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.
Medical Policies table
| ID | Title | Review | Description | Access |
|---|---|---|---|---|
| 07.001.071 | Radiofrequency Ablation Of Miscellaneous Solid Tumors Excluding Liver Tumors | Sep 2025 | In radiofrequency ablation (rfa), a probe is inserted into the center of a tumor; then, prong-shaped,... | View |
| 07.001.072 | Axial Lumbosacral Interbody Fusion | May 2026 | Axial lumbosacral interbody fusion (also called presacral, transsacral, or paracoccygeal interbody fusion) is... | View |
| 07.001.073 | Interspinous And Interlaminar Stabilization/Distraction Devices (Spacers) | May 2026 | Interspinous and interlaminar implants (spacers) stabilize or distract the adjacent lamina and/or spinous... | View |
| 07.001.074 | Facet Joint Denervation | Dec 2025 | Facet denervation is used to treat neck and back pain originating in facet joints with degenerative changes.... | View |
| 07.001.075 | Extracranial Carotid Artery Stenting | Jan 2026 | Carotid artery angioplasty with stenting and transcarotid artery revascularization are treatments for carotid... | View |
| 07.001.076 | Saturation Biopsy For Diagnosis, Staging, And Management Of Prostate Cancer | Aug 2025 | Saturation biopsy of the prostate, in which more cores are obtained than by standard biopsy protocol, has... | View |
| 07.001.077 | Plugs For Anal Fistula Repair | Dec 2025 | Anal fistula plugs (afps) are biosynthetic devices used to promote healing and prevent the recurrence of anal... | View |
| 07.001.079 | Occipital Nerve Stimulation | May 2026 | Occipital nerve stimulation delivers a small electrical charge to the occipital nerve intended to prevent... | View |
| 07.001.080 | Surgical Treatment Of Femoroacetabular Impingement | May 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 | Mar 2026 | Destruction of cutaneous vascular proliferative lesions (cvpls) involves the use of laser or other... | View |
| 07.001.082 | Bronchial Valves | Jul 2025 | 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 2020 | 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 2017 | ... | View |
| 07.001.085 | Autologous Fat Grafting To The Breast And Adipose-Derived Stem Cells | Oct 2020 | 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 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 2025 | Description – intro lung volume reduction surgery (lvrs) is proposed as a treatment option for patients... | View |
| 07.001.089 | Septoplasty | Nov 2021 | Septoplasty nasal septoplasty is a procedure to correct anatomical deformity or deviation of the nasal... | View |
| 07.001.090 | Microwave Tumor Ablation | Jan 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 | May 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 2026 | Interspinous fixation (fusion) devices are being developed to aid in the stabilization of the spine. they are... | View |