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 |
|---|---|---|---|---|---|
| 02.001.027 | Percutaneous treatment of fracture Non-Unions or Bone Defects with Autologous Bone Marrow with Demineralized Bone Matrix (DBM) | Apr 02, 2019 | Policy Archived | The percutaneous treatment of fracture non-unions of bone defects with the use of bone marrow aspirate with... | View |
| 02.001.028 | PSORALENS CON LUZ ULTRAVIOLETA A (PUVA) | May 10, 2016 | Policy Archived | Puva se considera para pago en casos de vitíligo y psoriasis severa que no responden a tratamiento... | View |
| 02.001.029 | MIRINGOTOMÍA Y TIMPANOSTOMÍA ASISTIDAS CON LASER | May 06, 2016 | Policy Archived | Timpanostomía asistida por láser con inserción de pet se considera para pago en casos de otitis media... | View |
| 02.001.030 | Actigraphy | Jul 07, 2023 | Jul 20, 2024 | Actigraphy is considered investigational when used as the sole technique to record and analyze body movement,... | View |
| 02.001.031 | Biofeedback as a Treatment of Chronic Pain | Dec 11, 2023 | Dec 20, 2024 | 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 13, 2023 | Nov 20, 2024 | 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 04, 2023 | Dec 20, 2024 | 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, 2023 | Nov 20, 2024 | Sublingual immunotherapy using oralair, grastek, or ragwitek may be considered medically necessary, when... | 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, 2023 | Dec 20, 2024 | 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 11, 2023 | Dec 20, 2024 | 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, 2023 | Dec 20, 2024 | 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 | Algunas formas de vértigo y nistagmo son evidentes sólo con cambios en la posición de la cabeza con... | 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 |
