Medical policies
Medical policies are based on research that provides evidence of scientific merit for a particular medical technology. They are also based on data from the peer-reviewed scientific literature, from criteria developed by specialty societies, from guidelines adopted by other health care organizations and from government agencies, such as the Centers for Medicare & Medicaid Services and the U.S. Food and Drug Administration. Medical policies are used as guidelines for coverage determinations in health care benefit programs, unless otherwise indicated.
These medical policies apply only to members who have health insurance through HealthSpring.
In the event of conflict between a medical policy and any plan document under which a member is entitled to covered services, the plan document will govern. Plan documents include, but are not limited to, Evidence of Coverage, benefit booklets, summary plan descriptions and other coverage documents.
Medical technology is constantly evolving, and these medical policies are subject to change without notice, except as required by law. Additional medical policies may be developed from time to time, and some may be withdrawn from use. The medical policies generally apply to all benefit plans, although some local variations may exist. Members should call the number on their ID card for specific coverage information.
Restrictions and limitations
Medical policies serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage, and some plans may not provide coverage for certain services discussed in the medical policies.
Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical policy does not constitute plan authorization, nor is it an explanation of benefits.
The medical policies do not constitute medical advice or medical care. They do not guarantee any results or outcomes. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. Members should discuss the information in the medical policies with their treating health care providers. HealthSpring is not a provider of health care and does not render medical advice.
Medical policies can be highly technical and complex and are provided here for informational purposes.
HealthSpring is under no obligation to update this site. Therefore, the medical policies displayed may be out of date. Contact your provider representative if you have any questions.
Medical policies are interpreted and applied at the sole discretion of HealthSpring.
Following are HealthSpring medical policies:
- OTH903.041, Ranibizumab Injections, Implants and Biosimilars [PDF]
- RX501.128, Valoctocogene Roxaparvovec-rvox [PDF]
- RX501.164, Gene Therapies for Treatment of Wounds in Dystrophic Epidermolysis Bullosa [PDF]
- RX502.061, Oncology Medications [PDF]
Refer to our provider manual for more details.
Current Procedural Terminology (CPT®) codes and descriptions are the property of the American Medical Association with all rights reserved.
The five-character codes included in the medical policies are obtained from the Physician's Current Procedural Terminology (CPT), copyright 2025 by the American Medical Association. CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. CPT is a registered trademark of the AMA.
The responsibility for the content of the medical policies is with HealthSpring, and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the medical policies. CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose.
No fee schedules, basis unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of the medical policies should refer to the most current Physician's Current Procedural Terminology, which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.