News
Food as an agent of change
Read more
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 |
|---|---|---|---|---|---|
| 07.001.040 | Post-Surgery Reconstructive Surgery Bariatric | Jun 26, 2023 | Policy Archived | Reconstructive procedures on the breasts, abdomen, back and lower back when you meet the following criteria... | View |
| 07.001.041 | 07.001.041 | Mar 12, 2025 | 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 | May 06, 2024 | May 20, 2025 | Percutaneous annuloplasty (eg, intradiscal electrothermal annuloplasty, intradiscal radiofrequency... | View |
| 07.001.043 | Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions | May 20, 2024 | May 20, 2025 | 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 12, 2025 | Mar 20, 2025 | 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 pago.... | View |
| 07.001.048 | Intraoperative Neurophysiologic Monitoring | May 06, 2024 | May 20, 2025 | 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 | Population Reference No. 7 | Dec 19, 2024 | Jun 20, 2025 | Transvenous implantable cardioverter defibrillator adults the use of the automatic implantable... | 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 23, 2024 | Sep 20, 2025 | 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 11, 2024 | Sep 20, 2025 | 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 |
| 07.001.056 | Transmyocardial Revascularization | Mar 28, 2024 | Mar 20, 2025 | 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 | Cervical disc arthroplasty may be considered medically necessary when all of the following criteria are... | View |
| 07.001.060 | Radiofrequency Ablation of Primary or Metastatic Liver Tumors | Aug 12, 2024 | Aug 20, 2025 | Radiofrequency ablation of primary, inoperable (eg, due to location of lesion[s] and/or comorbid conditions),... | View |
| 07.001.061 | Wireless Pressure Sensors in Endovascular Aneurysm Repair | May 08, 2019 | Policy Archived | Use of wireless pressure sensors is considered investigational for the management (intraoperative and/or... | View |
| 07.001.064 | Transanal Endoscopic Microsurgery | Dec 04, 2024 | Dec 20, 2025 | Transanal endoscopic microsurgery may be considered medically necessary for treatment of rectal adenomas,... | View |
