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 |
|---|---|---|---|---|---|
| 07.001.102 | Lumbar Spinal Fusion | Oct 17, 2025 | Oct 20, 2026 | 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 16, 2025 | Jul 20, 2026 | Transcatheter pulmonary valve implantation (tpvi) is a less invasive alternative to open surgical pulmonary... | View |
| 07.001.105 | Electromagnetic Navigational Bronchoscopy | Jan 23, 2026 | Aug 20, 2026 | 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 10, 2025 | Jul 20, 2026 | Laminectomy is a surgical procedure in which a portion of the vertebra (the lamina) is removed to decompress... | View |
| 07.001.109 | Vagus Nerve Bloking Therapy For Treatment Of Obesity | Apr 09, 2021 | Policy Archived | Vagus nerve blocking therapy for obesity consists of an implantable device that delivers electrical... | View |
| 07.001.110 | Blepharoplasty | Nov 09, 2022 | Policy Archived | Blepharoplasty is done to remove excess skin tissue of the upper eyelid. the repair of blepharoptosis... | View |
| 07.001.112 | Ablation Of Peripheral Nerves To Treat Pain | Oct 10, 2025 | Oct 20, 2026 | Radiofrequency ablation (rfa) and cryoneurolysis of nerves have been proposed as treatments for several... | View |
| 07.001.114 | Bioengineered Skin And Soft Tissue Substitutes | Jan 22, 2026 | May 20, 2026 | Bioengineered skin and soft tissue substitutes may be derived from human tissue (autologous or allogeneic),... | View |
| 07.001.115 | Vertical Expandable Prosthetic Titanium Rib | May 19, 2025 | May 20, 2026 | The vertical expandable prosthetic titanium rib is a curved rod placed vertically in the chest to help shape... | View |
| 07.001.116 | Routine Care Services Of The Foot | Jul 23, 2025 | Policy Archived | Routine foot care is defined as any service that treats preventively medical conditions with foot involvement... | View |
| 07.001.117 | Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas | Jul 11, 2025 | Policy Archived | Morton neuroma is a common and painful compression0001 neuropathy of the dorsal foot that is also referred to... | View |
| 07.001.118 | Percutaneous Electrical Nerve Stimulation And Pecutaneous Neuromodulation Therapy | Jul 15, 2025 | Jul 20, 2026 | Percutaneous electrical nerve stimulation (pens), percutaneous neuromodulation therapy (pnt), and restorative... | View |
| 07.001.119 | Surgical Treatments For Breast Cancer-Related Lymphedema | Oct 10, 2025 | Oct 20, 2026 | Surgery and radiotherapy for breast cancer can lead to lymphedema and are some of the most common causes of... | View |
| 07.001.120 | Facet Arthroplasty | May 07, 2025 | May 20, 2026 | Facet arthroplasty refers to the implantation of a spinal prosthesis to restore posterior element structure... | View |
| 07.001.121 | Absorbable Nasal Implant For Treatment Of Nasal Valve Collapse | Nov 12, 2025 | Nov 20, 2026 | Nasal valve collapse (nvc) is a readily identifiable cause of nasal obstruction. specifically, the internal... | View |
| 07.001.122 | Adipose-Derived Stem Cells In Autologous Fat Grafting To The Breast | Feb 13, 2025 | Feb 20, 2026 | Summary following a mastectomy, patients often experience pain and irradiated skin; as an adjunct to... | View |
| 07.001.123 | Hydrogel Spacer use During Radiotherapy for Prostate Cancer | Sep 25, 2025 | Sep 20, 2026 | For low- or intermediate-risk prostate cancer, radiation therapy is an option. because the rectum lies in... | View |
| 07.001.124 | Semi-Implantable And Fully Implantable Middle Ear Hearing Aids | Mar 03, 2025 | Mar 20, 2026 | Moderate-to-severe sensorineural hearing loss is often treated with external acoustic hearing aids, while... | View |
