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 |
|---|---|---|---|---|
| 08.001.023 | Erwinaze | Nov 2021 | Asparagine is an amino acid essential for cell growth. it occurs in most cells. the neoplastic cells present... | View |
| 08.001.024 | Correcion de los Trastornos de la refracción | May 2017 | ... | View |
| 08.001.025 | Adoptive Immunotherapy | Oct 2025 | The spontaneous regression of certain cancers (eg, renal cell carcinoma, melanoma) supports the idea that a... | View |
| 08.001.027 | Cellular Immunotherapy For Prostate Cancer | Aug 2025 | Sipuleucel-t (provenge) is a therapeutic agent used to treat asymptomatic or minimally symptomatic,... | View |
| 08.001.028 | Lysis Of Epidural Adhesions | Dec 2020 | Lysis of epidural adhesions involves passing a catheter, either endoscopically or percutaneously, under... | View |
| 08.001.029 | Compression Pumps Treatment of lymphedema and Venous Ulcers | Aug 2025 | Compression pumps are proposed as a treatment for patients with lymphedema who have failed conservative... | View |
| 08.001.030 | Occupational Therapy | Jan 2020 | Occupational therapy is defined as that therapy which promotes the restoration of the ability of a person... | View |
| 08.001.031 | Chemical Peels | Jan 2026 | A chemical peel is a controlled removal of various layers of the skin with the use of a chemical agent. the... | View |
| 08.001.033 | Hematopoietic Cell Transplantation For Plasma Cell Dyscrasias, Including Multiple Myeloma And Poems Syndrome | Feb 2026 | Multiple myeloma (mm) is a systemic malignancy of plasma cells that represents approximately 10% of all... | View |
| 08.001.034 | Dysphagia Therapy | Feb 2026 | Dysphagia, therapy to swallow, is a medical treatment indicated to improve or restore the functions of... | View |
| 08.001.035 | Aquatic Therapy | Sep 2024 | Aquatic therapy is a therapeutic intervention in which the aquatic environment provides flotation increase in... | View |
| 08.001.036 | Hematopoietic Cell Transplantation For Chronic Myeloid Leukemia | Feb 2025 | Chronic myeloid leukemia (cml) is a hematopoietic stem cell disorder characterized by the presence of a... | View |
| 08.001.037 | Hematopoietic Cell Transplantation For Hodgkin Lymphoma | Feb 2025 | Hodgkin lymphoma (hl) results from a clonal expansion of a b-cell lineage, characterized by the presence of... | View |
| 08.001.039 | Extracorporeal Membrane Oxygenation For Adult Conditions | Jun 2025 | Extracorporeal membrane oxygenation (ecmo) provides extracorporeal circulation and physiologic gas exchange... | View |
| 08.001.041 | Applicatiion Of Fluoride (Varnish) | Nov 2019 | Many oral health problems, including dental caries, malocclusion, and fluorosis, begin in childhood and can... | View |
| 08.001.042 | Orthopedic Applications Of Stem Cell Therapy (Including Allografts And Bone Substitutes Used With Autologous Bone Marrow) | Feb 2026 | Mesenchymal stem cells (mscs) have the capability to differentiate into a variety of tissue types, including... | View |
| 08.001.043 | Hematopoietic Cell Transplantation For Acute Lymphoblastic Leukemia | Feb 2025 | Acute lymphoblastic leukemia (all) is a heterogeneous disease with different genetic variations resulting in... | View |
| 08.001.044 | Treatment Of Hyperhidrosis | Jul 2025 | Hyperhidrosis, or excessive sweating, can lead to impairments in psychologic and social functioning. various... | View |
| 08.001.045 | Cranial Electrotherapy Stimulation And Auricular Electrostimulation | May 2026 | Cranial electrotherapy stimulation (ces), also known as cranial electrical stimulation, transcranial... | View |
| 08.001.046 | Electronic Brachytherapy For Nonmelanoma Skin Cancer | Feb 2026 | Electronic brachytherapy is a form of radiotherapy designed to deliver high-dose rate radiation to treat... | View |