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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 |
|---|---|---|---|---|---|
| 02.001.087 | Low-Dose Radiotherapy for Non-Oncologic Indications | Nov 19, 2024 | Nov 20, 2025 | Or (95% ci): 3 mos: 0.69 (0.22 to 2.17) 6 mos: 0.57 (0.18 to 1.81) 12 mos: 1.23 (0.37 to 4.12) mean treatment... | View |
| 02.001.103 | Trigger Point And Tender Point Injections | May 21, 2024 | May 20, 2025 | Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that... | View |
| 02.001.104 | Desensitization Treatment For Peanut Allergies | Jul 10, 2024 | Jul 20, 2025 | While peanut allergy is the most common cause of food allergy among children in the united states, deaths... | View |
| 02.001.105 | Digital Health Technologies: Diagnostic Applications | Sep 10, 2024 | Aug 20, 2025 | Digital health technologies is a broad term that includes categories such as mobile health, health... | View |
| 02.001.106 | High Intensity Laser Therapy for Chronic Pain Conditions | Aug 09, 2024 | Aug 20, 2025 | High-intensity laser therapy (hilt) is a class iv therapeutic non-surgical laser device with a power output... | View |
| 02.002.001 | Percutaneous Transluminal Coronary Angioplasty | Aug 31, 2023 | Policy Archived | Primary percutaneous transluminal coronary angioplasty (ptca), also referred to as direct, immediate, or... | View |
| 02.002.003 | Total Artificial Hearts And Implantable Ventricular Assist Devices | Sep 18, 2024 | Sep 20, 2025 | A ventricular assist device (vad) is mechanical support attached to the native heart and vessels to augment... | View |
| 02.002.004 | Electrocardiography (Ekg, Ecg) | Sep 11, 2024 | Policy Archived | The electrocardiogram (ecg or ekg) is a noninvasive test that is used to reflect underlying heart conditions... | View |
| 02.002.005 | Ecocardiografía | May 06, 2016 | Policy Archived | ... | View |
| 02.002.006 | Prueba De Esfuerzo Con Perfusion Del Miocardio (Stress Test) | Sep 11, 2024 | Policy Archived | ... | View |
| 02.002.007 | EKG de rutina previo a una sedación endovenosa | Jun 22, 2023 | Policy Archived | The electrocardiogram (ecg or ekg) is a noninvasive test that is used to reflect underlying heart conditions... | View |
| 02.002.008 | Ultrasonographic Measurement Of Carotid Intima-Medial Thickness As An Assessment Of Subclinical Atherosclerosis | Jul 18, 2024 | Policy Archived | Complete appendix to guidelines available at http://journals.aace.com. endocr pract. apr 02 2017; 23(4):... | View |
| 02.002.009 | Biventricular Pacemakers (Cardiac Resynchronization Therapy) For The Treatment Of Heart Failure | Jun 10, 2024 | Jun 20, 2025 | Cardiac resynchronization therapy (crt), which consists of synchronized pacing of the left and right... | View |
| 02.002.011 | Catheter Ablation For Cardiac Arrhythmias | Aug 21, 2023 | Policy Archived | Catheter ablation is a technique for eliminating cardiac arrhythmias by selectively destroying a portion of... | View |
| 02.002.012 | Enhanced External Counterpulsation | Jul 15, 2024 | Policy Archived | Enhanced external counterpulsation (eecp) is a noninvasive treatment used to augment diastolic pressure,... | 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 has been investigated in the treatment of peripheral vascular disease,... | View |
| 02.002.015 | Closure Devices For Patent Foramen Ovale And Atrial Septal Defects | Jun 11, 2024 | Jun 20, 2025 | Patent foramen ovale (pfo) and atrial septal defects (asds) are relatively common congenital heart defects... | View |
| 02.002.016 | Cardiac Hemodynamic Monitoring For The Management Of Heart Failure In The Outpatient Setting | Jul 16, 2024 | Jul 20, 2025 | A variety of outpatient cardiac hemodynamic monitoring devices are intended to improve quality of life and... | View |
| 02.002.017 | Transcoronary Ablation Of Septal Hypertrophy (TASH) | Jun 11, 2020 | Policy Archived | Hypertrophic cardiomyopathy is a complex cardiac disease associated with diverse clinical, morphologic, and... | View |
