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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 |
|---|---|---|---|---|---|
| 07.001.100 | Cryosurgical Ablation of Primary or Metastatic Liver Tumors | Oct 10, 2023 | Oct 20, 2024 | 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 18, 2023 | Oct 20, 2024 | 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 |
| 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 16, 2023 | Oct 20, 2024 | Radiofrequency ablation of peripheral nerves to treat pain associated with knee osteoarthritis or plantar... | View |
| 07.001.114 | Bioengineered Skin and Soft Tissue Substitutes | Apr 19, 2024 | Feb 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 neurostimulation is considered investigational. percutaneous neuromodulation... | View |
| 07.001.119 | Surgical Treatments for Breast Cancer-Related Lymphedema | Oct 17, 2023 | Oct 20, 2024 | 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 15, 2023 | Nov 20, 2024 | 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 | The use of adipose-derived stem cells in autologous fat grafting to the breast is considered investigational.... | View |
