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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 |
|---|---|---|---|---|---|
| 07.001.170 | Lithotripsy for Salivary Stones | Oct 24, 2024 | Oct 20, 2025 | The major salivary glands, parotid (front and behind the ear), submandibular (both sides of the jaw), and... | View |
| 07.001.171 | Laser Surgery of the Prostate for Benign Prostatic Hypertrophy | Oct 24, 2024 | Oct 20, 2025 | Benign prostatic hyperplasia (bph) is a common, noncancerous, and benign enlargement of the prostate gland.... | View |
| 07.001.172 | Suture Button Suspensionplasty Fixation System for Thumb Carpometacarpal Osteoarthritis | Nov 14, 2024 | Nov 20, 2025 | In the thumb, the most common site for arthritis to develop is in the joint at the base of the thumb, also... | View |
| 07.001.173 | Fractional Laser Treatment of Burn and Traumatic Scars for Functional Improvement | Feb 04, 2025 | Feb 20, 2026 | Hypertrophic scars and keloids are cutaneous lesions resulting from abnormal wound healing. there is no gold... | View |
| 07.001.174 | Peripheral Nerve Injury Repair Using Synthetic Conduits or Processed Nerve Allografts | Feb 19, 2025 | Feb 20, 2026 | Peripheral nerve injuries are common traumatic events for which the conventional treatment is the... | View |
| 07.001.175 | Intramedullary Limb-Lengthening Systems | Oct 24, 2024 | Oct 20, 2025 | Intramedullary limb-lengthening systems (ills) have been introduced as an alternative to the circular... | View |
| 07.001.176 | Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung | Dec 17, 2024 | Dec 20, 2025 | Irreversible electroporation produces high-frequency electric pulses to create an electric current that... | View |
| 07.001.177 | Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction | Mar 19, 2025 | Mar 20, 2026 | Nasal obstruction is defined clinically as a patient symptom that presents as a sensation of reduced or... | View |
| 07.002.001 | Intravenous Sedation | Nov 20, 2019 | Policy Archived | Adequate sedation and analgesia are important parts of many diagnostic and therapeutic procedures. several... | View |
| 07.002.002 | Monitored Anesthesia Care | Dec 13, 2024 | Dec 20, 2025 | Adequate sedation and analgesia are important parts of many diagnostic and therapeutic procedures. various... | View |
| 07.002.003 | Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease | Nov 07, 2024 | Nov 20, 2025 | Revascularization (either surgical or percutaneous) is a treatment option for certain individuals with lower... | View |
| 07.003.002 | Placental And Umbilical Cord Blood As A Source Of Stem Cells | Mar 19, 2021 | Policy Archived | This evidence review addresses the collection, storage, and transplantation of placental and umbilical cord... | View |
| 07.003.003 | Isolated Small Bowel Transplant | Sep 18, 2024 | Sep 20, 2025 | A small bowel transplant may be performed as an isolated procedure or in conjunction with other visceral... | View |
| 07.003.005 | Allogeneic Pancreas Transplant | Sep 23, 2024 | Sep 20, 2025 | Transplantation of a healthy pancreas is a treatment for patients with insulin-dependent diabetes. pancreas... | View |
| 07.003.006 | Liver Transplant And Combined Liver-Kidney Transplant | Sep 20, 2024 | Sep 20, 2025 | Liver transplantation is currently the treatment of last resort for patients with end-stage liver disease.... | View |
| 07.003.007 | Heart Transplant | Sep 23, 2024 | Sep 20, 2025 | A heart transplant and a retransplant consist of replacing a diseased heart with a healthy donor heart.... | View |
| 07.003.008 | Lung And Lobar Lung Transplant | Sep 20, 2024 | Sep 20, 2025 | A lung transplant consists of replacing all or part of diseased lungs with healthy lung(s) or lobes.... | View |
| 07.003.009 | Heart/Lung Transplant | Sep 20, 2024 | Sep 20, 2025 | Heart/lung transplantation involves a coordinated triple operative procedure consisting of procurement of a... | View |
| 07.003.010 | Small Bowel/Liver And Multivisceral Transplant | Sep 18, 2024 | Sep 20, 2025 | This evidence review addresses transplantation and retransplantation of an intestinal allograft in... | View |
| 07.003.011 | Islet Transplantation | Oct 23, 2024 | Oct 20, 2025 | Performed in conjunction with pancreatectomy for chronic pancreatitis, autologous islet transplantation is... | View |
