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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 |
|---|---|---|---|---|---|
| 07.001.029 | Spinal Cord and Dorsal Root Ganglion Stimulation | May 17, 2024 | May 20, 2025 | Spinal cord stimulation with standard or high-frequency stimulation may be considered medically... | View |
| 07.001.030 | Vagus Nerve Stimulation | Mar 15, 2024 | Mar 20, 2025 | Vagus nerve stimulation may be considered medically necessary as a treatment of medically refractory... | View |
| 07.001.031 | Deep Brain Stimulation | May 12, 2024 | May 20, 2025 | Unilateral deep brain stimulation of the thalamus may be considered medically necessary in individuals with... | 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 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 12, 2024 | May 20, 2025 | 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 06, 2024 | May 20, 2025 | 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 | 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 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 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 | Implantable Cardioverter Defibrillators | Jun 12, 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 |
