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 |
|---|---|---|---|---|---|
| 07.001.086 | 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 17, 2024 | Jul 20, 2025 | Lung volume reduction surgery (lvrs) is proposed as a treatment option for patients with severe emphysema who... | 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 | Nov 22, 2024 | Nov 20, 2025 | 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 12, 2024 | Dec 20, 2025 | 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 | Dec 06, 2024 | Aug 20, 2025 | 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 | Sep 09, 2024 | 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 07, 2024 | Oct 20, 2025 | 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 |
| 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 |
| 07.001.103 | Transcatheter Aortic Valve Implantation For Aortic Stenosis | Jun 06, 2025 | Jun 20, 2026 | Aortic stenosis is narrowing of the aortic valve opening, resulting in obstruction of blood flow from the... | View |
| 07.001.104 | Transcatheter Pulmonary Valve Implantation | Jul 19, 2024 | Jul 20, 2025 | Transcatheter pulmonary valve implantation (tpvi) is a less invasive alternative to open surgical pulmonary... | View |
| 07.001.105 | Electromagnetic Navigational Bronchoscopy | Jul 22, 2024 | Jul 20, 2025 | Electromagnetic navigation bronchoscopy (enb) is intended to enhance standard bronchoscopy by providing a... | View |
| 07.001.107 | Surgical Treatment Of Bilateral Gynecomastia | Nov 09, 2022 | Policy Archived | Gynecomastia, a benign proliferation of the glandular tissue of the male breast, is caused by an increase in... | View |
| 07.001.108 | Laminectomy | Jul 16, 2024 | Jul 20, 2025 | Laminectomy is a surgical procedure in which a portion of the vertebra (the lamina) is removed to decompress... | View |
