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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 |
|---|---|---|---|---|---|
| 02.002.014 | 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 |
| 02.002.017 | Transcoronary Ablation of Septal Hypertrophy (TASH) | Jun 11, 2020 | Policy Archived | Percutaneous transluminal septal myocardial ablation may be considered medically necessary as a treatment of... | View |
| 02.002.018 | Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia | Jun 18, 2024 | Jun 20, 2025 | Progenitor cell therapy, including but not limited to skeletal myoblasts or hematopoietic cells, is... | View |
| 02.002.019 | Catheter Ablation as Treatment for Atrial Fibrillation | Jun 11, 2024 | Jun 20, 2025 | Transcatheter radiofrequency ablation (rfa) or cryoablation to treat atrial fibrillation may be... | View |
| 02.002.020 | Correlated Audioelectric Cardiography | Jul 01, 2024 | Retired | Correlated audioelectric cardiography is considered investigational.... | View |
| 02.002.021 | EVALUACION DE LAS SUBCLASES DE LIPOPROTREI DE ALTA DENSIDAD EN EL DIGNÓSTICO Y MANEJO DE LA ENFERMEDAD CARDIOVASCULAR | Nov 16, 2017 | Policy Archived | La subclasificación de lipoproteínas de alta densidad en el cernimiento, diagnóstico y manejo de... | View |
| 02.002.022 | Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry | Jun 11, 2024 | Jun 20, 2025 | The use of patient-activated or auto-activated external ambulatory event monitors (aems) or continuous... | View |
| 02.002.023 | Wearable Cardioverter Defibrillators | Jun 06, 2024 | Jun 20, 2025 | Use of wearable cardioverter defibrillators (wcds) for the prevention of sudden cardiac death may be... | View |
| 02.002.024 | ELECTROCARDIOGRAFIA DE DERIVACION SENCILLA (SAECG) | Nov 16, 2017 | Policy Archived | La electrocardiografía de derivación sencilla no se considera para pago. su uso como una técnica de... | View |
| 02.002.026 | Computerized 2-Lead resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Desease | Jul 01, 2024 | Retired | Computerized 2-lead resting electrocardiogram analysis (eg, multifunction cardiogram) is considered... | View |
| 02.002.027 | MAPEO ELECTROFISIOLOGICO TRIDIMENSIOL INTRACARDIACO | May 17, 2016 | Policy Archived | ... | View |
| 02.002.028 | Echocardiography | May 08, 2019 | Policy Archived | Stress echocardiography the following are considered medically necessary for stress echo: 1. new,... | View |
| 02.002.029 | Optical Coherence Tomography for Imaging of Coronary Arteries | Mar 29, 2019 | Policy Archived | Optical coherence tomography is considered investigational when used as an adjunct to percutaneous coronary... | View |
| 02.002.030 | CARDIOGRAFIA ACUSTICA | Aug 22, 2017 | Policy Archived | Cardiografía acústica no procede para pago en el diagnóstico de la insuficiencia cardíaca y para la... | View |
| 02.002.031 | Transcatheter Mitral Valve Repair | Jun 14, 2024 | Jun 20, 2025 | Transcatheter mitral valve repair (tmvr) with a device approved by the u.s. food and drug administration... | View |
| 02.002.033 | Ultrafiltration in Decompensated Heart Failure | Jul 06, 2021 | Policy Archived | The use of ultrafiltration is considered investigational in patients with heart... | View |
| 02.002.034 | Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation | Jun 07, 2024 | Jun 20, 2025 | The use of a device with u.s. food and drug administration (fda) approval for percutaneous left atrial... | View |
| 02.002.035 | Myocardial Strain Imaging | Jun 18, 2024 | Jun 20, 2025 | Myocardial strain imaging in individuals who have exposure to medications or radiation that could result in... | View |
