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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 |
|---|---|---|---|---|---|
| 02.002.036 | 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 19, 2023 | Jun 20, 2024 | The micra™ vr or aveir™ (see policy guidelines) single-chamber transcatheter pacing system may be... | View |
| 02.003.002 | Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer | Feb 06, 2024 | Feb 20, 2025 | Autologous and allogeneic hematopoietic cell transplantation are considered investigational to treat advanced... | View |
| 02.003.003 | Policy Num: 02.003.003 | Feb 12, 2024 | Feb 20, 2024 | Single autologous hematopoietic cell transplantation (hct) may be considered medically necessary as salvage... | View |
| 02.003.004 | Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma | Feb 20, 2024 | Feb 20, 2025 | Embryonal tumors of the central nervous system autologous hematopoietic cell transplantation autologous... | View |
| 02.003.006 | Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults | Feb 07, 2024 | Feb 20, 2025 | Autologous or allogeneic hematopoietic cell transplant is considered investigational for the following... | View |
| 02.003.007 | Hematopoietic Cell Transplantation for Solid Tumors of Childhood | Feb 12, 2024 | Feb 20, 2025 | Autologous hematopoietic cell transplantation may be considered medically necessary for: initial... | View |
| 02.003.008 | Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies | Aug 11, 2023 | Aug 20, 2024 | Transcatheter arterial chemoembolization of the liver may be considered medically necessary: to treat... | View |
| 02.003.009 | TERMOTERAPIA DE MICROONDA PARA CANCER DE MAMA | Nov 16, 2017 | Policy Archived | Tratamiento no se considera para pago, ya que no ha sido aprobado por... | View |
| 02.003.013 | Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias | Mar 05, 2021 | Policy Archived | Allogeneic hematopoietic cell transplantation is considered medically necessary for select patients with... | View |
| 02.003.014 | Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms | Feb 20, 2024 | Feb 20, 2025 | Myeloablative allogeneic hematopoietic cell transplantation (allo-hct) may be considered medically... | View |
| 02.003.015 | RASTREO DEL TUMOR DURANTE LA RADIOTERAPIA | Oct 28, 2016 | Policy Archived | El rastreo intrafraccionario en tiempo real para ajustar dosis o para el monitoreo del movimiento de la... | View |
| 02.003.016 | INFUSIÓN DE LEUCOCITOS ALOGENEICOS PARA MALIGNIDADES HEMATOLÓGICAS QUE RECURREN DESPUÉS DE UN TRASPLANTE DE CÉLULAS ALOGENEICAS | Jun 20, 2011 | Oct 16, 2017 | Donantes de infusión de linfocitos procede para pago después de trasplante-alogeneico hematopoyético de... | View |
| 02.003.019 | Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies | Aug 09, 2023 | Aug 20, 2024 | Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (hipec) at the time of surgery may be... | View |
| 02.003.020 | AxIllary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema | Dec 12, 2023 | Dec 20, 2024 | Axillary reverse mapping/reverse lymphatic mapping performed during sentinel lymph node biopsy to prevent... | View |
| 02.004.001 | Esophageal pH Monitoring | Dec 12, 2023 | Dec 20, 2024 | Esophageal ph monitoring using a catheter or wireless-based system may be considered medically... | View |
| 02.004.002 | Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders | Jan 03, 2024 | Jan 20, 2025 | Wireless capsule endoscopy of the small bowel may be considered medically necessary for the following... | View |
| 02.004.005 | Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease | Jan 03, 2024 | Jan 20, 2025 | Transoral incisionless fundoplication (ie, esophyx) is considered investigational as a treatment of... | View |
| 02.004.006 | Transanal Radiofrequency Treatment of Fecal Incontinence | Dec 09, 2021 | Policy Archived | Transanal radiofrequency therapy is considered investigational as a treatment of fecal... | View |
| 02.004.007 | ALISIS POR FIBRA OPTICA DE POLIPOS COLORECTALES | May 16, 2016 | Policy Archived | El análisis de pólipos colorectales por medio de fibra óptica no se considera para pago. el significado... | View |
