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 |
|---|---|---|---|---|---|
| 07.001.056 | Transmyocardial Revascularization | Mar 18, 2024 | Mar 20, 2025 | Transmyocardial laser revascularization may be considered medically necessary for individuals with class iii... | View |
| 07.001.058 | Artificial Intervertebral Disc: Cervical Spine | May 19, 2023 | May 20, 2024 | 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 10, 2023 | Aug 20, 2024 | 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, 2023 | Dec 20, 2024 | Transanal endoscopic microsurgery may be considered medically necessary for treatment of rectal adenomas,... | View |
| 07.001.065 | Artificial Intervertebral Disc: Lumbar Spine | May 05, 2023 | May 20, 2024 | Artificial intervertebral discs of the lumbar spine are considered... | View |
| 07.001.066 | Risk-Reducing Mastectomy | Aug 08, 2023 | Aug 20, 2024 | Risk-reducing mastectomy may be considered medically necessary in patients at high risk of breast cancer.... | View |
| 07.001.067 | Nerve Graft With Radical Prostatectomy | May 04, 2023 | May 20, 2024 | Unilateral or bilateral nerve graft is considered investigational in patients who have had resection of one... | 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 | Oct 10, 2023 | Oct 20, 2024 | Osteolytic bone metastases radiofrequency ablation may be considered medically necessary to palliate pain... | View |
| 07.001.072 | Axial Lumbosacral Interbody Fusion | May 04, 2023 | May 20, 2024 | Axial lumbosacral interbody fusion is considered... | View |
| 07.001.073 | Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) | May 23, 2023 | May 20, 2024 | Interspinous or interlaminar distraction devices as a stand-alone procedure are... | View |
| 07.001.074 | Facet Joint Denervation | Dec 05, 2023 | Dec 20, 2024 | 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 09, 2023 | Jun 20, 2024 | Carotid angioplasty with associated stenting and embolic protection may be considered medically... | View |
| 07.001.076 | Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer | Aug 10, 2023 | Aug 20, 2024 | Saturation biopsy is considered investigational in the diagnosis, staging, and management of prostate... | View |
| 07.001.077 | Plugs for Anal Fistula Repair | Dec 13, 2023 | Dec 20, 2024 | Biosynthetic fistula plugs, including plugs made of porcine small intestine submucosa or of synthetic... | View |
| 07.001.079 | Occipital Nerve Stimulation | May 05, 2023 | May 20, 2024 | Occipital nerve stimulation is considered investigational for all... | View |
| 07.001.080 | Surgical Treatment of Femoroacetabular Impingement | May 23, 2023 | May 20, 2024 | 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 |
