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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 |
|---|---|---|---|---|---|
| 07.001.029 | Spinal Cord and Dorsal Root Ganglion Stimulation | Sep 11, 2024 | May 20, 2025 | Spinal cord stimulation with standard or high-frequency stimulation may be considered medically... | View |
| 07.001.037 | Bone Morphogenetic Protein | May 12, 2024 | May 20, 2025 | Two recombinant human bone morphogenetic proteins (rhbmps) have been extensively studied: recombinant human... | View |
| 07.001.048 | Intraoperative Neurophysiologic Monitoring | May 06, 2024 | May 20, 2025 | Intraoperative neurophysiologic monitoring, which includes somatosensory-evoked potentials, motor-evoked... | 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 |
| 07.001.065 | Artificial Intervertebral Disc: Lumbar Spine | May 20, 2024 | May 20, 2025 | 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 16, 2024 | May 20, 2025 | Axial lumbosacral interbody fusion is considered... | View |
| 07.001.074 | Facet Joint Denervation | Dec 04, 2024 | Dec 20, 2025 | 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 | 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 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 | 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 | 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 13, 2024 | Dec 20, 2025 | The use of monitored anesthesia care may be considered medically necessary for gastrointestinal endoscopy,... | View |
| 08.001.002 | Physical Therapy Services | Nov 26, 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 |
| 08.001.009 | Low-Level Laser Therapy | Jul 19, 2024 | Jul 20, 2025 | Low-level laser therapy may be considered medically necessary for prevention of oral mucositis in patients... | View |
| 08.001.011 | Manipulation Under Anesthesia | May 20, 2024 | May 20, 2025 | Manipulation under anesthesia consists of a series of mobilization, stretching, and traction procedures... | View |
