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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 |
|---|---|---|---|---|---|
| 02.001.086 | 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 |
| 02.001.087 | Low-Dose Radiotherapy for Non-Oncologic Indications | Nov 19, 2024 | Nov 20, 2025 | Low-dose radiotherapy is considered investigational for the treatment of osteoarthritis. low-dose... | View |
| 02.001.103 | Trigger Point and Tender Point Injections | May 21, 2024 | May 20, 2025 | Trigger point injections with anesthetic and/or corticosteroid may be considered medically necessary for the... | View |
| 02.001.104 | Desensitization Treatment for Peanut Allergies | Jul 10, 2024 | Jul 20, 2025 | The use of peanut (arachis hypogaea) allergen powder-dnfp is considered investigational for all... | View |
| 02.001.105 | Digital Health Technologies: Diagnostic Applications | Sep 10, 2024 | Aug 20, 2025 | Prescription digital health technologies for diagnostic application that have received clearance for... | View |
| 02.001.106 | High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell’s Palsy | Aug 09, 2024 | Aug 20, 2025 | High intensity laser therapy (hilt) for treatment of chronic musculoskeletal pain is considered... | View |
| 02.002.001 | Percutaneous Transluminal Coronary Angioplasty | Aug 31, 2023 | Policy Archived | Percutaneous coronary transluminal angioplasty is considered for payment in the treatment of acute myocardial... | View |
| 02.002.003 | Total Artificial Hearts and Implantable Ventricular Assist Devices | Sep 18, 2024 | Sep 20, 2025 | Destination therapy implantable ventricular assist devices (vads) with u.s. food and drug administration... | View |
| 02.002.004 | Electrocardiography (EKG, ECG) | Sep 11, 2024 | Policy Archived | 1. ekg services are covered diagnostic tests when there are documented signs and symptoms or other clinical... | View |
| 02.002.005 | ECOCARDIOGRAFIA POR DOPPLER | May 06, 2016 | Policy Archived | Esta tecnología no invasiva se considera para pago, en adultos y niños para medir gasto cardiaco, velocidad... | View |
| 02.002.006 | Prueba de Esfuerzo con Perfusion del Miocardio (Stress Test) | Sep 11, 2024 | Policy Archived | En la prueba de esfuerzo (cardiovascular “stress test”) se induce una angina cardiaca mediante el aumento... | View |
| 02.002.007 | Routine EKG Prior To IV Sedation & Other Indications | Jun 22, 2023 | Policy Archived | Triple-s considers for payment an ekg (code 93000) prior to a ambulatory procedure and under intravenous... | View |
| 02.002.008 | Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis | Jul 18, 2024 | Policy Archived | Ultrasonographic measurement of carotid intima-media thickness as a technique for identifying subclinical... | View |
| 02.002.009 | Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure | Jun 06, 2024 | Jun 20, 2025 | Biventricular pacemakers with or without an accompanying implantable cardiac defibrillator (ie, a combined... | View |
| 02.002.011 | Catheter Ablation for Cardiac Arrhythmias | Aug 21, 2023 | Policy Archived | Catheter ablation may be considered medically necessary for the treatment of supraventricular... | View |
| 02.002.012 | Enhanced External Counterpulsation | Jul 15, 2024 | Policy Archived | Enhanced external counterpulsation is considered investigational for all indications, including but not... | View |
| 02.002.013 | Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure | Aug 22, 2024 | Aug 20, 2025 | Ambulatory blood pressure (bp) monitors (24-hour sphygmomanometers) are portable devices that continually... | View |
| 02.002.014 | End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema | Nov 28, 2022 | Policy Archived | End-diastolic pneumatic compression boots are considered investigational as a treatment of peripheral... | View |
| 02.002.015 | Closure Devices for Patent Foramen Ovale and Atrial Septal Defects | Jun 11, 2024 | Jun 20, 2025 | The percutaneous transcatheter closure of a patent foramen ovale using a device that has been approved by the... | View |
| 02.002.016 | Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting | Jul 16, 2024 | Jul 20, 2025 | In the ambulatory care and outpatient setting, cardiac hemodynamic monitoring for the management of heart... | View |
