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 |
|---|---|---|---|---|
| 02.002.040 | Transcatheter Tricuspid Valve Repair or Replacement | Jun 2025 | Transcatheter tricuspid valve repair or replacement is an emerging alternative to surgical therapy for... | View |
| 02.003.002 | Hematopoietic Cell Transplantation For Epithelial Ovarian Cancer | Feb 2026 | The use of hematopoietic cell transplantation (hct) has been investigated to treat individuals with... | View |
| 02.003.003 | Hematopoietic Cell Transplantation In The Treatment Of Germ Cell Tumors | Feb 2025 | Description- intro therapy for germ cell tumors is generally dictated by several factors, including disease... | View |
| 02.003.005 | Galleta Gliadel | Aug 2017 | ... | View |
| 02.003.006 | Hematopoietic Cell Transplantation For Miscellaneous Solid Tumors In Adults | Feb 2026 | Hematopoietic cell transplantation (hct) is an established treatment for certain hematologic malignancies and... | View |
| 02.003.007 | Hematopoietic Cell Transplantation For Solid Tumors Childhood | Feb 2026 | Hematopoietic cell transplantation (hct) is a procedure in which hematopoietic stem cells are infused to... | View |
| 02.003.008 | Transcatheter Arterial Chemoembolization To Treat Primary Or Metastatic Liver Malignancies | Aug 2025 | Transcatheter arterial chemoembolization (tace) of the liver is a proposed alternative to conventional... | View |
| 02.003.011 | Quimioterapia Celulas Madres en Cancer de Mama | Aug 2017 | ... | View |
| 02.003.015 | RASTREO DEL TUMOR DURANTE LA RADIOTERAPIA | Oct 2016 | ... | View |
| 02.003.016 | Infusión de leucocitos alogenéicas para malignidades hematológicas que recuren | Nov 2017 | ... | View |
| 02.003.019 | Hyperthermic Intraperitoneal Chemotherapy For Select Intra-Abdominal And Pelvic Malignancies | Aug 2025 | Cytoreductive surgery (crs) includes peritonectomy (ie, peritoneal stripping) procedures and multivisceral... | View |
| 02.003.020 | Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema | Dec 2025 | Surgery and radiotherapy for breast cancer can lead to lymphedema and are some of the most common causes of... | View |
| 02.003.021 | Tumor-Infiltrating Lymphocytes for Advanced Melanoma | Sep 2025 | The spontaneous regression of certain cancers (eg, melanoma) supports the idea that an affected... | View |
| 02.004.001 | Esophageal Ph Monitoring | Dec 2025 | Esophageal ph monitoring, using wired or wireless devices, can record the ph of the lower esophagus for a... | View |
| 02.004.002 | Wireless Capsule Endoscopy To Diagnose Disorders Of The Small Bowel, Esophagus, And Colon | Jan 2026 | The wireless capsule endoscopy (ce) uses a noninvasive device to visualize segments of the gastrointestinal... | View |
| 02.004.005 | Transesophageal Endoscopic Therapies For Gastroesophageal Reflux Disease | Jan 2026 | Transesophageal endoscopic therapies are being developed for the treatment of gastroesophageal reflux disease... | View |
| 02.004.006 | Transanal Radiofrequency Treatment Of Fecal Incontinence | Dec 2021 | Radiofrequency energy has been investigated as a minimally invasive treatment of fecal incontinence, in a... | View |
| 02.004.007 | Análisis por fibra optica de polipos colorectales | May 2016 | ... | View |
| 02.004.048 | Nerve Fiber Density Measurement | Jan 2026 | Skin biopsy is used to assess the density of epidermal (intraepidermal) and sweat gland (sudomotor) nerve... | View |
| 02.004.049 | Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome | Nov 2025 | Percutaneous electrical nerve field stimulation involves the transmission of electrical impulses to cranial... | View |