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 |
|---|---|---|---|---|---|
| 07.001.015 | Reconstructive Breast Surgery/Management Of Breast Implants After Mastectomy | Jul 10, 2024 | Jul 20, 2025 | Reconstructive breast surgery is defined as a surgical procedure that is designed to restore the normal... | View |
| 07.001.016 | Stereotactic, Ultrasound Guided Breast Biopsy (Mibb) | Oct 24, 2024 | Oct 20, 2025 | Minimally invasive breast biopsy (mibb) is a breast biopsy that is done with a needle to obtain a diagnosis... | View |
| 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 | Jun 20, 2025 | Jun 20, 2026 | 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 19, 2025 | Jun 20, 2026 | 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 07, 2025 | May 20, 2026 | 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 | May 19, 2025 | May 20, 2026 | 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 07, 2025 | May 20, 2026 | 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 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 08, 2025 | May 20, 2026 | Two recombinant human bone morphogenetic proteins (rhbmps) have been extensively studied: recombinant human... | View |
