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 |
|---|---|---|---|---|---|
| 07.001.033 | OTOPLASTY | Nov 09, 2022 | Policy Archived | Reconstructive surgery of the ear is considered for payment if it meets the following criteria: • when... | View |
| 07.001.034 | Extracorporeal Shock Wave Lithotripsy (ESWL) | Jun 26, 2023 | Policy Archived | Extracorporeal shock wave lithotripsy (eswl) is considered for payment at the treatment of kidney stones.... | View |
| 07.001.037 | Bone Morphogenetic Protein | May 23, 2023 | May 20, 2024 | Use of recombinant human bone morphogenetic protein-2 (infuse™) may be considered medically necessary in... | View |
| 07.001.038 | Automated Percutaneous and Percutaneous Endoscopic Discectomy | Jul 12, 2022 | Jul 12, 2023 | Automated percutaneous discectomy is considered investigational as a technique of intervertebral disc... | View |
| 07.001.039 | Meniscal Allografts and Other Meniscal Implants | May 03, 2023 | May 20, 2024 | Meniscal allograft transplantation may be considered medically necessary in patients who have had a prior... | View |
| 07.001.040 | Post-Surgery Reconstructive Surgery Bariatric | Jun 23, 2023 | Policy Archived | Reconstructive procedures on the breasts, abdomen, back and lower back when you meet the following criteria... | View |
| 07.001.041 | Cochlear Implant | Mar 06, 2024 | Mar 20, 2025 | Bilateral or unilateral cochlear implantation of a u.s. food and drug administration (fda)-approved cochlear... | View |
| 07.001.042 | Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation | Oct 10, 2023 | Oct 20, 2024 | Percutaneous annuloplasty (eg, intradiscal electrothermal annuloplasty, intradiscal radiofrequency... | View |
| 07.001.043 | Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions | May 05, 2023 | May 20, 2024 | Fresh osteochondral allografting may be considered medically necessary as a technique to repair:... | View |
| 07.001.044 | Implantable Bone-Conduction and Bone-Anchored Hearing Aids | Mar 18, 2024 | Mar 20, 2025 | Unilateral or bilateral fully or partially implantable bone-conduction (bone-anchored) hearing aid(s) may be... | View |
| 07.001.045 | Surgical Ventricular Restoration | Mar 06, 2024 | Mar 20, 2024 | Surgical ventricular restoration is considered investigational for the treatment of ischemic dilated... | View |
| 07.001.047 | CIRUGIA ROBOTICA (Prostatectomía Radical Laparoscópica) | May 10, 2016 | Policy Archived | La prostatectomía radical por laparoscopía asistida por robot se considera para... | View |
| 07.001.048 | Intraoperative Neurophysiologic Monitoring | May 03, 2023 | May 20, 2024 | Intraoperative neurophysiologic monitoring, which includes somatosensory-evoked potentials, motor-evoked... | View |
| 07.001.049 | Percutaneous Nephrostolithotomy and Lithetripsy for Kidney Stones | Sep 05, 2019 | Policy Archived | Percutaneous nephrostolithotomy and lithotripsy are considered medically necessary for treating upper urinary... | View |
| 07.001.050 | Implantable Cardioverter Defibrillators | Jun 09, 2023 | Jun 20, 2024 | Adults the use of the automatic implantable cardioverter defibrillator (icd) may be considered medically... | View |
| 07.001.051 | Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis | Mar 07, 2024 | Mar 20, 2025 | Use of a catheter-based inflatable device (balloon ostial dilation) for the treatment of chronic... | View |
| 07.001.052 | Percutaneous and Subcutaneous Tibial Nerve Stimulation | Sep 12, 2023 | Sep 20, 2024 | Percutaneous tibial nerve stimulation for an initial 12-week course is considered medically necessary for... | View |
| 07.001.053 | Auditory Brainstem Implant | Mar 07, 2024 | Mar 20, 2025 | Unilateral use of an auditory brainstem implant (using surface electrodes on the cochlear nuclei) may be... | View |
| 07.001.054 | Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux | Sep 05, 2023 | Sep 20, 2024 | Periureteral bulking agents may be considered medically necessary as a treatment of vesicoureteral reflux... | View |
| 07.001.055 | Thermal Capsulorrhaphy as a Treatment of Joint Instability | Apr 29, 2019 | Policy Archived | Thermal capsulorrhaphy is considered not medically necessary as a treatment of joint instability, including,... | View |
