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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 |
|---|---|---|---|---|---|
| 02.003.004 | Hematopoietic Cell Transplantation For Central Nervous System Embryonal Tumors And Ependymoma | Feb 18, 2025 | Feb 20, 2026 | High-dose chemotherapy with hematopoietic cell transplantation (hct) has been investigated as a possible... | View |
| 02.003.006 | Hematopoietic Cell Transplantation For Miscellaneous Solid Tumors In Adults | Feb 04, 2025 | Feb 20, 2026 | Hematopoietic cell transplantation (hct) is an established treatment for certain hematologic malignancies and... | View |
| 02.003.007 | Hematopoietic Cell Transplantation For Solid Tumors Childhood | Feb 13, 2025 | Feb 20, 2026 | Hematopoietic cell transplantation (hct) is a procedure in which hematopoietic stem cells are infused to... | 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 18, 2025 | Feb 20, 2026 | Myelodysplastic syndromes (mds) and myeloproliferative neoplasms refer to a heterogeneous group of clonal... | View |
| 02.003.015 | RASTREO DEL TUMOR DURANTE LA RADIOTERAPIA | Oct 28, 2016 | Policy Archived | ... | View |
| 02.003.016 | Infusión de leucocitos alogenéicas para malignidades hematológicas que recuren | Nov 16, 2017 | Policy Archived | ... | View |
| 02.003.019 | Hyperthermic Intraperitoneal Chemotherapy For Select Intra-Abdominal And Pelvic Malignancies | Aug 19, 2024 | Aug 20, 2025 | Cytoreductive surgery (crs) includes peritonectomy (ie, peritoneal stripping) procedures and multivisceral... | View |
| 02.003.020 | Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema | Dec 09, 2024 | Dec 20, 2025 | Surgery and radiotherapy for breast cancer can lead to lymphedema and are some of the most common causes of... | View |
| 02.003.021 | Tumor-Infiltrating Lymphocytes for Advanced Melanoma | Sep 20, 2024 | Sep 20, 2025 | The spontaneous regression of certain cancers (eg, melanoma) supports the idea that an affected... | View |
| 02.004.001 | Esophageal Ph Monitoring | Dec 12, 2024 | Dec 20, 2025 | Esophageal ph monitoring, using wired or wireless devices, can record the ph of the lower esophagus for a... | View |
| 02.004.002 | Wireless Capsule Endoscopy To Diagnose Disorders Of The Small Bowel, Esophagus, And Colon | 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 | Análisis por fibra optica de polipos colorectales | May 16, 2016 | Policy Archived | ... | View |
| 02.004.048 | Nerve Fiber Density Measurement | Jan 20, 2025 | Jan 20, 2026 | Skin biopsy is used to assess the density of epidermal (intraepidermal) and sweat gland (sudomotor) nerve... | View |
| 02.004.049 | Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome | Sep 10, 2024 | Jun 20, 2025 | Percutaneous electrical nerve field stimulation involves the transmission of electrical impulses to cranial... | View |
| 02.005.001 | Pulmonary Function Test | Nov 04, 2022 | Policy Archived | Pulmonary function tests are those that measure the ability of the lungs to use air. these are done with the... | View |
| 02.005.002 | ASISTENCIA Y MANEJO DEL VENTILADOR MECANICO (VENTILATION ASSIST AND MANAGEMENT) | Aug 22, 2017 | Policy Archived | ... | View |
| 02.005.003 | Oximetry | Jan 31, 2020 | Policy Archived | Pulse oximetry is a non-invasive way to measure oxygen levels in the blood. it may be used in a home, office... | View |
