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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.
| ID | Title | Last Review | Next Review | Description | Access |
|---|---|---|---|---|---|
| 04.002.001 | TRATAMIENTO DEL SINDROME DE TRANSFUSION DE FETO A FETO UTILIZANDO AMNIOREDUCCION Y/O CIRUGIA FETOSCOPICA ASISTIDA POR LASER | Dec 13, 2017 | Policy Archived | Reducción de líquido amniótico y/o terapia de coagulación por ablación con láser se considera para pago... | View |
| 04.002.002 | Fetal Surgery for Prenatally Diagnosed Malformations | Dec 08, 2022 | Policy Archived | Vesicoamniotic shunting as a treatment of urinary tract obstruction may be considered medically necessary in... | View |
| 04.002.004 | GENDER AFFIRMING SURGERY | Oct 24, 2024 | Oct 20, 2025 | Gender affirming surgery is considered medically necessary for the treatment of individuals with gender... | View |
| 04.002.005 | Infertility Treatment | Oct 26, 2023 | Policy Archived | Evaluation and treatment of infertility is considered medicaly necessary and maybe submitted for... | View |
| 05.001.002 | SEVELAMER (REGEL, RENVELA) y FOSRENOL | May 10, 2016 | Policy Archived | Se considera para pago el uso de sevelamer en pacientes de enfermedad renal de último estadío ó diálisis... | View |
| 05.001.004 | Botulinum Toxin | Nov 04, 2024 | Nov 20, 2025 | The use of botulinum toxin may be considered medically necessary for the following:... | View |
| 05.001.005 | Off Label Use of Human Growth Hormone | Nov 14, 2024 | Nov 20, 2025 | Off-label use of recombinant human growth hormone (gh) therapy may be considered medically necessary for... | View |
| 05.001.006 | Recombinant And Autologous Platelet-Derived Growth Factors For Wound Healing And Other Non‒Orthopedic Conditions | Feb 13, 2025 | Feb 20, 2026 | The use of blood-derived growth factors, including recombinant platelet-derived growth factors (pdgfs) and... | View |
| 05.001.007 | HEPATITIS-C CRONICA (PEG-INTRON & REBETOL) | May 16, 2016 | Policy Archived | Triple-s cubrirá medicamentos para el tratamiento de infección crónica de hepatitis-c a los asegurados que... | View |
| 05.001.008 | Immunoglobulin Therapy | Dec 05, 2024 | Nov 20, 2025 | Immunoglobulins are derived from human donor plasma and used to treat an array of disorders, including... | View |
| 05.001.009 | Infliximab (Remicade, Inflectra, Renflexis, Avsola and Unbranded Infliximab) | Oct 24, 2024 | Oct 20, 2025 | Infliximab is a tumor necrosis factor (tnf) blocker that may be used and medically necessary for treatment... | View |
| 05.001.010 | Immune Prophylaxis for Respiratory Syncytial Virus | Sep 11, 2024 | Policy Archived | Monthly administration of immune prophylaxis for respiratory syncytial virus (rsv) with palivizumab during... | View |
| 05.001.011 | Acute and Maintenance Tocolysis | Aug 07, 2019 | Policy Archived | Acute tocolytic therapy with calcium channel blockers, magnesium sulfate, prostaglandin inhibitors, and... | View |
| 05.001.012 | (Trastuzumab) Herceptin® | Sep 11, 2024 | Sep 20, 2025 | Trastuzumab may be considered medically necessary for the treatment of patients with breast cancer whose... | View |
| 05.001.014 | Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders | Dec 03, 2024 | Dec 20, 2025 | Intravenous infusion of anesthetics (eg, ketamine or lidocaine) for the treatment of chronic pain, including,... | View |
| 05.001.015 | Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension | Dec 20, 2024 | Dec 20, 2025 | Pulmonary arterial hypertension (pah) combination therapy for the treatment of pah (world health... | View |
| 05.001.016 | Uses of Monoclonal Antibodies for the Treatment of Non-Hodgkin Lymphoma | Dec 04, 2024 | Policy Archived | Intravenous rituximab intravenous rituximab (rituxan) may be considered medically necessary to treat... | View |
| 05.001.017 | Bevacizumab | Oct 24, 2024 | Oct 20, 2025 | The use of bevacizumab is considered medically necessary for the following conditions: i. fda-approved... | View |
| 05.001.019 | ABATACEPT (ORENCIA) | Oct 24, 2024 | Oct 20, 2025 | Abatacept is considered for payment in the following indications: adults with rheumatoid arthritis (ra)... | View |
| 05.001.021 | Vandetanib) – Oral Chemotheray | Oct 24, 2025 | Policy Archived | A. vandetanib is considered medically indicated in the treatment of metastatic or unresectable locally... | View |
