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Políticas Médicas
Las políticas médicas son documentos que definen el reconocimiento de cubierta para tecnologías, procedimientos y tratamientos. Las declaraciones de necesidad médica en las políticas, sobre si una tecnología, procedimiento, tratamiento, suplido, equipo, medicamento u otro servicio mejora el resultado en la salud de la población para la cual dicha tecnología o tratamiento fue diseñado se basan en evidencia científica, estudios clínicos y opiniones profesionales de nuestros proveedores y de las organizaciones médicas reconocidas.
Cada documento desplegado en este sitio Web se provee con propósitos informativos solamente y no es una autorización, explicación de beneficios o un contrato. El recibir beneficios está sujeto a la satisfacción de todos los términos y condiciones de la cubierta. La tecnología médica cambia constantemente y nos reservamos el derecho de revisar y actualizar nuestras políticas periódicamente.
| ID | Título | Última Revisión | Siguiente Revisión | Descripción | Acceso |
|---|---|---|---|---|---|
| 11.003.140 | Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB) | May 12, 2024 | May 20, 2025 | Braf v600 variant testing braf v600 variant testing of tumor tissue to select individuals for immune... | Ver |
| 11.003.141 | Laboratory Testing Investigational Services | Nov 17, 2023 | Nov 20, 2024 | All tests listed in this policy are considered investigational as there is insufficient evidence to determine... | Ver |
| 12.002.001 | Regional Anesthesia in Vaginal Birth | Mar 31, 2019 | Policy Archived | Local infiltration and pudendal blockade are considered part of the management of labor and are included in... | Ver |
| 13.001.001 | Restorative Single Crowns, Inlays and Onlays | Oct 26, 2023 | Policy Archived | Single crowns, inlays or onlays require predetermination and must be accompanied by periapical radiographic... | Ver |
| 13.002.001 | Removable Prostheses; Complete and Partial Removable Dentures | Oct 26, 2023 | Policy Archived | All removable dentures; complete or partial, require predetermination in the line of buisiness advantage... | Ver |
| 13.002.002 | Fixed Prosthesis | Oct 26, 2023 | Oct 20, 2024 | All fixed bridges require predetermination. please refer to the section of predetermination of benefits for... | Ver |
| 13.002.003 | Other Fixed Partial Dentures Services | Oct 26, 2023 | Policy Archived | Rules and limitations for other fixed partial dentures services: 1. code d6940 stress breaker and... | Ver |
| 13.003.001 | Endodontic Retreatment | Nov 11, 2020 | Policy Archived | If it is necessary to make a retreatment before 5 years, a predetermination is required and this must be... | Ver |
| 13.004.001 | Periodontal Surgical Services | Oct 26, 2023 | Oct 20, 2024 | 1.a history of a surgical code will limit for payment the approval of a second surgical code in a same... | Ver |
| 13.004.002 | Periodontal non-Surgical Services | Oct 26, 2023 | Oct 20, 2024 | All periodontal treatments need predetermination of benefits and the treatment plan for evaluation, should be... | Ver |
| 13.005.001 | Dental Implants | Oct 26, 2023 | Oct 20, 2024 | 1. there must be bone integration of the implant, to be able move to the prosthesis phase of crowns,... | Ver |
| 13.005.002 | Implant Services; Crowns, bridges (retainers and Pontics) and Prostheses Supported by Implants | Oct 26, 2023 | Oct 20, 2024 | 1. crowns should be predetermined and are subject to the corresponding coinsurances and caps. 2. the... | Ver |
| 13.006.001 | Visit to Ambulatory Surgical Center and / or Hospital | Nov 11, 2020 | Policy Archived | Code d9420 requires predeterminationand the required documents are; (a) patient’s diagnostic (b)... | Ver |
| 13.007.001 | Maxillofacial Prosthesis | Oct 26, 2023 | Oct 20, 2024 | The maxillofacial prosthesis services require predetermination. 1. the maxillofacial prosthesis services... | Ver |
| 13.008.001 | Frenectomy | Oct 26, 2023 | Policy Archived | 1.requires predetermination. 2.the predetermination must be accompanied by the evaluation and... | Ver |
| 13.009.001 | Maxillary Obturators | Aug 22, 2023 | Policy Archived | These services are covered for all patients that have a palatal or nasopharyngeal defect that impairs the... | Ver |
| 13.009.002 | Oral Surgical Splint, Impression and Preparation | Nov 11, 2020 | Policy Archived | This service is considered as surgical guidance and stabilization for orthognathic surgery (surgical... | Ver |
| 13.009.003 | Orthognathic Surgery | Oct 26, 2023 | Oct 20, 2024 | These surgeries may be recognized for payment as long as one of the following criteria is met:... | Ver |
| 13.009.004 | Temporomandibular Joint Disorder | Mar 05, 2024 | Mar 20, 2025 | Diagnostic procedures the following diagnostic procedures may be considered medically necessary in the... | Ver |
| 13.010.001 | Orthodontic Services | Oct 26, 2023 | Oct 20, 2024 | 1. that sufficient functional disability be present as a result of disease, trauma, congenital anomalies... | Ver |
