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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 |
|---|---|---|---|---|---|
| 02.001.053 | Ingestible pH and Pressure Capsule | Dec 28, 2020 | Policy Archived | Measurement of gastrointestinal transit times, including gastric emptying and colonic transit times, using an... | View |
| 02.001.054 | Alcohol Injections for Treatment of Peripheral Neuromas | Jul 08, 2023 | Policy Archived | Alcohol injections are considered investigational for treatment of morton... | 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 | Policy Archived | This policy statement applies to clinical review performed for pre-service (prior approval, precertification,... | View |
| 02.001.059 | Pediatric Central Nervous System Cancers – Pediatric Diffuse High-Grade Gliomas | Oct 24, 2024 | Oct 20, 2025 | Keytruda may be considered medically necessary in patients with: labeled indications: biliary tract... | View |
| 02.001.061 | Gazyva® (obinutuzumab) | Oct 24, 2024 | Oct 20, 2025 | Obinutuzumab intravenous obinutuzumab (gazyva) may be considered medically necessary to treat patients... | View |
| 02.001.063 | Intra-Articular Hyaluronan Injections for Osteoarthritis | May 06, 2024 | May 20, 2025 | Intra-articular hyaluronan injections of the knee are considered investigational. intra-articular... | View |
| 02.001.065 | Polysomnography for Non-Respiratory Sleep Disorders | Jul 08, 2024 | Jul 20, 2025 | Polysomnography (psg) and a multiple sleep latency test performed on the day after the psg may be... | View |
| 02.001.066 | Navigated Transcranial Magnetic Stimulation | Aug 27, 2024 | Policy Archived | Navigated transcranial magnetic stimulation is considered investigational for all purposes, including but... | View |
| 02.001.067 | Neurofeedback | Aug 06, 2024 | Policy Archived | Neurofeedback is... | 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 may be considered medically necessary as a treatment of: nonhyperkeratotic actinic... | View |
| 02.001.070 | Laser Treatment of Onychomycosis | Jan 20, 2025 | Jan 20, 2026 | Laser treatment of onychomycosis is... | View |
| 02.001.071 | Vestibular Function Testing | Mar 05, 2024 | Mar 20, 2025 | Vestibular function testing using an electronystagmography and videonystagmography testing batteries, caloric... | View |
| 02.001.072 | Biofeedback as a Treatment of Fecal Incontinence or Constipation | Dec 03, 2024 | Dec 20, 2025 | Biofeedback for constipation in adults may be considered medically necessary for patients with... | View |
| 02.001.073 | Neural Therapy | Dec 20, 2024 | Dec 20, 2025 | Neural therapy is considered investigational for all... | 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 and Gastroparesis | Dec 09, 2024 | Dec 20, 2025 | Peroral endoscopic myotomy is considered investigational as a treatment for pediatric and adult esophageal... | View |
| 02.001.076 | Fecal Microbiota Transplantation | Dec 09, 2024 | Dec 20, 2025 | Fecal microbiota transplantation using a compounded product (see policy guidelines) may be... | View |
| 02.001.077 | Epidural Steroid Injections for Neck or Back Pain | Dec 20, 2024 | Dec 20, 2025 | Epidural steroid injections performed with fluoroscopic guidance may be considered medically necessary for... | View |
