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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 |
|---|---|---|---|---|---|
| 07.001.088 | 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 it is considered medically necessary when any of the following clinical conditions is present:... | View |
| 07.001.090 | Microwave Tumor Ablation | Nov 22, 2024 | Nov 20, 2025 | 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 | Both invasive and noninvasive electrical bone growth stimulators have been investigated as an adjunct to... | View |
| 07.001.092 | Interspinous Fixation (Fusion) Devices | May 12, 2024 | May 20, 2025 | 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 Gastroesophageal Reflux Disease | Dec 12, 2024 | Dec 20, 2025 | Magnetic esophageal sphincter augmentation to treat gastroesophageal reflux disease... | 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 | 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 | Transcatheter closure of a patent ductus arteriosus using an fda-approved device may be considered medically... | View |
| 07.001.098 | Debridment | Sep 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 |
| 07.001.100 | Cryosurgical Ablation of Primary or Metastatic Liver Tumors | Oct 07, 2024 | Oct 20, 2025 | Cryosurgical ablation of either primary or metastatic tumors in the liver is... | View |
| 07.001.101 | Subtalar Arthroereisis | May 20, 2024 | May 20, 2025 | Subtalar arthroereisis is considered... | 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 |
| 07.001.103 | Transcatheter Aortic Valve Implantation for Aortic Stenosis | Mar 15, 2024 | Mar 20, 2025 | Transcatheter aortic valve replacement with a u.s. food and drug administration (fda) approved transcatheter... | View |
| 07.001.104 | Transcatheter Pulmonary Valve Implantation | Jul 19, 2024 | Jul 20, 2025 | Transcatheter pulmonary valve implantation with a food and drug administration-approved valve is considered... | View |
| 07.001.105 | Electromagnetic Navigational Bronchoscopy | Jul 22, 2024 | Jul 20, 2025 | When flexible bronchoscopy alone, or with endobronchial ultrasound, are considered inadequate to accomplish... | View |
| 07.001.107 | Surgical Treatment of Bilateral Gynecomastia | Nov 09, 2022 | Policy Archived | Surgical removal of breast tissue, such as mastectomy or liposuction, as a treatment of gynecomastia, is... | View |
| 07.001.108 | Laminectomy | Jul 16, 2024 | Jul 20, 2025 | Cervical laminectomy may be considered medically necessary when all of the following conditions are met:... | View |
| 07.001.109 | Vagus Nerve Blocking Therapy for Treatment of Obesity | Apr 09, 2021 | Policy Archived | Intra-abdominal vagus nerve blocking therapy is considered investigational in all situations, including but... | View |
