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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 |
|---|---|---|---|---|---|
| 07.001.139 | Peripheral Subcutaneous Field Stimulation | May 20, 2024 | May 20, 2025 | ... | View |
| 07.001.143 | Responsive Neurostimulation For The Treatment Of Refractory Focal Epilepsy | May 10, 2024 | May 20, 2025 | Approximately one-third of individuals with epilepsy do not respond to typical first-line therapy with... | View |
| 07.001.146 | Discectomy | Oct 24, 2024 | Oct 20, 2025 | ... | View |
| 07.001.148 | Endovascular Therapies For Extracranial Vertebral Artery Disease | Jul 18, 2024 | Policy Archived | Vertebral artery diseases, including atherosclerotic stenosis, dissections, and aneurysms, can lead to... | View |
| 07.001.151 | Prostatic Urethral Lift | Sep 11, 2024 | Sep 20, 2025 | Benign prostatic hyperplasia (bph) is a common condition in older individuals that can lead to increased... | View |
| 07.001.152 | Magnetic Resonance Imaging-Targeted Biopsy Of The Prostate | Oct 23, 2024 | Policy Archived | Before a transrectal ultrasound-guided biopsy, a magnetic resonance imaging (mri) scan can be used to... | View |
| 07.001.155 | Functional Endoscopic Sinus Surgery For Chronic Rhinosinusitis | Mar 19, 2025 | Mar 20, 2026 | Chronic rhinosinusitis (crs) is a common chronic condition associated with significant morbidity. functional... | View |
| 07.001.156 | Autologous Chondrocyte Implantation For Focal Articular Cartilage Lesions | May 16, 2024 | May 20, 2025 | A variety of procedures are being developed to resurface articular cartilage defects. autologous chondrocyte... | View |
| 07.001.157 | Open And Thoracoscopic Approaches To Treat Atrial Fibrillation And Atrial Flutter (Maze And Related Procedures) | Jun 12, 2024 | Jun 20, 2025 | There are various surgical approaches to treat atrial fibrillation (af) that work by interrupting abnormal... | View |
| 07.001.158 | Three-Dimensional Printed Orthopedic Implants | Sep 09, 2020 | Policy Archived | This evidence review addresses orthopedic implants that are constructed by additive manufacturing, commonly... | View |
| 07.001.159 | Radiofrequency Ablation Of The Renal Sympathetic Nerves As A Treatment For Resistant Hypertension | Nov 22, 2024 | Nov 20, 2025 | Radiofrequency ablation (rfa) of the renal sympathetic nerves is thought to decrease both the afferent... | View |
| 07.001.161 | Patient Specific Instrumentation (Eg Cutting Guides) For Joint Arthroplasty | May 20, 2024 | May 20, 2025 | Patient-specific instrumentation has been developed as an alternative to conventional cutting guides for... | View |
| 07.001.162 | Allograft Injection For Degenerative Disc Disease | Jun 18, 2024 | Jun 20, 2025 | Degeneration of the intervertebral discs is commonly observed in imaging and has been proposed to be a source... | View |
| 07.001.163 | Cryoablation for Chronic Rhinitis | Mar 10, 2025 | Mar 20, 2026 | Chronic rhinitis is a common medical condition that encompasses allergic rhinitis, nonallergic rhinitis, and... | View |
| 07.001.164 | Liposuction for Lipedema and Lymphedema | Feb 18, 2025 | Feb 20, 2026 | Lipedema is a disorder characterized by a large amount of subcutaneous fat in the extremities, typically the... | View |
| 07.001.165 | Laser Interstitial Thermal Therapy for Neurological Conditions | Jan 15, 2025 | Jan 20, 2026 | Laser interstitial thermal therapy (litt) involves the introduction of a laser fiber probe to deliver thermal... | View |
| 07.001.166 | Uterus Transplantation for Absolute Uterine Factor Infertility | Sep 18, 2024 | Sep 20, 2025 | Absolute uterine factor infertility is a condition in which an individual is unable to achieve pregnancy due... | View |
| 07.001.167 | Remote Electrical Neuromodulation for Migraines | Dec 03, 2024 | Nov 20, 2025 | Migraine attacks due to episodic or chronic migraine require acute management. some individuals may also... | View |
| 07.001.168 | Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation | Sep 18, 2024 | Sep 20, 2025 | Atrial fibrillation (af) is the most common type of cardiac arrhythmia. stroke associated with af is... | View |
| 07.001.169 | Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia | Jan 08, 2025 | Jan 20, 2026 | Benign prostatic hyperplasia (bph) is a common condition in older individuals that can lead to increased... | View |
