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 |
|---|---|---|---|---|---|
| 07.001.054 | Periureteral Bulking Agents As A Treatment Of Vesicoureteral Reflux | Sep 04, 2025 | Sep 20, 2026 | Most commonly seen in children, vesicoureteral reflux (vur) is the retrograde flow of urine from the bladder... | View |
| 07.001.055 | Thermal Capsulorrhaphy As A Treatment Of Joint Instability | Apr 29, 2019 | Policy Archived | Thermal capsulorrhaphy uses thermal energy to restructure collagen in the capsule or ligaments to reduce the... | View |
| 07.001.056 | Transmyocardial Revascularization | Mar 19, 2025 | Mar 20, 2026 | Transmyocardial revascularization (tmr), also known as transmyocardial laser revascularization, is a surgical... | View |
| 07.001.058 | Artificial Intervertebral Disc: Cervical Spine | May 19, 2025 | May 20, 2026 | Several prosthetic devices are currently available for cervical disc arthroplasty. cervical disc arthroplasty... | View |
| 07.001.060 | Radiofrequency Ablation Of Primary Or Metastatic Liver Tumors | Aug 13, 2025 | Aug 20, 2026 | Radiofrequency ablation (rfa) is a procedure in which a probe is inserted into the center of a tumor and... | View |
| 07.001.061 | Wireless Pressure Sensors In Endovascular Aneurysm Repair | May 08, 2019 | Policy Archived | Wireless sensors implanted in an aortic aneurysm sac after endovascular repair are being investigated to... | View |
| 07.001.064 | Transanal Endoscopic Microsurgery | Dec 04, 2025 | Dec 20, 2026 | Transanal endoscopic microsurgery (tem) is a minimally invasive approach for local excision of rectal lesions... | View |
| 07.001.065 | Artificial Intervertebral Disc: Lumbar Spine | May 07, 2025 | May 20, 2026 | Total disc replacement, using an artificial intervertebral disc designed for the lumbar spine, is proposed as... | View |
| 07.001.066 | Risk-Reducing Mastectomy | Oct 16, 2025 | Oct 20, 2026 | 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 | Jun 06, 2025 | Policy Archived | 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 | Sep 25, 2025 | Sep 20, 2026 | 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 07, 2025 | May 20, 2026 | 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 08, 2025 | May 20, 2026 | Interspinous and interlaminar implants (spacers) stabilize or distract the adjacent lamina and/or spinous... | View |
| 07.001.074 | Facet Joint Denervation | Dec 04, 2025 | Dec 20, 2026 | 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 | Jan 09, 2026 | Jan 20, 2027 | 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 18, 2025 | Aug 20, 2026 | 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 17, 2025 | Dec 20, 2026 | Anal fistula plugs (afps) are biosynthetic devices used to promote healing and prevent the recurrence of anal... | View |
| 07.001.079 | Occipital Nerve Stimulation | Jun 13, 2025 | May 20, 2026 | Occipital nerve stimulation delivers a small electrical charge to the occipital nerve intended to prevent... | View |
