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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 |
|---|---|---|---|---|---|
| 02.003.003 | Policy Num: 02.003.003 | Feb 12, 2024 | Feb 20, 2025 | 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 04, 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 22, 2024 | Aug 20, 2025 | Transcatheter arterial chemoembolization (tace) of the liver is a proposed alternative to conventional... | 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 | Esta política describe el uso de tiempo real, el rastreo de los objetivos dentro de la fracción durante la... | View |
| 02.003.016 | INFUSIÓN DE LEUCOCITOS ALOGENEICOS PARA MALIGNIDADES HEMATOLÓGICAS QUE RECURREN DESPUÉS DE UN TRASPLANTE DE CÉLULAS ALOGENEICAS | Nov 16, 2017 | Policy Archived | Donante de infusión de linfocitos (dli), también conocido como leucocitos de donantes o infusión capa... | View |
| 02.003.019 | Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies | Aug 19, 2024 | Aug 20, 2025 | 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 09, 2024 | Dec 20, 2025 | Axillary reverse mapping/reverse lymphatic mapping performed during sentinel lymph node biopsy to prevent... | View |
| 02.003.021 | Tumor-Infiltrating Lymphocytes for Advanced Melanoma | Sep 20, 2024 | Sep 20, 2025 | Tumor-infiltrating lymphocyte (til) therapy with an indication approved by the u.s. food and drug... | View |
| 02.004.001 | Esophageal pH Monitoring | Dec 12, 2024 | Dec 20, 2025 | 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 07, 2025 | Jan 20, 2026 | The wireless capsule endoscopy (ce) uses a noninvasive device to visualize segments of the gastrointestinal... | View |
| 02.004.005 | Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease | Jan 07, 2025 | Jan 20, 2026 | Transesophageal endoscopic therapies are being developed for the treatment of gastroesophageal reflux disease... | View |
| 02.004.006 | Transanal Radiofrequency Treatment of Fecal Incontinence | Dec 09, 2021 | Policy Archived | Radiofrequency energy has been investigated as a minimally invasive treatment of fecal incontinence, in a... | 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 |
| 02.004.048 | Nerve Fiber Density Measurement | Jan 20, 2025 | Jan 20, 2026 | Skin biopsy with epidermal nerve fiber density measurement for the diagnosis of small fiber neuropathy may be... | View |
| 02.004.049 | Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome | Sep 10, 2024 | Jun 20, 2025 | Percutaneous electrical nerve field stimulation for abdominal pain in individuals with irritable bowel... | View |
| 02.005.001 | Pulmonary Function Test | Nov 04, 2022 | Policy Archived | The following specific tests for evaluating pulmonary diseases are considered for payment: pulmonary... | View |
| 02.005.002 | ASISTENCIA Y MANEJO DEL VENTILADOR MECANICO (VENTILATION ASSIST AND MAGEMENT) | Aug 22, 2017 | Policy Archived | Se consideran para pago estos servicios en el tratamiento de las siguientes enfermedades: síndrome guillain... | View |
