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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 |
|---|---|---|---|---|---|
| 07.001.110 | Blepharoplasty | Nov 09, 2022 | Policy Archived | Blepharoplasty or blepharoplasty repair is covered for payment if the following conditions are met: 1.... | View |
| 07.001.112 | Ablation of Peripheral Nerves to Treat Pain | Oct 10, 2024 | Oct 20, 2025 | Radiofrequency ablation (rfa) and cryoneurolysis of nerves have been proposed as treatments for several... | View |
| 07.001.114 | Bioengineered Skin and Soft Tissue Substitutes | Dec 12, 2024 | May 20, 2025 | Breast reconstructive surgery using allogeneic acellular dermal matrix productsa (including each of the... | View |
| 07.001.115 | Vertical Expandable Prosthetic Titanium Rib | May 20, 2024 | May 20, 2025 | Use of the vertical expandable prosthetic titanium rib is considered medically necessary in the treatment... | View |
| 07.001.116 | ROUTINE CARE SERVICES OF THE FOOT | Nov 09, 2022 | Policy Archived | Triple-s considers for routine foot care services when: · the provider has the proper qualifications.... | View |
| 07.001.117 | Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas | Jul 18, 2024 | Jul 20, 2025 | Minimally invasive ablation procedures, including intralesional alcohol injection, radiofrequency ablation,... | View |
| 07.001.118 | Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy | Jul 17, 2024 | Jul 20, 2025 | Percutaneous electrical nerve stimulation (pens), percutaneous neuromodulation therapy (pnt), and restorative... | View |
| 07.001.119 | Surgical Treatments for Breast Cancer-Related Lymphedema | Oct 10, 2024 | Oct 20, 2025 | Lymphatic physiologic microsurgery to treat lymphedema (including, but not limited to, lymphatico-lymphatic... | View |
| 07.001.120 | Facet Arthroplasty | May 16, 2024 | May 20, 2025 | Total facet arthroplasty in individuals with lumbar spinal stenosis undergoing spinal decompression is... | View |
| 07.001.121 | Absorbable Nasal Implant for Treatment of Nasal Valve Collapse | Nov 14, 2024 | Nov 20, 2025 | The insertion of an absorbable lateral nasal implant for the treatment of symptomatic nasal valve collapse is... | View |
| 07.001.122 | Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast | Feb 12, 2024 | Feb 20, 2025 | Following a mastectomy, patients often experience pain and irradiated skin; as an adjunct to reconstructive... | View |
| 07.001.123 | Hydrogel Spacer use During Radiotherapy for Prostate Cancer | Oct 24, 2024 | Oct 24, 2025 | Hydrogel spacer use radiotherapy for prostate cancer may be considered medically necessary in individuals... | View |
| 07.001.124 | Semi-Implantable and Fully Implantable Middle Ear Hearing Aids | Mar 07, 2024 | Mar 20, 2025 | Semi-implantable and fully implantable middle ear hearing aids are... | View |
| 07.001.125 | Surgical Deactivation of Headache Trigger Sites | Mar 07, 2024 | Mar 20, 2025 | Surgical deactivation of trigger sites is considered investigational for the treatment of migraine and... | View |
| 07.001.126 | Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery | Mar 07, 2024 | Mar 20, 2025 | Handheld radiofrequency spectroscopy for intraoperative assessment of surgical margins during... | View |
| 07.001.127 | Surgery for Groin Pain in Athletes | Mar 07, 2024 | Mar 20, 2025 | Surgical treatment of groin pain in athletes (also known as athletic pubalgia, gilmore groin, osteitis pubis,... | View |
| 07.001.128 | Balloon Dilation of the Eustachian Tube | Oct 07, 2024 | Oct 20, 2025 | Balloon dilation of the eustachian tube (bdet) for treatment of chronic obstructive eustachian tube... | View |
| 07.001.129 | Synthetic Cartilage Implants for Joint Pain | Aug 09, 2024 | Aug 20, 2025 | Synthetic cartilage implants are considered investigational for the treatment of articular cartilage... | View |
| 07.001.132 | RHINOPLASTY | Nov 10, 2021 | Policy Archived | Rhinoplasty rhinoplasty may be considered for payment only in the following limited situations:... | View |
| 07.001.133 | Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions | Jan 17, 2025 | Jan 20, 2026 | Radiofrequency coblation tenotomy is considered investigational as a treatment for musculoskeletal... | View |
