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 |
|---|---|---|---|---|---|
| 07.001.080 | Surgical Treatment Of Femoroacetabular Impingement | May 09, 2025 | May 20, 2026 | Femoroacetabular impingement results from localized compression within the joint as a result of an anatomic... | View |
| 07.001.081 | Laser Treatment Of Wine Stains | Aug 24, 2022 | Policy Archived | Studies have generally found that laser treatment can be effective at lightening port wine stains. the... | View |
| 07.001.082 | Bronchial Valves | Jul 16, 2025 | Jul 20, 2026 | Bronchial valves are synthetic devices deployed with bronchoscopy into ventilatory airways of the lung to... | View |
| 07.001.083 | Surgery Of Paranasal Sinuses Guided By Images | Nov 11, 2020 | Policy Archived | Surgery guided by images is a system of three-dimensional mapping that combines computerized tomography and... | View |
| 07.001.084 | Fusion Vertebral Lumbar minimamente Invasiva | Aug 22, 2017 | Policy Archived | ... | View |
| 07.001.085 | Autologous Fat Grafting To The Breast And Adipose-Derived Stem Cells | Oct 26, 2020 | Policy Archived | Autologous fat grafting to the breast has been used as an adjunct to reconstructive breast surgery, for... | View |
| 07.001.086 | Image-Guided Minimally Invasive Decompression For Spinal Stenosis | May 08, 2025 | May 20, 2026 | Image-guided minimally invasive decompression describes a percutaneous procedure for decompression of the... | View |
| 07.001.088 | Lung Volume Reduction Surgery For Severe Emphysema | Jul 11, 2025 | Jul 20, 2026 | Description – intro lung volume reduction surgery (lvrs) is proposed as a treatment option for patients... | View |
| 07.001.089 | Septoplasty | Nov 10, 2021 | Policy Archived | Septoplasty nasal septoplasty is a procedure to correct anatomical deformity or deviation of the nasal... | View |
| 07.001.090 | Microwave Tumor Ablation | Jan 23, 2026 | Nov 20, 2026 | Microwave ablation (mwa) is a technique to destroy tumors and soft tissue using microwave energy to create... | View |
| 07.001.091 | Electrical Stimulation Of The Spine As An Adjunct To Spinal Fusion Procedures | Jun 13, 2025 | May 20, 2026 | Both invasive and noninvasive electrical bone growth stimulators have been investigated as an adjunct to... | View |
| 07.001.092 | Interspinous Fixation (Fusion) Devices | May 09, 2025 | May 20, 2026 | Interspinous fixation (fusion) devices are being developed to aid in the stabilization of the spine. they are... | View |
| 07.001.094 | Magnetic Esophageal Sphincter Augmentation To Treat Gastroespphageal Reflux Disease | Dec 08, 2025 | Dec 20, 2026 | A laparoscopically implanted ring composed of interlinked titanium beads with magnetic cores has been... | View |
| 07.001.095 | Coblation Assisted Tonsilectomy | Nov 10, 2021 | Policy Archived | Standard electro-surgical instruments and lasers use thermal energy. other methods to break down tissues have... | View |
| 07.001.096 | Magnetic Resonance-Guided Focused Ultrasound | Aug 08, 2025 | Aug 20, 2026 | An integrated system providing magnetic resonance-guided focused ultrasound (mrgfus) treatment is proposed as... | View |
| 07.001.097 | Transcatheter Closure Of Patent Ductus Arteriosus | Jun 13, 2019 | Policy Archived | The ductus arteriosus is the vascular remnant of the left sixth aortic arch, connecting the main pulmonary... | View |
| 07.001.098 | Debridment | Oct 30, 2025 | Policy Archived | A wound is a disruption of the normal structure and function of the skin and skin architecture. an acute... | View |
| 07.001.099 | Hip Resurfacing | May 07, 2025 | May 20, 2026 | Hip resurfacing is an alternative to total hip arthroplasty (also known as hip replacement) for patients with... | View |
| 07.001.100 | Cryosurgical Ablation Of Primary Or Metastatic Liver Tumors | Oct 15, 2025 | Oct 20, 2026 | Cryosurgical ablation (csa) involves the freezing of target tissues, often by inserting a probe through which... | View |
| 07.001.101 | Subtalar Arthroereisis | May 08, 2025 | May 20, 2026 | Arthroereisis is a surgical procedure that purposely limits movement across a joint. subtalar arthroereisis... | View |
