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.

Medical Policies table

ID Title Review Description Access
07.003.010 Small Bowel/Liver And Multivisceral Transplant Sep 2026 This evidence review addresses transplantation and retransplantation of an intestinal allograft in... View
07.003.011 Islet Transplantation Sep 2026 Performed in conjunction with pancreatectomy for chronic pancreatitis, autologous islet transplantation is... View
07.003.012 Amniotic Membrane And Amniotic Fluid May 2026 Several commercially available forms of human amniotic membrane (ham) and amniotic fluid can be administered... View
07.003.013 Composite Tissue Allotransplantation Of The Hand And Face Sep 2026 Composite tissue allotransplantation (also referred to as vascularized composite allotransplantation) is... View
07.003.014 Kidney Transplant Sep 2026 Kidney transplant, a treatment option for end-stage renal disease, involves the surgical removal of a kidney... View
07.004.003 Vascular Endothelial Growth Factor Inhibitors for Sickle Cell Retinopathy Apr 2026 Sickle cell retinopathy is a known complication of sickle cell disease. sickle cell retinopathy is... View
08.001.004 Speech Therapy Jul 2026 Developmental language disorder is the most common developmental disability of childhood, occurring in 5 to... View
08.001.005 Photodynamic Therapy For Choroidal Neovascularization Apr 2026 Verteporfin photodynamic therapy is a treatment modality designed to selectively occlude ocular choroidal... View
08.001.006 Vertebral Axial Decompression May 2026 Vertebral axial decompression applies traction to the vertebral column to reduce intradiscal pressure and, in... View
08.001.007 Dry Needling Of Myofascial Trigger Points May 2026 Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that... View
08.001.009 Low-Level Laser Therapy Jul 2026 Low-level laser therapy (lllt), also called photobiomodulation, is being evaluated to treat various... View
08.001.011 Manipulation Under Anesthesia May 2026 Manipulation under anesthesia consists of a series of mobilization, stretching, and traction procedures... View
08.001.014 Chelation Therapy For Off-Label Uses Mar 2026 Chelation therapy, an established treatment for heavy metal toxicities and transfusional hemosiderosis, has... View
08.001.045 Cranial Electrotherapy Stimulation And Auricular Electrostimulation May 2026 Cranial electrotherapy stimulation (ces), also known as cranial electrical stimulation, transcranial... View
08.001.057 Baroreflex Stimulation Devices Sep 2026 Baroreflex stimulation devices provide electrical stimulation of the baroreceptors in the carotid arteries... View
08.001.059 Focal Treatments For Prostate Cancer Mar 2026 Prostate cancer is the second most common cancer diagnosis men receive in the u.s., and the behavior of... View
08.003.001 Treatment Of Tinnitus Mar 2026 Various nonpharmacologic treatments are being evaluated to improve the symptoms of tinnitus. these approaches... View
08.003.002 Outpatient Pulmonary Rehabilitation Apr 2026 Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life... View
08.003.004 Sensory Integration Therapy and Auditory Therapy Apr 2026 Sensory integration therapy has been proposed as a treatment of developmental disorders in patients with... View
08.003.006 Cardiac Rehabilitation In The Outpatient Setting Apr 2026 Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that... View