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 |
|---|---|---|---|---|---|
| 07.001.012 | Whole Gland Cryoablation of Prostate Cancer | Sep 08, 2023 | Sep 20, 2024 | Whole gland cryoablation of the prostate may be considered medically necessary as treatment of clinically... | View |
| 07.001.013 | Treatment of Varicose Veins/Venous Insufficiency | Jun 08, 2023 | Jun 20, 2024 | Saphenous veins great or small saphenous veins treatment of the great or small saphenous veins by... | View |
| 07.001.014 | Reduction Mammaplasty for Breast-Related Symptoms | Mar 14, 2024 | Mar 20, 2025 | Reduction mammaplasty may be considered medically necessary for the treatment of macromastia when... | View |
| 07.001.015 | Reconstructive Breast Surgery/Management of Breast Implants after Mastectomy | Oct 12, 2023 | Jul 20, 2024 | Coverage eligibility of breast implants for the purposes of augmentation may depend on contract language.... | View |
| 07.001.016 | STEREOTACTIC, ULTRASOUND & MRI GUIDED BREAST BIOPSY (MIBB) | Nov 09, 2022 | Nov 09, 2023 | 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 19, 2023 | May 20, 2024 | 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 | Al ocurrir una obstrucción de alguna(s) de la(s) arteria(s) principales del corazón, y si no ha ocurrido... | View |
| 07.001.021 | Endovascular Stent Grafts for Abdominal Aortic Aneurysms | Nov 09, 2023 | Jun 20, 2024 | 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 | Jul 06, 2023 | Jul 20, 2024 | Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty, uvulopalatal flap, expansion... | View |
| 07.001.023 | Bariatric Surgery | Mar 14, 2024 | Mar 20, 2025 | Bariatric surgery in adults with class iii obesity the following bariatric surgery procedures may be... | 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 22, 2023 | May 20, 2024 | Urinary incontinence and nonobstructive retention criteria a a trial period of sacral nerve... | View |
| 07.001.026 | Bronchial Thermoplasty | Jul 10, 2023 | Jul 20, 2024 | Bronchial thermoplasty for the treatment of asthma is considered... | 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 15, 2023 | Nov 20, 2024 | The use of carbon-coated spheres, calcium hydroxylapatite, polyacrylamide hydrogel, or polydimethylsiloxane... | View |
| 07.001.029 | Spinal Cord and Dorsal Root Ganglion Stimulation | May 19, 2023 | May 20, 2024 | Spinal cord stimulation with standard or high-frequency stimulation may be considered medically... | View |
| 07.001.030 | Vagus Nerve Stimulation | Mar 15, 2024 | Mar 20, 2025 | Vagus nerve stimulation may be considered medically necessary as a treatment of medically refractory... | View |
| 07.001.031 | Policy Name: Deep Brain Stimulation | Aug 21, 2023 | May 20, 2024 | Unilateral deep brain stimulation of the thalamus may be considered medically necessary in individuals with... | 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 |
