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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 |
|---|---|---|---|---|---|
| 07.001.065 | 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 |
| 07.001.066 | Risk-Reducing Mastectomy | Oct 07, 2024 | Aug 20, 2025 | Risk-reducing mastectomy is defined as the removal of the breast in the absence of malignant disease to... | View |
| 07.001.067 | Nerve Graft With Radical Prostatectomy | May 16, 2024 | May 20, 2025 | Nerve grafting at the time of radical prostatectomy, most commonly using the sural nerve, has been proposed... | View |
| 07.001.069 | Isolated Limb Perfusion/Infision for Malignant Melanoma | Apr 15, 2019 | Policy Archived | Isolated limb perfusion (ilp) when used as a therapeutic treatment of local recurrence of nonresectable... | View |
| 07.001.070 | TONSILECTOMIA ASISTIDA POR LASER | May 16, 2016 | Policy Archived | Tonsilectomia asistida por láser realizada en una o más sesiones no procede para pago. tonsilectomia... | View |
| 07.001.071 | Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors | Jan 08, 2025 | Oct 20, 2025 | In radiofrequency ablation (rfa), a probe is inserted into the center of a tumor; then, prong-shaped,... | View |
| 07.001.072 | Axial Lumbosacral Interbody Fusion | May 16, 2024 | May 20, 2025 | Axial lumbosacral interbody fusion is considered... | View |
| 07.001.073 | Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) | May 12, 2024 | May 20, 2025 | Interspinous and interlaminar implants (spacers) stabilize or distract the adjacent lamina and/or spinous... | View |
| 07.001.074 | Facet Joint Denervation | Dec 04, 2024 | Dec 20, 2025 | Nonpulsed radiofrequency denervation of cervical facet joints (c3-4 and below) and lumbar facet joints is... | View |
| 07.001.075 | Extracranial Carotid Artery Stenting | Jun 07, 2024 | Jun 20, 2025 | Carotid angioplasty with associated stenting and embolic protection may be considered medically necessary in... | View |
| 07.001.076 | Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer | Aug 12, 2024 | Aug 20, 2025 | Saturation biopsy is considered investigational in the diagnosis, staging, and management of prostate... | View |
| 07.001.077 | Plugs for Anal Fistula Repair | Dec 12, 2024 | Dec 20, 2025 | Biosynthetic fistula plugs, including plugs made of porcine small intestine submucosa or of synthetic... | View |
| 07.001.079 | Occipital Nerve Stimulation | May 20, 2024 | May 20, 2025 | Occipital nerve stimulation is considered investigational for all... | View |
| 07.001.080 | Surgical Treatment of Femoroacetabular Impingement | May 12, 2024 | May 20, 2025 | Open or arthroscopic treatment of femoroacetabular impingement may be medically necessary when all of the... | View |
| 07.001.081 | Laser Treatment of Port Wine Stains | Aug 24, 2022 | Policy Archived | Laser treatment of port wine stains in the presence of functional impairment related to the port wine stains... | View |
| 07.001.082 | Bronchial Valves | Jul 18, 2024 | Jul 20, 2025 | Bronchial valves are considered investigational in all situations including, but not limited to: treatment... | View |
| 07.001.083 | SURGERY OF PARANASAL SINUSES GUIDED BY IMAGES | Nov 11, 2020 | Policy Archived | Image-guided surgery is recognized for payment for the following indications: revision of surgery on the... | View |
| 07.001.084 | FUSION VERTEBRAL LUMBAR MINIMAMENTE INVASIVA | Aug 22, 2017 | Policy Archived | Los siguientes procedimientos se reconocen para pago: fusión anterior: alif-abierto fusión posterior:... | View |
| 07.001.085 | Autologous Fat Grafting to the Breast and Adipose-Derived Stem Cells | Oct 26, 2020 | Policy Archived | The use of autologous fat grafting to the breast, with or without adipose-derived stem cells, is considered... | View |
| 07.001.086 | Image-Guided Minimally Invasive Decompression for Spinal Stenosis | May 20, 2024 | May 20, 2025 | Image-guided minimally invasive spinal decompression is... | View |
