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
11.003.140 Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB) May 2025 Multiple biomarkers are being evaluated to predict response to immunotherapy for individuals with cancer.... View
11.003.141 Laboratory Testing Investigational Services Mar 2026 There are numerous commercially available genetic and molecular diagnostic, prognostic, and therapeutic tests... View
11.003.142 Circulating Tumor-Tissue-Modified Viral DNA Testing Apr 2026 This evidence review addresses the use of circulating tumor-tissue-viral modified (ttmv) human papillomavirus... View
13.001.001 Restorative Single Crowns, Inlays And Onlays Oct 2023 A crown, inlay or onlay is the prosthetic construction that is placed fixed in a previously prepared tooth... View
13.002.001 Removable Prostheses; Complete And Partial Removable Dentures Oct 2023 It is an artificial removable device designed to restore the anatomy of one, several or all the teeth,... View
13.002.002 Fixed Prosthesis Oct 2024 Fixed partial denture is a series of crowns that replace one or more of the edentulous spaces. retainers or... View
13.002.003 Other Fixed Partial Dentures Services Oct 2023 They are components that help with the construction of fixed partial dentures when the condition or position... View
13.003.001 Endodontic Retreatment Nov 2020 It is remaking of a contaminated endodontic, in a tooth with a previously root canal treatment. <a... View
13.004.001 Periodontal Surgical Services Sep 2025 The main objective of the periodontal surgical procedures is to be able to preserve the periodontal tissues... View
13.004.002 Periodontal non-Surgical Services Oct 2024 Periodontal non- surgical services include all post-operative care. they are a range of therapeutic... View
13.005.001 Dental Implants Sep 2025 Dental implants are attachments that replace the root function of a tooth that are placed in the edentulous... View
13.005.002 Implant Services; Crowns, bridges (retainers and Pontics) and Prostheses Supported by Implants Sep 2025 The crown on implants is a fixed prosthesis that is placed on an osseointegrated implant. retainers of... View
13.006.001 Visit To Ambulatory Surgical Center And / Or Hospital Nov 2020 When a participating dentist leaves his office to perform dental services in an ambulatory surgical center or... View
13.007.001 Maxillofacial Prosthesis Oct 2024 These are specialized and extensive prosthesis services to replace the loss of a great part of the facial and... View
13.008.001 Frenectomy Oct 2023 It is the surgical procedure of the extirpation, dissection or muscular liberation of the frenulum that... View
13.009.001 Maxillary Obturators Aug 2023 Maxillary obturators are considered a maxillofacial prosthesis. maxillary prosthetic devices are generally... View
13.009.002 Oral Surgical Splint, Impression And Preparation Nov 2020 The oral splints are molds manufactured by the oral and maxillofacial surgeon prior to surgery. these molds... View
13.009.003 Orthognathic Surgery Sep 2025 Are procedures that include surgical manipulation of the maxilla and /or the mandible to restore the correct... View
13.009.004 Temporomandibular Joint Disorder Mar 2026 Temporomandibular joint disorder (tmjd) refers to a group of disorders characterized by pain in the... View
13.010.001 Orthodontic Services Oct 2024 The branch of dentistry that is responsible for the study, prevention, diagnosis and treatment of anomalies... View