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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 |
|---|---|---|---|---|---|
| 07.001.017 | Ilizarov Bone-Lengthening Procedure | Feb 03, 2021 | Policy Archived | The ilizarov bone-lengthening procedure uses a circular external fixator device that attaches to the bone via... | View |
| 07.001.018 | Electrical Bone Growth Stimulation Of The Appendicular Skeleton | May 17, 2024 | May 20, 2025 | In the appendicular skeleton, electrical stimulation with either implantable electrodes or noninvasive... | View |
| 07.001.019 | Cirugía de puentes coronarios | May 10, 2016 | Policy Archived | ... | View |
| 07.001.021 | Endovascular Stent Grafts For Abdominal Aortic Aneurysms | Jun 10, 2024 | Jun 20, 2025 | Endovascular stent grafts can be used as minimally invasive alternatives to open surgical repair for... | View |
| 07.001.022 | Surgical Treatment Of Snoring And Obstructive Sleep Apnea Syndrome | Aug 15, 2024 | Aug 20, 2025 | Obstructive sleep apnea (osa) syndrome is characterized by repetitive episodes of upper airway obstruction... | View |
| 07.001.023 | Bariatric Surgery | Jan 15, 2025 | Mar 20, 2025 | Complete guidelines available at https://www.aace.com/publications/guidelines. endocr pract. jul 2016; 22(7):... | View |
| 07.001.024 | Transurethral Radiofrequency Needle Ablation Of The Prostate | May 08, 2019 | Policy Archived | Transurethral radiofrequency needle ablation of the prostate (also known as tuna or rfna) of the prostate has... | 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 is a potential treatment option for individuals with severe persistent asthma. it... | View |
| 07.001.027 | Destrucción transuretral de tejido prostático mediante termoterapia de microonda | Jun 23, 2023 | Policy Archived | Transurethral destruction of prostate tissue by microwave therapy is an alternative to transurethral... | View |
| 07.001.028 | Injectable Bulking Agents For The Treatment Of Urinary And Fecal Incontinence | Nov 14, 2024 | Nov 20, 2025 | Bulking agents are injectable substances used to increase tissue bulk. they can be injected periurethrally to... | View |
| 07.001.029 | Spinal Cord And Dorsal Root Ganglion Stimulation | Sep 11, 2024 | May 20, 2025 | Spinal cord stimulation delivers low-voltage electrical stimulation to the dorsal columns of the spinal cord... | View |
| 07.001.030 | Vagus Nerve Stimulation | Mar 12, 2025 | Mar 20, 2026 | Stimulation of the vagus nerve can be performed using a pulsed electrical stimulator implanted within the... | View |
| 07.001.031 | Deep Brain Stimulation | May 12, 2024 | May 20, 2025 | Ummary deep brain stimulation involves the stereotactic placement of an electrode into a central nervous... | 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 can be considered for injury, trauma or congenital conditions. congenital... | View |
| 07.001.034 | Litotripcia, onda de choque extracorporea (ESWL) | Jun 26, 2023 | Policy Archived | Shock wave lithotripsy — extracorporeal shock wave lithotripsy (eswl)remains one of the most commonly... | 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 allografts and other meniscal implants (eg, collagen) are intended to improve symptoms and reduce... | View |
| 07.001.040 | Cirugia reconstructiva post cirugia baríatrica | Jun 26, 2023 | Policy Archived | Morbid obesity is defined as an increase in body weight above an optimal level resulting in significant... | View |
