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
02.001.076 Fecal Microbiota Transplantation Dec 2025 Fecal microbiota transplantation (fmt) involves the administration of intestinal microorganisms via the... View
02.001.077 Epidural Steroid Injections For Neck Or Back Pain Dec 2025 Epidural steroid injections (esis) are a treatment for neck or back pain that has not responded to... View
02.001.086 Targeted Phototherapy And Psoralen With Ultraviolet A For Vitiligo Jan 2026 Vitiligo is an idiopathic skin disorder that causes depigmentation of sections of skin, most commonly on the... View
02.001.087 Low-Dose Radiotherapy for Non-Oncologic Indications Dec 2025 Or (95% ci): 3 mos: 0.69 (0.22 to 2.17) 6 mos: 0.57 (0.18 to 1.81) 12 mos: 1.23 (0.37 to 4.12) mean treatment... View
02.001.103 Trigger Point And Tender Point Injections May 2026 Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that... View
02.001.105 Digital Health Technologies: Diagnostic Applications Mar 2026 Digital health technologies is a broad term that includes categories such as mobile health, health... View
02.001.106 High Intensity Laser Therapy for Chronic Pain Conditions Aug 2025 High-intensity laser therapy (hilt) is a class iv therapeutic non-surgical laser device with a power output... View
02.002.001 Percutaneous Transluminal Coronary Angioplasty Jan 2025 Primary percutaneous transluminal coronary angioplasty (ptca), also referred to as direct, immediate, or... View
02.002.003 Total Artificial Hearts And Implantable Ventricular Assist Devices Oct 2025 A ventricular assist device (vad) is mechanical support attached to the native heart and vessels to augment... View
02.002.004 Electrocardiography (Ekg, Ecg) Aug 2025 The electrocardiogram (ecg or ekg) is a noninvasive test that is used to reflect underlying heart conditions... View
02.002.005 Ecocardiografía May 2016 ... View
02.002.006 Prueba De Esfuerzo Con Perfusion Del Miocardio (Stress Test) Jun 2025 ... View
02.002.007 EKG de rutina previo a una sedación endovenosa Jun 2023 The electrocardiogram (ecg or ekg) is a noninvasive test that is used to reflect underlying heart conditions... View
02.002.008 Ultrasonographic Measurement Of Carotid Intima-Medial Thickness As An Assessment Of Subclinical Atherosclerosis Jul 2024 Complete appendix to guidelines available at http://journals.aace.com. endocr pract. apr 02 2017; 23(4):... View
02.002.009 Biventricular Pacemakers (Cardiac Resynchronization Therapy) For The Treatment Of Heart Failure Jun 2025 Cardiac resynchronization therapy (crt), which consists of synchronized pacing of the left and right... View
02.002.011 Catheter Ablation For Cardiac Arrhythmias Nov 2025 Catheter ablation is a technique for eliminating cardiac arrhythmias by selectively destroying a portion of... View
02.002.012 Enhanced External Counterpulsation Jul 2024 Enhanced external counterpulsation (eecp) is a noninvasive treatment used to augment diastolic pressure,... View
02.002.013 Automated Ambulatory Blood Pressure Monitoring For Diagnosis Of Hypertension In Patients With Elevated Office Blood Pressure Aug 2025 Ambulatory blood pressure (bp) monitors (24-hour sphygmomanometers) are portable devices that continually... View
02.002.014 End-Diastolic Pneumatic Compression Boot As A Treatment Of Peripheral Vascular Disease Or Lymphedema Nov 2022 End-diastolic pneumatic compression has been investigated in the treatment of peripheral vascular disease,... View
02.002.015 Closure Devices For Patent Foramen Ovale And Atrial Septal Defects Jun 2025 Patent foramen ovale (pfo) and atrial septal defects (asds) are relatively common congenital heart defects... View