024 | Dec 20, 2025 | In barrett esophagus (be), the normal squamous epithelium is replaced by specialized columnar-type... | View |
| 02.001.036 | Rinomanometria y Rinometria Acustica / Optica | May 06, 2016 | Policy Archived | ... | View |
| 02.001.037 | Sublingual Immunotherapy As A Technique Of Allergen-Specific Therapy | Nov 06, 2024 | Nov 20, 2025 | Sublingual immunotherapy (slit) is a potential alternative to subcutaneous immunotherapy (scit) for providing... | View |
| 02.001.038 | Evaluación cardiovascular por tabla de oscilación (Tilt Table) | May 06, 2016 | Policy Archived | ... | View |
| 02.001.039 | Análisis de la marcha (Gait Anlysis) | Jun 22, 2016 | Policy Archived | ... | View |
| 02.001.041 | Biofeedback For Miscellaneous Indications | Dec 20, 2024 | Dec 20, 2025 | Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes that... | View |
| 02.001.042 | Home Oxygen Therapy | Aug 22, 2023 | Policy Archived | Home oxygen therapy is used to treat and prevent symptoms and manifestations of hypoxemia. home oxygen... | View |
| 02.001.043 | Interventions For Progressive Scoliosis | May 13, 2024 | May 20, 2025 | ... | View |
| 02.001.044 | Biofeedback As A Treatment Of Headache | Dec 09, 2024 | Dec 20, 2025 | Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not... | View |
| 02.001.045 | Light Therapy For Psoriasis | Jan 29, 2021 | Policy Archived | Light therapy for psoriasis includes phototherapy with ultraviolet b (uvb) light boxes, targeted... | View |
| 02.001.046 | Chromoendoscopy As An Adjunct To Colonoscopy | Dec 20, 2024 | Dec 20, 2025 | Chromoendoscopy refers to the use of dyes or stains during endoscopy to enhance tissue differentiation or... | View |
| 02.001.047 | Tratamiento de vertigo paroxistico posicional benigno (BPPV) | Jun 28, 2016 | Policy Archived | ... | View |
| 02.001.048 | Bioimpedance Devices For Detection And Management Of Lymphedema | Feb 10, 2025 | Feb 20, 2026 | Secondary lymphedema may develop following treatment for breast cancer. bioimpedance, which uses resistance... | View |
| 02.001.049 | Hypnosis | Apr 05, 2019 | Policy Archived | Hypnosis is an induced state in which there is an increased amenability and responsiveness to suggestions and... | View |
| 02.001.051 | Orthopedic Applications Of Platelet-Rich Plasma | May 17, 2024 | May 20, 2025 | The use of platelet-rich plasma has been proposed as a treatment for various musculoskeletal conditions and... | View |
| 02.001.052 | Noncontact Ultrasound Treatment For Wounds | Feb 10, 2025 | Feb 20, 2026 | Low-frequency ultrasound in the kilohertz range may improve wound healing. several noncontact low-frequency... | View |
| 02.001.053 | Ingestible Ph And Pressure Capsule | Dec 28, 2020 | Policy Archived | An ingestible ph and pressure-sensing capsule (smartpill gi monitoring system) measures ph, pressure, and... | View |
