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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 |
|---|---|---|---|---|---|
| 07.001.041 | Cochlear Implant | Mar 04, 2025 | Mar 20, 2026 | A cochlear implant is a device for treatment of severe-to-profound hearing loss in individuals who only... | View |
| 07.001.042 | Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, And Biacuplasty | May 06, 2024 | May 20, 2025 | Electrothermal intradiscal annuloplasty therapies use radiofrequency energy sources to treat discogenic low... | View |
| 07.001.043 | Autografts And Allografts In The Treatment Of Focal Articular Cartilage Lesions | May 20, 2024 | May 20, 2025 | Osteochondral grafts are used to repair full-thickness chondral defects involving a joint. in the case of... | View |
| 07.001.044 | Implantable Bone-Conduction And Bone-Anchored Hearing Aids | Mar 19, 2025 | Mar 20, 2026 | Sensorineural, conductive, and mixed hearing loss may be treated with various devices, including conventional... | View |
| 07.001.045 | Surgical Ventricular Restoration | Mar 05, 2025 | Mar 20, 2026 | Surgical ventricular restoration is designed to restore or remodel the left ventricle to its normal,... | View |
| 07.001.047 | Cirugía robótica | May 10, 2016 | Policy Archived | ... | View |
| 07.001.048 | Intraoperative Neurophysiologic Monitoring | May 06, 2024 | May 20, 2025 | Intraoperative neurophysiologic monitoring describes a variety of procedures used to monitor the integrity of... | View |
| 07.001.049 | Percutaneous Nephrostolithotomy And Lithetripsy For Kidney Stones | Sep 05, 2019 | Policy Archived | Percutaneous nephrostolithotomy (pcn) is an invasive procedure for removing upper urinary tract stones by... | View |
| 07.001.050 | Implantable Cardioverter Defibrillators | Dec 19, 2024 | Jun 20, 2025 | An implantable cardioverter defibrillator (icd) is a device designed to monitor a patient's heart rate,... | View |
| 07.001.051 | Balloon Ostial Dilation For Treatment Of Chronic Rhinosinusitis | Mar 05, 2025 | Mar 20, 2026 | Balloon ostial dilation (bod, also known as balloon sinuplasty) is proposed as an alternative to functional... | View |
| 07.001.052 | Percutaneous Tibial Nerve Stimulation | Sep 23, 2024 | Sep 20, 2025 | Percutaneous tibial nerve stimulation (ptns; also known as posterior tibial nerve stimulation) is an... | View |
| 07.001.053 | Auditory Brainstem Implant | Mar 10, 2025 | Mar 20, 2026 | An auditory brainstem implant (abi) is designed to restore some hearing in people with neurofibromatosis type... | View |
| 07.001.054 | Periureteral Bulking Agents As A Treatment Of Vesicoureteral Reflux | Sep 11, 2024 | Sep 20, 2025 | Most commonly seen in children, vesicoureteral reflux (vur) is the retrograde flow of urine from the bladder... | View |
| 07.001.055 | Thermal Capsulorrhaphy As A Treatment Of Joint Instability | Apr 29, 2019 | Policy Archived | Thermal capsulorrhaphy uses thermal energy to restructure collagen in the capsule or ligaments to reduce the... | View |
| 07.001.056 | Transmyocardial Revascularization | Mar 19, 2025 | Mar 20, 2026 | Transmyocardial revascularization (tmr), also known as transmyocardial laser revascularization, is a surgical... | View |
| 07.001.058 | Artificial Intervertebral Disc: Cervical Spine | May 17, 2024 | May 20, 2025 | Several prosthetic devices are currently available for cervical disc arthroplasty. cervical disc arthroplasty... | View |
| 07.001.060 | Radiofrequency Ablation Of Primary Or Metastatic Liver Tumors | Aug 12, 2024 | Aug 20, 2025 | Radiofrequency ablation (rfa) is a procedure in which a probe is inserted into the center of a tumor and... | View |
| 07.001.061 | Wireless Pressure Sensors In Endovascular Aneurysm Repair | May 08, 2019 | Policy Archived | Wireless sensors implanted in an aortic aneurysm sac after endovascular repair are being investigated to... | View |
| 07.001.064 | Transanal Endoscopic Microsurgery | Dec 04, 2024 | Dec 20, 2025 | Transanal endoscopic microsurgery (tem) is a minimally invasive approach for local excision of rectal lesions... | View |
| 07.001.065 | Artificial Intervertebral Disc: Lumbar Spine | May 20, 2024 | May 20, 2025 | Total disc replacement, using an artificial intervertebral disc designed for the lumbar spine, is proposed as... | View |
