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 |
|---|---|---|---|---|---|
| 07.001.037 | Bone Morphogenetic Protein | May 08, 2025 | May 20, 2026 | Two recombinant human bone morphogenetic proteins (rhbmps) have been extensively studied: recombinant human... | View |
| 07.001.048 | Intraoperative Neurophysiologic Monitoring | May 06, 2025 | May 20, 2026 | Intraoperative neurophysiologic monitoring describes a variety of procedures used to monitor the integrity of... | 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 |
| 07.001.065 | 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 |
| 07.001.072 | Axial Lumbosacral Interbody Fusion | May 07, 2025 | May 20, 2026 | Axial lumbosacral interbody fusion (also called presacral, transsacral, or paracoccygeal interbody fusion) is... | View |
| 07.001.074 | 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 |
| 07.001.084 | Fusion Vertebral Lumbar minimamente Invasiva | Aug 22, 2017 | Policy Archived | ... | View |
| 07.001.091 | Electrical Stimulation Of The Spine As An Adjunct To Spinal Fusion Procedures | May 07, 2025 | May 20, 2026 | Both invasive and noninvasive electrical bone growth stimulators have been investigated as an adjunct to... | View |
| 07.001.102 | Lumbar Spinal Fusion | Oct 15, 2024 | Oct 20, 2025 | Lumbar spinal fusion (arthrodesis) is a surgical technique that involves fusing 2 or more lumbar vertebrae... | View |
| 07.001.118 | Percutaneous Electrical Nerve Stimulation And Pecutaneous Neuromodulation Therapy | Jul 17, 2024 | Jul 20, 2025 | Percutaneous electrical nerve stimulation (pens), percutaneous neuromodulation therapy (pnt), and restorative... | View |
| 07.001.146 | Discectomy | Oct 24, 2024 | Oct 20, 2025 | ... | View |
| 07.001.158 | Three-Dimensional Printed Orthopedic Implants | Sep 09, 2020 | Policy Archived | This evidence review addresses orthopedic implants that are constructed by additive manufacturing, commonly... | View |
| 07.001.162 | Allograft Injection For Degenerative Disc Disease | Jun 18, 2024 | Jun 20, 2025 | Degeneration of the intervertebral discs is commonly observed in imaging and has been proposed to be a source... | View |
| 07.002.001 | Intravenous Sedation | Nov 20, 2019 | Policy Archived | Adequate sedation and analgesia are important parts of many diagnostic and therapeutic procedures. several... | View |
| 07.002.002 | Monitored Anesthesia Care | Dec 13, 2024 | Dec 20, 2025 | Adequate sedation and analgesia are important parts of many diagnostic and therapeutic procedures. various... | View |
| 08.001.002 | Physical Therapy Services | Feb 19, 2025 | Policy Archived | Physical therapy is the treatment of illness or physical damage through the use of therapeutic exercise,... | View |
| 08.001.006 | Vertebral Axial Decompression | May 12, 2025 | May 20, 2026 | Vertebral axial decompression applies traction to the vertebral column to reduce intradiscal pressure and, in... | View |
| 08.001.009 | Low-Level Laser Therapy | Jul 19, 2024 | Jul 20, 2025 | Low-level laser therapy (lllt), also called photobiomodulation, is being evaluated to treat various... | View |
| 08.001.011 | Manipulation Under Anesthesia | May 19, 2025 | May 20, 2026 | Manipulation under anesthesia consists of a series of mobilization, stretching, and traction procedures... | View |
| 08.001.030 | Occupational Therapy | Jan 29, 2020 | Policy Archived | Occupational therapy is defined as that therapy which promotes the restoration of the ability of a person... | View |
