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.
Medical Policies table
| ID | Title | Review | Description | Access |
|---|---|---|---|---|
| 07.001.002 | Implantable Infusion Pump For Pain And Spasticity | Mar 2020 | Implantable infusion pumps can provide long-term drug infusion at constant or variable rates; several devices... | View |
| 07.001.003 | Breast Duct Endoscopy | May 2019 | Breast duct endoscopy is a technique that provides for direct visual examination of the breast ducts through... | View |
| 07.001.004 | VALVULOPLASTIA PERCUTANEA | Dec 2023 | Percutaneous balloon valvuloplasty is a method of treating stenotic pulmonary, mitral, and aortic valves... | View |
| 07.001.005 | Decompression Of The Intervertebral Disc Using Laser Energy (Laser Discectomy) Or Radiofrequency Coblation (Nucleoplasty) | May 2026 | Laser energy (laser discectomy) and radiofrequency coblation (nucleoplasty) are being evaluated for... | View |
| 07.001.006 | Cryoablation Of Tumors Located In The Kidney, Lung, Breast, Pancreas, Or Bone | Aug 2025 | Cryosurgical ablation (hereafter referred to as cryosurgery or cryoablation) involves freezing of target... | View |
| 07.001.007 | Gastric Electrical Stimulation | Mar 2026 | Gastric electrical stimulation (ges) is performed using an implantable device designed to treat chronic... | View |
| 07.001.008 | Endovascular Stent Grafts For Disorders Of The Thoracic Aorta | Jan 2026 | Thoracic endovascular aortic repair (tevar) involves the percutaneous placement of a stent graft in the... | View |
| 07.001.009 | Computer-Assisted Navigation For Orthopedic Procedure | May 2026 | Computer-assisted navigation in orthopedic procedures describes the use of computer-enabled tracking systems... | View |
| 07.001.010 | Artroplastía de cadera por método mínimamente invasivo | May 2016 | ... | View |
| 07.001.011 | Transurethral Water Vapor Thermal Therapy For Benign Prostatic Hyperplasia | Feb 2026 | Transurethral water vapor thermal therapy and transurethral waterjet ablation (aquablation) have been... | View |
| 07.001.012 | Whole Gland Cryoablation Of Prostate Cancer | Oct 2024 | Cryoablation, also known as cryotherapy or cryosurgery, is a procedure that attacks cancer cells using... | View |
| 07.001.013 | Treatment Of Varicose Veins/Venous Insufficiency | Feb 2026 | A variety of treatment modalities are available to treat varicose veins/venous insufficiency, including... | View |
| 07.001.014 | Reduction Mammaplasty For Breast-Related Symptoms | Mar 2026 | Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. macromastia... | View |
| 07.001.015 | Reconstructive Breast Surgery/Management Of Breast Implants After Mastectomy | Jul 2025 | Reconstructive breast surgery is defined as a surgical procedure that is designed to restore the normal... | View |
| 07.001.016 | STEREOTACTIC, ULTRASOUND & MRI GUIDED BREAST BIOPSY (MIBB) | Sep 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 2021 | 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 2026 | In the appendicular skeleton, electrical stimulation with either implantable electrodes or noninvasive... | View |
| 07.001.019 | Cirugía de puentes coronarios | May 2016 | ... | View |
| 07.001.021 | Endovascular Stent Grafts For Abdominal Aortic Aneurysms | Jun 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 | Jan 2026 | Obstructive sleep apnea (osa) syndrome is characterized by repetitive episodes of upper airway obstruction... | View |