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 |
|---|---|---|---|---|---|
| 02.005.001 | 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 |
| 02.005.003 | OXIMETRY | Jan 31, 2020 | Policy Archived | Oximetry is considered for payment when: it is performed at the physician’s office or at the patient’s... | View |
| 02.005.004 | OXIMETRIA CONTINUA | May 10, 2016 | Policy Archived | Esta medición se considera para pago si se realiza en pacientes: cuya saturación de oxígeno está... | View |
| 02.005.005 | TERAPIA CON INHIBIDORES DE ALFA 1 PROTEISA | May 10, 2016 | Policy Archived | Se considera para pago en pacientes adultos con: enfisema, que tengan una deficiencia de -1-at demostrada... | View |
| 02.005.006 | Diagnosis of Obstructive Sleep Apnea Syndrome | Jan 08, 2024 | Jul 20, 2024 | A single unattended (unsupervised) home sleep apnea test with a minimum of 3 recording channels with the... | View |
| 02.005.007 | ESPIROMETRIA CASERA | Aug 22, 2017 | Policy Archived | La espirometría casera o espirometría ambulatoria no se considera para pago. la escasez de datos no... | View |
| 02.005.008 | SÍNDROME DE OBSTRUCCION EN EL CONDUCTO AEREO SUPERIOR | Nov 16, 2017 | Policy Archived | El tratamiento de síndrome de obstrucción en el conducto aéreo superior con cpap (continuous positive... | View |
| 02.005.009 | Home Non-Invasive Positive Airway Pressure Devices for the Treatment of Respiratory Insufficiency and Failure | Apr 15, 2024 | Oct 20, 2024 | For individuals with chronic obstructive pulmonary disease (copd) without significant hypercapnia (paco2 52... | View |
| 02.005.010 | Medical Management of Obstructive Sleep Apnea Syndrome | Jan 22, 2024 | Jul 20, 2024 | Auto-adjusting positive airway pressure (apap) may be considered medically necessary for the titration of... | View |
| 02.007.001 | Repetitive Nerve Stimulation | Jun 22, 2023 | Policy Archived | Triple-s considers for payment "repetitive nerve stimulation (rns)" when criteria for medically necessity... | View |
| 02.007.003 | ELECTROENCEFALOGRAFIA CON EKG | May 10, 2016 | Policy Archived | Triple-s considerará para pago el estudio electroencefalográfico en aquellas situaciones y condiciones en... | View |
| 02.007.004 | Somatosensory evoked potential studies visual/auditory | Nov 10, 2021 | Policy Archived | Triple-s will consider for payment studies of evoked potentials when they are performed with the purpose of:... | View |
| 02.007.006 | TOPOGRAFIA CEREBRAL (“TOPOGRAPHIC BRAIN MAPPING”) | Nov 16, 2017 | Policy Archived | La topografía cerebral no se considera para... | View |
| 02.007.007 | Digital Electroencephalography | Jun 23, 2023 | Policy Archived | Digital eeg is considered for payment: ▪ for early detection of intracranial complications during surgery... | View |
| 02.007.008 | Electroencephalograms (EEG) | Jul 11, 2023 | Policy Archived | Transmission of the eeg by telephone, radio, or cable is considered medically necessary when the closest... | View |
| 02.007.009 | Autonomic Nervous System Testing | Jul 18, 2023 | Jul 20, 2024 | Autonomic nervous system testing, consisting of a battery of tests in several domains (see policy guidelines... | View |
| 02.007.011 | Neuropsychological Testing | Aug 22, 2023 | Policy Archived | Neuropsychological tests are considered for payment in the following situations if they are administered by a... | View |
| 02.009.002 | CUIDADO CRITICO PEDIATRICO | May 10, 2016 | Policy Archived | Los servicios de cuidado pediátrico crítico se proveen (pero no están limitados) a pacientes con fallo en... | View |
| 02.009.003 | Neonatal Auditory Screening | Jun 23, 2023 | Policy Archived | The neonatal hearing screening program establishes performing hearing screening tests on all infants before... | View |
