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 |
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02.001.021 | Inyecciones intratimpánicas en el tratamiento de la enfermedad de Meniere o perd | Jul 01, 2024 | Retired Policy | Definition meniere's disease, also known as endolymphatic hydrops, is a middle ear disorder of unknown... | View |
02.001.022 | Quantitative Sensory Testing | Jul 15, 2024 | Jul 20, 2025 | Quantitative sensory testing (qst) systems are used for the noninvasive assessment and quantification of... | View |
02.001.024 | Onda de choque extracorporea en el tratamiento de la enfermedad de peyronie | Dec 31, 1969 | NA | Na... | View |
02.001.025 | High Intensity Laser Therapy | Nov 09, 2022 | Policy Archived | Conventional laser therapy has been used in europe for more than 25 years. up to this moment, this therapy... | View |
02.001.026 | Electromyography And Nerve Conduction Studies | Sep 09, 2024 | Jul 20, 2025 | Electromyography (emg) and nerve conduction studies (ncs), also collectively known as an electrodiagnostic... | View |
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 standard treatment of problem fractures or osseous defects has been an autologous cancellous bone graft... | View |
02.001.028 | Psoralens con luz ultravioleta A (PUVA) | Dec 31, 1969 | NA | Na... | View |
02.001.029 | MIRINGOTOMÍA Y TIMPANOSTOMÍA ASISTIDAS CON LASER | Dec 31, 1969 | NA | Na... | View |
02.001.030 | Actigraphy | Aug 06, 2024 | Jul 20, 2025 | Actigraphy refers to the assessment of body movement activity patterns using devices, typically placed on the... | View |
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 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) 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 | Dec 31, 1969 | NA | Na... | 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) | Dec 31, 1969 | NA | Na... | View |
02.001.039 | Análisis de la marcha (Gait Anlysis) | Dec 31, 1969 | NA | Na... | 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 | Of safety and probable benefit (sspb): the tether vertebral body tethering system. 2019;... | View |