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 |
|---|---|---|---|---|
| 02.001.051 | Orthopedic Applications Of Platelet-Rich Plasma | May 2026 | The use of platelet-rich plasma has been proposed as a treatment for various musculoskeletal conditions and... | View |
| 02.001.052 | Noncontact Ultrasound Treatment For Wounds | Feb 2026 | Low-frequency ultrasound in the kilohertz range may improve wound healing. several noncontact low-frequency... | View |
| 02.001.053 | Ingestible Ph And Pressure Capsule | Dec 2020 | An ingestible ph and pressure-sensing capsule (smartpill gi monitoring system) measures ph, pressure, and... | View |
| 02.001.054 | Alcohol Injections For Treatment Of Peripheral Neuromas | Jul 2023 | Morton neuroma is a common and painful compression neuropathy of the dorsal foot that is also referred to as... | View |
| 02.001.055 | Automated Point-Of-Care Nerve Conduction Tests | Dec 2020 | Portable devices have been developed to provide point-of-care (poc) nerve conductions studies (ncss). these... | View |
| 02.001.056 | Oncologic application for OPDIVO® (nivolumab) | Sep 2025 | Opdivo® (nivolumab) is a pd-1 inhibitor indicated in multiple solid tumors and hematologic malignancies.... | View |
| 02.001.059 | KEYTRUDA® (pembrolizumab) | May 2026 | Pembrolizumab (keytruda®) is a programmed death receptor-1 (pd-1) blocking antibody that enhances t-cell... | View |
| 02.001.061 | (Obinutuzumab) Gazyva | Oct 2024 | Gazyva (obinutuzumab) is an antineoplastic agent, anti-cd20 monoclonal antibody. for individuals who have nhl... | View |
| 02.001.063 | Intra-Articular Hyaluronan Injections For Osteoarthritis | May 2026 | Intra-articular injection of hyaluronan into osteoarthritic joints is proposed to reduce pain and improve... | View |
| 02.001.065 | Polysomnography For Non-Respiratory Sleep Disorders | Jul 2025 | Polysomnography records multiple physiologic parameters relevant to sleep. video recording may also be... | View |
| 02.001.066 | Navigated Transcranial Magnetic Stimulation | Aug 2024 | Navigated transcranial magnetic stimulation (ntms) is a noninvasive imaging method for evaluating eloquent... | View |
| 02.001.067 | Neurofeedback | Aug 2024 | Description – intro neurofeedback describes techniques for providing feedback about neuronal activity,... | View |
| 02.001.068 | Biofeedback As A Treatment Of Urinary Incontinence In Adults | Dec 2025 | Biofeedback is a technique to teach individuals self-regulation of physiologic processes not generally... | View |
| 02.001.069 | Dermatologic Applications Of Photodynamic Therapy | Jan 2026 | Photodynamic therapy (pdt) refers to light activation of a photosensitizer to generate highly reactive... | View |
| 02.001.070 | Laser Treatment For Onychomycosis | Jan 2026 | Onychomycosis is a common fungal infection of the nail. currently, available treatments for onychomycosis,... | View |
| 02.001.071 | Vestibular Function Testing | Mar 2026 | Dizziness, vertigo, and balance impairments can arise from a loss of vestibular function. a number of... | View |
| 02.001.072 | Biofeedback As A Treatment Of Fecal Incontinence Or Constipation | Dec 2025 | Biofeedback is a technique to teach individuals self-regulation of physiological processes not generally... | View |
| 02.001.073 | Neural Therapy | Dec 2025 | Neural therapy involves the injection of a local anesthetic such as procaine or lidocaine into various... | View |
| 02.001.074 | Confocal Laser Endomicroscopy | Dec 2025 | Confocal laser endomicroscopy (cle), also known as confocal fluorescent endomicroscopy and optical... | View |
| 02.001.075 | Peroral Endoscopic Myotomy For Treatment Of Esophageal Achalasia | Dec 2025 | Esophageal achalasia is characterized by reduced numbers of neurons in the esophageal myenteric plexuses and... | View |