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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 |
|---|---|---|---|---|---|
| 07.001.052 | 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 |
| 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 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 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 20, 2024 | May 20, 2025 | Artificial intervertebral discs of the lumbar spine are considered investigational.... | 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 16, 2024 | May 20, 2025 | 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 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 or interlaminar distraction devices as a stand-alone procedure are considered investigational as... | 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 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 10, 2023 | Aug 20, 2024 | Saturation biopsy is considered investigational in the diagnosis, staging, and management of prostate... | View |
