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 |
|---|---|---|---|---|---|
| 02.001.051 | Orthopedic Applications of Platelet-Rich Plasma | May 19, 2023 | May 20, 2024 | Use of platelet-rich plasma is considered investigational for all orthopedic indications. this includes,... | View |
| 02.001.052 | Noncontact Ultrasound Treatment for Wounds | Feb 12, 2024 | Feb 20, 2025 | Noncontact ultrasound treatment for wounds is... | View |
| 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 07, 2023 | Jul 20, 2024 | 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 | Automated point-of-care nerve conduction tests are considered investigational.... | View |
| 02.001.056 | Oncologic application for OPDIVO® (nivolumab) | Dec 14, 2023 | Oct 20, 2024 | This policy statement applies to clinical review performed for pre-service (prior approval, precertification,... | View |
| 02.001.059 | KEYTRUDA® (pembrolizumab) | Dec 14, 2023 | Oct 20, 2024 | Keytruda may be considered medically necessary in patients with: labeled indications: melanoma:... | View |
| 02.001.061 | Gazyva® (obinutuzumab) | Oct 26, 2023 | Oct 20, 2024 | Obinutuzumab intravenous obinutuzumab (gazyva) may be considered medically necessary to treat patients... | View |
| 02.001.063 | Intra-Articular Hyaluronan Injections for Osteoarthritis | May 03, 2023 | May 20, 2024 | Intra-articular hyaluronan injections of the knee are considered investigational. intra-articular... | View |
| 02.001.065 | Polysomnography for Non-Respiratory Sleep Disorders | Jul 03, 2023 | Jul 20, 2024 | 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 | Jul 03, 2023 | Jul 20, 2024 | Navigated transcranial magnetic stimulation is considered investigational for all purposes, including but not... | View |
| 02.001.067 | Neurofeedback | Jul 07, 2023 | Jul 20, 2024 | Neurofeedback is considered... | View |
| 02.001.068 | Biofeedback as a Treatment of Urinary Incontinence in Adults | Sep 05, 2023 | Sep 20, 2024 | Biofeedback in the outpatient setting is considered investigational as a treatment of urinary incontinence in... | View |
| 02.001.069 | Dermatologic Applications of Photodynamic Therapy | Jan 08, 2024 | Jan 20, 2025 | Photodynamic therapy may be considered medically necessary as a treatment of: nonhyperkeratotic actinic... | View |
| 02.001.070 | Laser Treatment of Onychomycosis | Jan 22, 2024 | Jan 20, 2025 | Laser treatment of onychomycosis is... | View |
| 02.001.071 | Vestibular Function Testing | Mar 06, 2023 | Mar 06, 2024 | 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 04, 2023 | Dec 20, 2024 | Biofeedback for constipation in adults may be considered medically necessary for patients with... | View |
| 02.001.073 | Neural Therapy | Dec 20, 2023 | Dec 20, 2024 | Neural therapy is considered investigational for all... | View |
| 02.001.074 | Confocal Laser Endomicroscopy | Dec 20, 2023 | Dec 20, 2024 | Use of confocal laser endomicroscopy is considered... | View |
| 02.001.075 | Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis | Dec 11, 2023 | Dec 20, 2024 | Peroral endoscopic myotomy is considered investigational as a treatment for pediatric and adult esophageal... | View |
