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 |
|---|---|---|---|---|---|
| 07.001.163 | Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis | Apr 08, 2024 | Apr 20, 2025 | Cryoablation for chronic rhinitis (allergic or nonallergic) is considered investigational. radiofrequency... | View |
| 07.001.164 | Liposuction for Lipedema and Lymphedema | Nov 16, 2023 | Nov 20, 2024 | Liposuction for lipedema or lymphedema is considered... | View |
| 07.001.165 | Laser Interstitial Thermal therapy for Neurological Conditions | Jan 09, 2024 | Jan 20, 2025 | Laser interstitial thermal therapy (litt) is considered investigational for all neurological indications,... | View |
| 07.001.166 | Uterus Transplantation for Absolute Uterine Factor Infertility | Sep 12, 2023 | Sep 20, 2024 | Uterus transplantation for absolute uterine factor infertility is considered... | View |
| 07.001.167 | Remote electrical Neuromodulation for Migraines | Jan 09, 2024 | Jun 20, 2024 | Remote electrical neuromodulation for acute migraine is... | View |
| 07.001.168 | Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation | Sep 14, 2023 | Sep 20, 2024 | The use of surgical left atrial appendage occlusion devices, including the atriclip device, for stroke... | View |
| 07.001.169 | Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia | Feb 07, 2024 | Feb 20, 2025 | The use of a temporarily implanted nitinol device (eg, itind) is considered investigational as a treatment of... | View |
| 07.001.170 | Lithotripsy for Salivary Stones | Oct 26, 2023 | Jan 09, 2024 | The following are investigational for treating salivary stones due to insufficient... | View |
| 07.001.171 | Laser Surgery of the Prostate for Benign Prostatic Hypertrophy | Oct 26, 2023 | Oct 20, 2024 | 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 15, 2023 | Nov 20, 2024 | Suture button suspensionplasty for thumb carpometacarpal joint osteoarthritis is considered... | View |
| 07.001.173 | Fractional Carbon Dioxide (CO2) Laser Ablation Treatment of Hypertrophic Scars or Keloids for Functional Improvement | Feb 07, 2024 | Feb 20, 2025 | Carbon dioxide (co2) fractional laser ablation treatment of hypertrophic scars or keloids for functional... | View |
| 07.001.174 | Peripheral Nerve Injury Repair Using Synthetic Conduits or Processed Nerve Allografts | Feb 12, 2024 | Feb 20, 2024 | The use of processed nerve allograft for the repair and closure of peripheral nerve gaps is considered... | View |
| 07.002.001 | Intravenous Sedation | Sep 11, 2019 | Policy Archived | Triple-s salud does not routinely recognize separate sedation payment for endoscopic procedures. these... | View |
| 07.002.002 | Monitored Anesthesia Care | Dec 04, 2023 | Dec 20, 2024 | The use of monitored anesthesia care may be considered medically necessary for gastrointestinal endoscopy,... | View |
| 07.003.002 | Placental and Umbilical Cord Blood as a Source of Stem Cells | Mar 19, 2021 | Policy Archived | Transplantation of cord blood stem cells from related or unrelated donors may be considered medically... | View |
| 07.003.003 | Isolated Small Bowel Transplant | Sep 12, 2023 | Sep 20, 2024 | A small bowel transplant using cadaveric intestine may be considered medically necessary in adult and... | View |
| 07.003.005 | Allogeneic Pancreas Transplant | Sep 08, 2023 | Sep 20, 2024 | Pancreas transplant after a prior kidney transplant may be considered medically necessary in patients with... | View |
| 07.003.006 | Liver Transplant and Combined Liver-Kidney Transplant | Sep 12, 2023 | Sep 20, 2024 | A liver transplant using a cadaver or living donor may be considered medically necessary for carefully... | View |
| 07.003.007 | Heart Transplant | Sep 11, 2023 | Sep 20, 2024 | Human heart transplantation may be considered medically necessary for select adults and children with... | View |
| 07.003.008 | Lung and Lobar Lung Transplant | Sep 12, 2023 | Sep 20, 2024 | Lung transplantation may be considered medically necessary for carefully selected patients with irreversible,... | View |
