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 | Hypertrophic cardiomyopathy is a complex cardiac disease associated with diverse clinical, morphologic, and... | View |
| 02.002.018 | Progenitor Cell Therapy For The Treatment Of Damaged Myocardium Due To Ischemia | Jul 18, 2024 | Policy Archived | Progenitor cell therapy describes the use of multipotent cells of various cell lineages (autologous or... | View |
| 02.002.019 | Catheter Ablation As Treatment For Atrial Fibrillation | Jun 05, 2025 | Apr 20, 2026 | Atrial fibrillation frequently arises from an abnormal focus at or near the junction of the pulmonary veins... | View |
| 02.002.021 | Evaluación de las subclases de lipoproteína de alta densidad en el diagnóstico | Nov 16, 2017 | Policy Archived | ... | View |
| 02.002.022 | Ambulatory Event Monitors And Mobile Cardiac Outpatient Telemetry | Jun 05, 2025 | Jun 20, 2026 | ... | View |
| 02.002.023 | Wearable Cardioverter Defibrillators | Jun 06, 2025 | Jun 20, 2026 | A wearable cardioverter defibrillator (wcd) is a temporary, external device that is an alternative to an... | View |
| 02.002.024 | Electrocardiografia de derivacion sencilla (SAECG) | Nov 16, 2017 | Policy Archived | ... | View |
| 02.002.027 | Mapeo Electrofisiologico Tridimensional Intracardiaco | May 17, 2016 | Policy Archived | ... | View |
| 02.002.028 | Echocardiography | May 08, 2019 | Policy Archived | ... | View |
| 02.002.029 | Optical Coherence Tomography For Imaging Of Coronary Arteries | Mar 29, 2019 | Policy Archived | Optical coherence tomography (oct) is an imaging technique that uses near-infrared light to image the... | View |
| 02.002.030 | Cardiografia Acustica | Aug 22, 2017 | Policy Archived | ... | View |
| 02.002.031 | Transcatheter Mitral Valve Repair | Jun 06, 2025 | Jun 06, 2026 | Transcatheter mitral valve repair (tmvr) is an alternative to surgical therapy for mitral regurgitation (mr).... | View |
| 02.002.033 | Ultrafiltration In Decompensated Heart Failure | Jul 06, 2021 | Policy Archived | Ultrafiltration is used to remove excess fluid from patients with volume overload and heart failure. it... | View |
| 02.002.034 | Percutaneous Left Atrial Appendage Closure Devices For Stroke Prevention In Atrial Fibrillation | Jun 06, 2025 | Jun 20, 2026 | Stroke prevention in patients with atrial fibrillation (af) is an important goal of treatment. treatment with... | View |
| 02.002.035 | Myocardial Strain Imaging | Jun 19, 2025 | Jun 20, 2026 | Myocardial strain refers to the deformation (shortening, lengthening, or thickening) of the myocardium... | View |
| 02.002.036 | Phrenic Nerve Stimulation For Central Sleep Apnea | Jun 19, 2025 | Jun 20, 2026 | Central sleep apnea (csa) is characterized by sleep-disordered breathing due to diminished or absent... | View |
| 02.002.037 | Leadless Cardiac Pacemakers | Jun 19, 2025 | Jun 20, 2026 | Pacemakers are intended to be used as a substitute for the heart’s intrinsic pacing system to correct... | View |
| 02.002.038 | Intravascular Lithotripsy | Oct 24, 2024 | Oct 20, 2025 | Intravascular lithotripsy (ivl) delivers unfocused, circumferential, pulsatile mechanical energy to safely... | View |
| 02.002.039 | Treatment of Congenital Athymia | Oct 07, 2024 | Oct 20, 2025 | Congenital athymia is an ultra rare condition in which infants are born without a functioning thymus. the... | View |
| 02.002.040 | Transcatheter Tricuspid Valve Repair or Replacement | Jun 05, 2025 | Jun 20, 2026 | Transcatheter tricuspid valve repair or replacement is an emerging alternative to surgical therapy for... | View |
