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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 |
|---|---|---|---|---|---|
| 02.002.017 | 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 | Jul 18, 2024 | Policy Archived | 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 |
| 02.002.021 | 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, 2016 | Policy Archived | La electrocardiografía de derivación sencilla no se considera para pago. su uso como una técnica de... | View |
| 02.002.027 | MAPEO ELECTROFISIOLOGICO TRIDIMENSIOL INTRACARDIACO | May 17, 2016 | Policy Archived | El uso de un sistema de mapeo electrofisiológico intracardiaco tridimensional se considera para pago en las... | 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 | Sep 24, 2024 | Aug 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 | Stroke prevention in patients with atrial fibrillation (af) is an important goal of treatment. treatment with... | 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 |
| 02.002.036 | Phrenic Nerve Stimulation for Central Sleep Apnea | Jun 10, 2024 | Jun 20, 2025 | The use of phrenic nerve stimulation for central sleep apnea is considered investigational in all situations.... | View |
| 02.002.037 | Leadless Cardiac Pacemakers | Jun 18, 2024 | Jun 20, 2025 | The micra™ vr or aveir™ (see policy guidelines) single-chamber transcatheter pacing system may be... | View |
| 02.002.038 | Coronary Intravascular Lithotripsy | Oct 23, 2024 | Oct 20, 2025 | There is not enough research to support the use of coronary intravascular lithotripsy in inviduals with... | View |
| 02.002.039 | Treatment of Congenital Athymia | Oct 07, 2024 | Oct 20, 2025 | Revised allogeneic processed thymus tissue-agdc is considered medically necessary for pediatric... | View |
| 02.003.002 | Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer | Feb 04, 2025 | Feb 20, 2026 | Autologous and allogeneic hematopoietic cell transplantation are considered investigational to treat advanced... | View |
