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Policies and Guidelines

Coverage Policies Intro

Coverage policies are developed to communicate Medica decisions about coverage and benefits for various medical services. Each coverage policy contains a description of the medical service, as well as the coverage determination, product application, coding considerations and requirements for prior authorization. Learn more about Medica coverage policies.

Both the coverage policy and utilization management policy sections should be checked to determine coverage for a particular service.  For medical services that require prior authorization, see the Utilization Management Policies.

Important note: Before using these policies, read Coverage Policies Usage Notice.
View inactivated policies »

Coverage Policies

Coverage Policies (Categories)

Devices / Equipment

Diagnostics – General

Diagnostics – Laboratory Tests

Genetic Tests


Medical Treatments – General

Surgical Procedure – Back Treatments

Surgical Procedures – General


Wound Therapy

Coverage Policies (Alpha Order)

Medical Technology Assessment Submission

Use this form to submit an inquiry regarding a Medica Coverage Policy. Medica makes every effort to conduct a thorough evaluation of new and emerging technologies using an evidence-based approach. The evidence used when making a determination includes well-designed and well-conducted investigations published in peer-reviewed journals, national physician specialty association and consensus or expert panel opinions, technology assessment reports, FDA and other regulatory approval status, and local physician input, including network specialty physicians and other local consensus opinions.

Download Medical Technology Assessment Submission Form »

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