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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 |
|---|---|---|---|---|---|
| 07.001.016 | STEREOTACTIC, ULTRASOUND & MRI GUIDED BREAST BIOPSY (MIBB) | Oct 24, 2024 | Oct 20, 2025 | Triple-s will consider for payment stereotactic-guided non-palpable breast lesions that are seen only... | View |
| 07.001.017 | Ilizarov Bone-Lengthening Procedure | Feb 03, 2021 | Policy Archived | These services are considered for payment in the treatment of the following conditions: • treatment of... | View |
| 07.001.018 | Electrical Bone Growth Stimulation of the Appendicular Skeleton | May 17, 2024 | May 20, 2025 | Noninvasive electrical bone growth stimulation may be considered medically necessary for the treatment of... | View |
| 07.001.019 | CIRUGÍA DE PUENTES CORORIOS (CABG) | May 10, 2016 | Policy Archived | E utilizará la regla mencionada a continuación: v1 v2 v3 guÍas para codificar un cabg coninjertos de... | View |
| 07.001.021 | Endovascular Stent Grafts for Abdominal Aortic Aneurysms | Jun 10, 2024 | Jun 20, 2025 | The use of endoprostheses approved by the u.s. food and drug administration (fda) as a treatment of abdominal... | View |
| 07.001.022 | Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome | Aug 15, 2024 | Aug 20, 2025 | Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty, uvulopalatal flap, expansion... | View |
| 07.001.023 | Bariatric Surgery | Jan 15, 2025 | Mar 20, 2025 | Bariatric surgery in adults with class 3 obesity (bmi ≥40 kg/m2) the following bariatric surgery... | View |
| 07.001.024 | Transurethral Radiofrequency Needle Ablation of the Prostate | May 08, 2019 | Policy Archived | Transurethral radiofrequency needle ablation of the prostate (tuna) may be considered medically necessary as... | View |
| 07.001.025 | Sacral Nerve Neuromodulation/Stimulation | May 12, 2024 | May 20, 2025 | Sacral nerve neuromodulation, also known as sacral nerve stimulation, involves the implantation of a... | View |
| 07.001.026 | Bronchial Thermoplasty | Jul 10, 2024 | Jul 20, 2025 | Bronchial thermoplasty for the treatment of asthma is... | View |
| 07.001.027 | Transurethral destruction Of Prostate Tissue Using Microwave Thermotherapy | Jun 23, 2023 | Policy Archived | Transurethral destruction of prostate tissue as a treatment for benign prostatic hyperplasia by microwave... | View |
| 07.001.028 | Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence | Nov 14, 2024 | Nov 20, 2025 | The use of carbon-coated spheres, calcium hydroxylapatite, polyacrylamide hydrogel, or polydimethylsiloxane... | View |
| 07.001.029 | Spinal Cord and Dorsal Root Ganglion Stimulation | Sep 11, 2024 | May 20, 2025 | Spinal cord stimulation with standard or high-frequency stimulation may be considered medically... | View |
| 07.001.030 | Vagus Nerve Stimulation | Mar 15, 2024 | May 20, 2025 | Vagus nerve stimulation may be considered medically necessary as a treatment of medically refractory... | View |
| 07.001.031 | Deep Brain Stimulation | May 12, 2024 | May 20, 2025 | Deep brain stimulation involves the stereotactic placement of an electrode into a central nervous system... | View |
| 07.001.032 | Phototherapeutic Keratectomy | Jun 23, 2023 | Policy Archived | Phototherapeutic keratectomy is considered for payment when used as an alternative to lamellar keratoplasty... | View |
| 07.001.033 | OTOPLASTY | Nov 09, 2022 | Policy Archived | Reconstructive surgery of the ear is considered for payment if it meets the following criteria: • when... | View |
| 07.001.034 | Extracorporeal Shock Wave Lithotripsy (ESWL) | Jun 26, 2023 | Policy Archived | Extracorporeal shock wave lithotripsy (eswl) is considered for payment at the treatment of kidney stones.... | View |
| 07.001.037 | Bone Morphogenetic Protein | May 12, 2024 | May 20, 2025 | Two recombinant human bone morphogenetic proteins (rhbmps) have been extensively studied: recombinant human... | View |
| 07.001.039 | Meniscal Allografts and Other Meniscal Implants | May 06, 2024 | May 20, 2025 | Meniscal allograft transplantation may be considered medically necessary in patients who have had a prior... | View |
