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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 |
|---|---|---|---|---|---|
| 02.001.054 | Alcohol Injections For Treatment Of Peripheral Neuromas | Jul 08, 2023 | Policy Archived | Morton neuroma is a common and painful compression neuropathy of the dorsal foot that is also referred to as... | View |
| 02.001.055 | Automated Point-Of-Care Nerve Conduction Tests | Dec 08, 2020 | Policy Archived | Portable devices have been developed to provide point-of-care (poc) nerve conductions studies (ncss). these... | View |
| 02.001.056 | Oncologic Application For Opdivo (Nivolumab) | Oct 24, 2024 | Oct 20, 2025 | Opdivo is a programmed death receptor-1 (pd-1) blocking antibody indicated for the treatment of: •... | View |
| 02.001.059 | Pembrolizumab (Keytruda) | Oct 24, 2024 | Oct 20, 2025 | Pembrolizumab is a highly selective anti-pd-1 humanized monoclonal antibody which inhibits programmed cell... | View |
| 02.001.061 | (Obinutuzumab) Gazyva | Oct 24, 2024 | Oct 20, 2025 | Gazyva (obinutuzumab) is an antineoplastic agent, anti-cd20 monoclonal antibody. for individuals who have nhl... | View |
| 02.001.063 | Intra-Articular Hyaluronan Injections For Osteoarthritis | May 06, 2024 | May 20, 2025 | Intra-articular injection of hyaluronan into osteoarthritic joints is proposed to reduce pain and improve... | View |
| 02.001.065 | Polysomnography For Non-Respiratory Sleep Disorders | Jul 08, 2024 | Jul 20, 2025 | Polysomnography records multiple physiologic parameters relevant to sleep. video recording may also be... | View |
| 02.001.066 | Navigated Transcranial Magnetic Stimulation | Aug 27, 2024 | Policy Archived | Navigated transcranial magnetic stimulation (ntms) is a noninvasive imaging method for evaluating eloquent... | View |
| 02.001.067 | Neurofeedback | Aug 06, 2024 | Policy Archived | Description – intro neurofeedback describes techniques for providing feedback about neuronal activity,... | View |
| 02.001.068 | Biofeedback As A Treatment Of Urinary Incontinence In Adults | Nov 06, 2024 | Nov 20, 2025 | Biofeedback is a technique to teach patients self-regulation of physiologic processes not generally... | View |
| 02.001.069 | Dermatologic Applications Of Photodynamic Therapy | Jan 14, 2025 | Jan 20, 2026 | Photodynamic therapy (pdt) refers to light activation of a photosensitizer to generate highly reactive... | View |
| 02.001.070 | Laser Treatment For Onychomycosis | Jan 20, 2025 | Jan 20, 2026 | Onychomycosis is a common fungal infection of the nail. currently available treatments for onychomycosis,... | View |
| 02.001.071 | Vestibular Function Testing | Mar 03, 2025 | Mar 20, 2026 | Dizziness, vertigo, and balance impairments can arise from a loss of vestibular function. a number of... | View |
| 02.001.072 | Biofeedback As A Treatment Of Fecal Incontinence Or Constipation | Dec 03, 2024 | Dec 20, 2025 | Biofeedback is a technique to teach patients self-regulation of physiological processes not generally... | View |
| 02.001.073 | Neural Therapy | Dec 20, 2024 | Dec 20, 2025 | Neural therapy involves the injection of a local anesthetic such as procaine or lidocaine into various... | View |
| 02.001.074 | Confocal Laser Endomicroscopy | Dec 20, 2024 | Dec 20, 2025 | Confocal laser endomicroscopy (cle), also known as confocal fluorescent endomicroscopy and optical... | View |
| 02.001.075 | Peroral Endoscopic Myotomy For Treatment Of Esophageal Achalasia | Dec 09, 2024 | Dec 20, 2025 | Esophageal achalasia is characterized by reduced numbers of neurons in the esophageal myenteric plexuses and... | View |
| 02.001.076 | Fecal Microbiota Transplantation | Dec 09, 2024 | Dec 20, 2025 | Fecal microbiota transplantation (fmt) involves the administration of intestinal microorganisms via the... | View |
| 02.001.077 | Epidural Steroid Injections For Neck Or Back Pain | Dec 20, 2024 | Dec 20, 2025 | Epidural steroid injections (esis) are a treatment for neck or back pain that has not responded to... | View |
| 02.001.086 | Targeted Phototherapy And Psoralen With Ultraviolet A For Vitiligo | Jan 14, 2025 | Jan 20, 2026 | Vitiligo is an idiopathic skin disorder that causes depigmentation of sections of skin, most commonly on the... | View |
