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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 |
|---|---|---|---|---|---|
| 07.001.134 | Steroid-Eluting Sinus Stents and Implants | Mar 07, 2024 | Mar 20, 2025 | The use of steroid-eluting sinus stents and implants for postoperative treatment following endoscopic sinus... | View |
| 07.001.139 | Peripheral Subcutaneous Field Stimulation | May 20, 2024 | May 20, 2025 | Peripheral subcutaneous field stimulation is a form of neuromodulation intended to treat chronic neuropathic... | 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 | Lumbar discectomy traditional approach (open) automated percutaneous discectomy automated endoscopic... | View |
| 07.001.148 | Endovascular Therapies for Extracranial Vertebral Artery Disease | Jul 18, 2024 | Policy Archived | Endovascular therapy, including percutaneous transluminal angioplasty with or without stenting, is... | View |
| 07.001.151 | Prostatic Urethral Lift | Sep 11, 2024 | Sep 20, 2025 | Use of prostatic urethral lift in individuals with moderate-to-severe lower urinary tract obstruction due to... | View |
| 07.001.152 | Magnetic Resonance Imaging-Targeted Biopsy of the Prostate | Oct 23, 2024 | Policy Archived | Magnetic resonance imaging-targeted biopsy of the prostate may be considered medically necessary for... | View |
| 07.001.155 | Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis | Mar 18, 2024 | Mar 20, 2025 | The use of functional endoscopic sinus surgery is considered medically necessary for individuals with chronic... | View |
| 07.001.156 | Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions | May 16, 2024 | May 20, 2025 | Autologous chondrocyte implantation may be considered medically necessary for the treatment of disabling... | 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 | The maze or modified maze procedure, performed on a non-beating heart during cardiopulmonary bypass with... | View |
| 07.001.158 | Three-Dimensional Printed Orthopedic Implants | Sep 09, 2020 | Policy Archived | Three-dimensional (3d) printed orthopedic implants that have a design that is approved or cleared by the food... | View |
| 07.001.159 | Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension | Nov 22, 2024 | Nov 20, 2025 | Radiofrequency ablation of the renal sympathetic nerves is considered investigational for the treatment of... | View |
| 07.001.161 | Patient Specific Instrumentation (eg Cutting Guides) for Joint Arthroplasty | May 20, 2024 | May 20, 2025 | Use of patient-specific instrumentation (eg, cutting guides) for joint arthroplasty, including but not... | View |
| 07.001.162 | Allograft Injection for Degenerative Disc Disease | Jun 18, 2024 | Jun 20, 2025 | Injection of allograft into the intervertebral disc for the treatment of degenerative disc disease is... | View |
| 07.001.163 | Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis | Apr 08, 2024 | Apr 20, 2025 | Chronic rhinitis is a common medical condition that encompasses allergic rhinitis, nonallergic rhinitis, and... | View |
| 07.001.164 | Liposuction for Lipedema and Lymphedema | Nov 22, 2024 | Nov 20, 2025 | Liposuction for lipedema or lymphedema is considered... | View |
| 07.001.165 | Laser Interstitial Thermal therapy for Neurological Conditions | Jan 15, 2025 | Jan 20, 2026 | Laser interstitial thermal therapy (litt) is considered investigational for all neurological indications,... | View |
| 07.001.166 | Uterus Transplantation for Absolute Uterine Factor Infertility | Sep 18, 2024 | Sep 20, 2025 | Uterus transplantation for absolute uterine factor infertility is... | View |
| 07.001.167 | Remote electrical Neuromodulation for Migraines | Dec 03, 2024 | Nov 20, 2025 | Remote electrical neuromodulation for acute migraine or prevention of migraine is... | View |
| 07.001.168 | Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation | Sep 18, 2024 | Sep 20, 2025 | The use of surgical left atrial appendage occlusion devices, including the atriclip device, for stroke... | View |
