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 |
|---|---|---|---|---|---|
| 07.001.127 | Surgery for Groin Pain in Athletes | Mar 07, 2024 | Mar 20, 2025 | Surgical treatment of groin pain in athletes (also known as athletic pubalgia, gilmore groin, osteitis pubis,... | View |
| 07.001.128 | Balloon Dilation of the Eustachian Tube | Oct 11, 2023 | Oct 20, 2024 | Balloon dilation of the eustachian tube (bdet) for treatment of chronic obstructive eustachian tube... | View |
| 07.001.129 | Synthetic Cartilage Implants for Joint Pain | Oct 11, 2023 | Aug 20, 2024 | Synthetic cartilage implants are considered investigational for the treatment of articular cartilage... | View |
| 07.001.132 | RHINOPLASTY | Nov 10, 2021 | Policy Archived | Rhinoplasty rhinoplasty may be considered for payment only in the following limited situations:... | View |
| 07.001.133 | Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions | Jan 08, 2024 | Jan 20, 2025 | Radiofrequency coblation tenotomy is considered investigational as a treatment for musculoskeletal... | View |
| 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 19, 2023 | May 20, 2024 | Peripheral subcutaneous field stimulation is... | View |
| 07.001.143 | Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy | May 22, 2023 | May 20, 2023 | Responsive neurostimulation may be considered medically necessary for individuals with focal epilepsy who... | View |
| 07.001.146 | Discectomy | Oct 26, 2023 | Oct 20, 2024 | Lumbar discectomy traditional approach (open) automated percutaneous discectomy automated endoscopic... | View |
| 07.001.148 | Endovascular Therapies for Extracranial Vertebral Artery Disease | Jun 19, 2023 | Jun 20, 2024 | Endovascular therapy, including percutaneous transluminal angioplasty with or without stenting, is... | View |
| 07.001.151 | Prostatic Urethral Lift | Sep 08, 2023 | Sep 20, 2024 | 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 | Sep 18, 2023 | Sep 20, 2024 | 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 05, 2023 | May 20, 2024 | 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, 2023 | Jun 20, 2024 | 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 15, 2023 | Nov 20, 2024 | Radiofrequency ablation of the renal sympathetic nerves is considered investigational for the treatment of... | View |
| 07.001.160 | Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation | May 19, 2023 | May 20, 2024 | Balloon kyphoplasty may be considered medically necessary for the treatment of symptomatic thoracolumbar... | View |
| 07.001.161 | Patient Specific Instrumentation (eg Cutting Guides) for Joint Arthroplasty | May 08, 2023 | May 20, 2024 | 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 19, 2023 | Jun 20, 2024 | Injection of allograft into the intervertebral disc for the treatment of degenerative disc disease is... | View |
