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
08.003.012 Hippotherapy May 2024 Hippotherapy, also referred to as equine-assisted therapy, describes a treatment strategy that uses equine... View
08.003.013 Functional Neuromuscular Electrical Stimulation Apr 2026 Functional electrical stimulation (fes) involves the use of an orthotic device or exercise equipment with... View
09.001.001 Consultas Aug 2017 ... View
09.001.002 Hospice Services At Home Nov 2020 ... View
09.001.003 Tratamiento de la degeneracion macular con colocacion de retaane en area yuxtoes Sep 2016 ... View
09.001.004 Endothelial Keratoplasty May 2025 Endothelial keratoplasty also referred to as posterior lamellar keratoplasty, is a form of corneal... View
09.003.001 Corneal Topography/Computer-Assisted Corneal Topography/ Photokeratoscopy May 2024 Computer-assisted corneal topography (also called photokeratoscopy or videokeratography) provides a... View
09.003.002 Retinal Prosthesis May 2024 A retinal prosthesis replaces lost photoreceptor function by transmitting external images to an array of... View
09.003.003 Fotocoagulación del drusen macular Sep 2016 ... View
09.003.004 Intraocular Radiotherapy For Age-Related Macular Degeneration Apr 2026 Intraocular radiation, including brachytherapy, proton beam therapy, and stereotactic radiotherapy, are being... View
09.003.005 Intravitreal And Punctum Corticosteroid Implants May 2026 An intravitreal implant is a drug delivery system, injected or surgically implanted in the vitreous of the... View
09.003.006 Intravitreal Angiogenesis Inhibitors For Retinal Vascular Conditions Feb 2026 ... View
09.003.007 Contact Lenses For The Pediatric Population Nov 2021 It is estimated that 40.9 million people over the age of 18 in the united states (one in six adults) wear... View
09.003.008 Intravitreal Angiogenesis Inhibitors For Choroidal Vascular Conditions Feb 2026 Angiogenesis inhibitors (eg, ranibizumab, bevacizumab, pegaptanib, aflibercept) are being evaluated for the... View
09.003.009 Eyelid Thermal Pulsation For The Treatment Of Dry Eye Syndrome Apr 2026 Thermal pulsation is a treatment option for meibomian gland dysfunction. meibomian gland dysfunction is... View
09.003.010 Aqueous Shunts And Stents For Glaucoma Dec 2025 Glaucoma surgery is intended to reduce intraocular pressure (iop) when the target iop cannot be reached using... View
09.003.011 Keratoprosthesis Apr 2026 A keratoprosthesis, consisting of a central optic held in a cylindrical frame, is an artificial cornea... View
09.003.012 Orthoptic Training For The Treatment Of Vision Or Learning May 2024 Orthoptic training refers to techniques designed to correct accommodative and convergence insufficiency (or... View
09.003.013 Retinal Telescreening For Diabetic Retinopathy May 2025 Retinopathy telescreening and risk assessment with digital imaging systems are proposed as an alternative to... View
09.003.014 Corneal Collagen Cross-Linking Mar 2026 Corneal collagen cross-linking is a photochemical procedure approved by the u.s. food and drug administration... View