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 |
|---|---|---|---|---|---|
| 07.001.058 | 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 |
| 07.001.065 | Artificial Intervertebral Disc: Lumbar Spine | May 20, 2024 | May 20, 2025 | Artificial intervertebral discs of the lumbar spine are considered investigational.... | View |
| 07.001.072 | Axial Lumbosacral Interbody Fusion | May 16, 2024 | May 20, 2025 | Axial lumbosacral interbody fusion is considered... | 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 |
| 07.001.084 | FUSION VERTEBRAL LUMBAR MINIMAMENTE INVASIVA | Aug 22, 2017 | Policy Archived | Los siguientes procedimientos se reconocen para pago: fusión anterior: alif-abierto fusión posterior:... | View |
| 07.001.091 | Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures | May 16, 2024 | May 20, 2025 | Either invasive or noninvasive methods of electrical bone growth stimulation may be considered medically... | View |
| 07.001.102 | Lumbar Spinal Fusion | Oct 18, 2023 | Oct 20, 2024 | Lumbar spinal fusion may be considered medically necessary for any one of the following conditions:... | View |
| 07.001.118 | Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy | Aug 14, 2023 | Aug 20, 2024 | Percutaneous electrical neurostimulation is considered investigational. percutaneous neuromodulation... | View |
| 07.001.146 | Discectomy | Oct 26, 2023 | Oct 20, 2024 | Lumbar discectomy traditional approach (open) automated percutaneous discectomy automated endoscopic... | View |
| 07.001.158 | Three-Dimensional Printed Orthopedic Implants | Sep 09, 2020 | Policy Archived | Three-dimensional (3d) printed orthopedic implants that have a design that is approved or cleared by the food... | View |
| 07.001.162 | Allograft Injection for Degenerative Disc Disease | Jun 18, 2024 | Jun 20, 2025 | Injection of allograft into the intervertebral disc for the treatment of degenerative disc disease is... | View |
| 07.002.001 | Intravenous Sedation | Sep 11, 2019 | Policy Archived | Triple-s salud does not routinely recognize separate sedation payment for endoscopic procedures. these... | View |
| 07.002.002 | Monitored Anesthesia Care | Dec 04, 2023 | Dec 20, 2024 | The use of monitored anesthesia care may be considered medically necessary for gastrointestinal endoscopy,... | View |
| 08.001.002 | Physical Therapy Services | Mar 25, 2024 | Policy Archived | However, not all studies have found a benefit for mld over standard management for reducing limb volume... | View |
| 08.001.006 | Vertebral Axial Decompression | May 20, 2024 | May 20, 2025 | Vertebral axial decompression is considered... | View |
| 08.001.011 | Manipulation Under Anesthesia | May 20, 2024 | May 20, 2025 | Spinal manipulation and manipulation of other joints performed during the procedure (eg, hip joint) with the... | View |
| 08.001.030 | OCCUPATIONAL THERAPY | Jan 29, 2020 | Policy Archived | Occupational therapy services are considered for payment when they are performed to address the need of a... | View |
| 08.001.035 | Aquatic Therapy | Nov 11, 2020 | Policy Archived | Aquatic therapy to improve or restore physical function after illness, trauma or physical damage or loss of... | View |
| 08.001.050 | Hematopoietic Cell Transplantation for Acute Myeloid Leukemia | Feb 20, 2024 | Feb 20, 2025 | Allogeneic hematopoietic cell transplantation (hct) using a myeloablative conditioning regimen may be... | View |
| 08.001.053 | Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma | Jan 08, 2024 | Jan 20, 2025 | Tisagenlecleucel for b-cell acute lymphoblastic leukemia tisagenlecleucel is considered medically... | View |
