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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 |
|---|---|---|---|---|---|
| 07.001.077 | Plugs for Anal Fistula Repair | Dec 13, 2023 | Dec 20, 2024 | Biosynthetic fistula plugs, including plugs made of porcine small intestine submucosa or of synthetic... | View |
| 07.001.079 | Occipital Nerve Stimulation | May 20, 2024 | May 20, 2025 | Occipital nerve stimulation is considered investigational for all... | View |
| 07.001.080 | Surgical Treatment of Femoroacetabular Impingement | May 12, 2024 | May 20, 2025 | Open or arthroscopic treatment of femoroacetabular impingement may be medically necessary when all of the... | View |
| 07.001.081 | Laser Treatment of Port Wine Stains | Aug 24, 2022 | Policy Archived | Laser treatment of port wine stains in the presence of functional impairment related to the port wine stains... | View |
| 07.001.082 | Bronchial Valves | Jul 18, 2024 | Jul 20, 2025 | Bronchial valves are considered investigational in all situations including, but not limited to: treatment... | View |
| 07.001.083 | SURGERY OF PARANASAL SINUSES GUIDED BY IMAGES | Nov 11, 2020 | Policy Archived | Image-guided surgery is recognized for payment for the following indications: revision of surgery on the... | 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 |
| 07.001.085 | Autologous Fat Grafting to the Breast and Adipose-Derived Stem Cells | Oct 26, 2020 | Policy Archived | The use of autologous fat grafting to the breast, with or without adipose-derived stem cells, is considered... | View |
| 07.001.086 | Image-Guided Minimally Invasive Decompression for Spinal Stenosis | May 20, 2024 | May 20, 2025 | Image-guided minimally invasive spinal decompression is... | View |
| 07.001.088 | Lung Volume Reduction Surgery for Severe Emphysema | Jul 17, 2024 | Jul 20, 2025 | Lung volume reduction surgery as a treatment for emphysema may be considered medically necessary in... | View |
| 07.001.089 | SEPTOPLASTY | Nov 10, 2021 | Policy Archived | Septoplasty it is considered medically necessary when any of the following clinical conditions is present:... | View |
| 07.001.090 | Microwave Tumor Ablation | Nov 15, 2023 | Nov 20, 2024 | Microwave ablation of primary or metastatic hepatic tumors may be considered medically necessary under the... | 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 |
| 07.001.092 | Interspinous Fixation (Fusion) Devices | May 12, 2024 | May 20, 2025 | Interspinous fixation (fusion) devices are considered investigational for any indication, including but not... | View |
| 07.001.094 | Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease | Dec 13, 2023 | Dec 20, 2024 | Magnetic esophageal sphincter augmentation to treat gastroesophageal reflux disease is investigational.... | View |
| 07.001.095 | COBLATION ASSISTED TONSILECTOMY | Nov 10, 2021 | Policy Archived | Tonsillectomy by coblation is not considered for additional payment for the treatment of any of the following... | View |
| 07.001.096 | Magnetic Resonance-Guided Focused Ultrasound | Aug 08, 2023 | Aug 20, 2024 | Magnetic resonance-guided high-intensity ultrasound ablation may be considered medically necessary for pain... | View |
| 07.001.097 | Transcatheter Closure of Patent Ductus Arteriosus | Jun 13, 2019 | Policy Archived | Transcatheter closure of a patent ductus arteriosus using an fda-approved device may be considered medically... | View |
| 07.001.098 | Debridment | Jul 09, 2024 | Policy Archived | Triple-s salud considers payment for debridement when provided by the surgeon for the management of ulcers or... | View |
| 07.001.099 | Hip Resurfacing | May 16, 2024 | May 20, 2025 | Metal-on-metal total hip resurfacing with a device system approved by the u.s. food and drug administration... | View |
