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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 |
|---|---|---|---|---|---|
| 07.001.169 | Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia | Jan 08, 2025 | Jan 20, 2026 | 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 24, 2024 | Oct 20, 2025 | Intraductal shockwave lithotripsy (iswl) may be considered medically necessary as a combination approach in... | 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 | 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 04, 2025 | Feb 20, 2026 | 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, 2025 | Peripheral nerve injuries are common traumatic events for which the conventional treatment is the... | View |
| 07.001.175 | Intramedullary Limb-Lengthening System | Oct 24, 2024 | Oct 20, 2025 | Intramedullary limb-lengthening systems with the purpose of bone-lengthening are considered medically... | View |
| 07.001.176 | Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung | Dec 17, 2024 | Dec 20, 2025 | Irreversible electroporation is considered investigational for treatment of primary or metastatic solid... | 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 13, 2024 | Dec 20, 2025 | The use of monitored anesthesia care may be considered medically necessary for gastrointestinal endoscopy,... | View |
| 07.002.003 | Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease | Nov 07, 2024 | Nov 20, 2025 | Percutaneous revascularization using balloon angioplasty, stent procedures, or atherectomy in individuals... | 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 18, 2024 | Sep 20, 2025 | A small bowel transplant using cadaveric intestine may be considered medically necessary in adult and... | View |
| 07.003.005 | Allogeneic Pancreas Transplant | Sep 23, 2024 | Sep 20, 2025 | 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 20, 2024 | Sep 20, 2025 | A liver transplant using a cadaver or living donor may be considered medically necessary for carefully... | View |
| 07.003.007 | Heart Transplant | Sep 23, 2024 | Sep 20, 2025 | Human heart transplantation may be considered medically necessary for select adults and children with... | 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 may be considered medically necessary for carefully selected patients with... | View |
| 07.003.010 | Small Bowel/Liver and Multivisceral Transplant | Sep 18, 2024 | Sep 20, 2025 | Transplants, such as a multivisceral transplant and a small bowel and liver transplant, may be... | View |
| 07.003.011 | Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes | Oct 23, 2024 | Oct 20, 2025 | Autologous pancreas islet transplantation may be considered medically necessary as an adjunct to a total or... | View |
