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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 |
|---|---|---|---|---|---|
| 07.001.066 | 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 Láser | May 16, 2016 | Policy Archived | ... | 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 (also called presacral, transsacral, or paracoccygeal interbody fusion) is... | 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 | Facet denervation is used to treat neck and back pain originating in facet joints with degenerative changes.... | View |
| 07.001.075 | Extracranial Carotid Artery Stenting | Jun 07, 2024 | Jun 20, 2025 | Carotid artery angioplasty with stenting and transcarotid artery revascularization are treatments for carotid... | View |
| 07.001.076 | Saturation Biopsy For Diagnosis, Staging, And Management Of Prostate Cancer | Aug 12, 2024 | Aug 20, 2025 | Saturation biopsy of the prostate, in which more cores are obtained than by standard biopsy protocol, has... | View |
| 07.001.077 | Plugs For Anal Fistula Repair | Dec 12, 2024 | Dec 20, 2025 | Anal fistula plugs (afps) are biosynthetic devices used to promote healing and prevent the recurrence of anal... | View |
| 07.001.079 | Occipital Nerve Stimulation | May 20, 2024 | May 20, 2025 | Occipital nerve stimulation delivers a small electrical charge to the occipital nerve intended to prevent... | View |
| 07.001.080 | Surgical Treatment Of Femoroacetabular Impingement | May 12, 2024 | May 20, 2025 | Femoroacetabular impingement results from localized compression within the joint as a result of an anatomic... | View |
| 07.001.081 | Laser Treatment Of Wine Stains | Aug 24, 2022 | Policy Archived | Studies have generally found that laser treatment can be effective at lightening port wine stains. the... | View |
| 07.001.082 | Bronchial Valves | Jul 18, 2024 | Jul 20, 2025 | Bronchial valves are synthetic devices deployed with bronchoscopy into ventilatory airways of the lung to... | View |
| 07.001.083 | Surgery Of Paranasal Sinuses Guided By Images | Nov 11, 2020 | Policy Archived | Surgery guided by images is a system of three-dimensional mapping that combines computerized tomography and... | View |
| 07.001.084 | Fusion Vertebral Lumbar minimamente Invasiva | Aug 22, 2017 | Policy Archived | ... | View |
| 07.001.085 | Autologous Fat Grafting To The Breast And Adipose-Derived Stem Cells | Oct 26, 2020 | Policy Archived | Autologous fat grafting to the breast has been used as an adjunct to reconstructive breast surgery, for... | View |
| 07.001.086 | Image-Guided Minimally Invasive Decompression For Spinal Stenosis | May 20, 2024 | May 20, 2025 | Image-guided minimally invasive decompression describes a percutaneous procedure for decompression of the... | View |
| 07.001.088 | Lung Volume Reduction Surgery For Severe Emphysema | Jul 17, 2024 | Jul 20, 2025 | Lung volume reduction surgery (lvrs) is proposed as a treatment option for patients with severe emphysema who... | View |
