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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 |
|---|---|---|---|---|---|
| 02.001.074 | 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 |
| 02.001.076 | Fecal Microbiota Transplantation | Dec 11, 2023 | Dec 20, 2024 | 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, 2023 | Dec 20, 2024 | The diagnosis of lumbar radiculopathy is typically made by a combination of suggestive signs and symptoms in... | View |
| 02.001.086 | Targeted Phototherapy and Psoralen with Ultraviolet A for Vitiligo | Jan 08, 2024 | Jan 20, 2025 | Psoralen plus ultraviolet a for the treatment of vitiligo that is not responsive to other forms of... | 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 05, 2023 | Sep 20, 2024 | Prescription digital health technologies for diagnostic application that have received clearance for... | 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 |
| 02.002.002 | Gamma Radiation in the Prevention of Dilation Catheter restenosis Coronary | Jul 01, 2024 | Retired | Intravascular coronary brachytherapy using beta or gamma radiation is considered for payment as treatment of... | View |
| 02.002.003 | Total Artificial Hearts and Implantable Ventricular Assist Devices | Sep 12, 2023 | Sep 20, 2024 | Implantable ventricular assist devices (vads) with u.s. food and drug administration (fda) approval or... | View |
| 02.002.004 | Electrocardiography (EKG, ECG) | Aug 22, 2023 | 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) | Aug 22, 2023 | Policy Archived | Si el cardiólogo sólo supervisa una prueba de esfuerzo cardiovascular, debe usar el código 93016.... | 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 | Jun 18, 2024 | Jun 20, 2025 | 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 10, 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 | Jun 11, 2024 | Jun 20, 2025 | 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 11, 2023 | Aug 20, 2024 | Automated ambulatory blood pressure (bp) monitoring over a 24-hour period may be considered medically... | View |
