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 |
|---|---|---|---|---|
| 07.001.094 | Magnetic Esophageal Sphincter Augmentation To Treat Gastroespphageal Reflux Disease | Dec 2025 | A laparoscopically implanted ring composed of interlinked titanium beads with magnetic cores has been... | View |
| 07.001.095 | Coblation Assisted Tonsilectomy | Nov 2021 | Standard electro-surgical instruments and lasers use thermal energy. other methods to break down tissues have... | View |
| 07.001.096 | Magnetic Resonance-Guided Focused Ultrasound | Aug 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 2019 | The ductus arteriosus is the vascular remnant of the left sixth aortic arch, connecting the main pulmonary... | View |
| 07.001.098 | Debridment | Oct 2025 | A wound is a disruption of the normal structure and function of the skin and skin architecture. an acute... | View |
| 07.001.099 | Hip Resurfacing | May 2026 | Hip resurfacing is an alternative to total hip arthroplasty (also known as hip replacement) for patients with... | View |
| 07.001.100 | Cryosurgical Ablation Of Primary Or Metastatic Liver Tumors | Oct 2025 | Cryosurgical ablation (csa) involves the freezing of target tissues, often by inserting a probe through which... | View |
| 07.001.101 | Subtalar Arthroereisis | May 2026 | Arthroereisis is a surgical procedure that purposely limits movement across a joint. subtalar arthroereisis... | View |
| 07.001.102 | Lumbar Spinal Fusion | Oct 2025 | 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 2025 | 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 2025 | Transcatheter pulmonary valve implantation (tpvi) is a less invasive alternative to open surgical pulmonary... | View |
| 07.001.105 | Electromagnetic Navigational Bronchoscopy | Jan 2026 | Electromagnetic navigation bronchoscopy (enb) is intended to enhance standard bronchoscopy by providing a... | View |
| 07.001.107 | Surgical Treatment Of Bilateral Gynecomastia | Mar 2026 | Gynecomastia, a benign proliferation of the glandular tissue of the male breast, is caused by an increase in... | View |
| 07.001.108 | Laminectomy | Jul 2025 | 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 2021 | Vagus nerve blocking therapy for obesity consists of an implantable device that delivers electrical... | View |
| 07.001.110 | Blepharoplasty | Nov 2022 | 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 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 | May 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 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 2025 | Routine foot care is defined as any service that treats preventively medical conditions with foot involvement... | View |