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 |
|---|---|---|---|---|
| 02.001.028 | Psoralens con luz ultravioleta A (PUVA) | May 2016 | ... | View |
| 02.001.029 | MIRINGOTOMÍA Y TIMPANOSTOMÍA ASISTIDAS CON LASER | May 2016 | ... | View |
| 02.001.030 | Actigraphy | Jul 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 2025 | Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not... | View |
| 02.001.032 | Dynamic Posturography | Mar 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 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 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 2016 | ... | View |
| 02.001.037 | Sublingual Immunotherapy As A Technique Of Allergen-Specific Therapy | Nov 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 2016 | ... | View |
| 02.001.039 | Análisis de la marcha (Gait Anlysis) | Jun 2016 | ... | View |
| 02.001.041 | Biofeedback For Miscellaneous Indications | Dec 2025 | Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes that... | View |
| 02.001.042 | Home Oxygen Therapy | Aug 2023 | 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 2026 | ... | View |
| 02.001.044 | Biofeedback As A Treatment Of Headache | Dec 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 2021 | Light therapy for psoriasis includes phototherapy with ultraviolet b (uvb) light boxes, targeted... | View |
| 02.001.046 | Chromoendoscopy As An Adjunct To Colonoscopy | Dec 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 2016 | ... | View |
| 02.001.048 | Bioimpedance Devices For Detection And Management Of Lymphedema | Aug 2025 | Secondary lymphedema may develop following treatment for breast cancer. bioimpedance, which uses resistance... | View |
| 02.001.049 | Hypnosis | Apr 2019 | Hypnosis is an induced state in which there is an increased amenability and responsiveness to suggestions and... | View |