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.
Medical Policies table
| ID | Title | Review | Description | Access |
|---|---|---|---|---|
| 07.001.151 | Prostatic Urethral Lift | Sep 2025 | Benign prostatic hyperplasia (bph) is a common condition in older individuals that can lead to increased... | View |
| 07.001.152 | Magnetic Resonance Imaging-Targeted Biopsy Of The Prostate | Oct 2024 | Before a transrectal ultrasound-guided biopsy, a magnetic resonance imaging (mri) scan can be used to... | View |
| 07.001.155 | Functional Endoscopic Sinus Surgery For Chronic Rhinosinusitis | Mar 2026 | Chronic rhinosinusitis (crs) is a common chronic condition associated with significant morbidity. functional... | View |
| 07.001.156 | Autologous Chondrocyte Implantation For Focal Articular Cartilage Lesions | May 2026 | A variety of procedures are being developed to resurface articular cartilage defects. autologous chondrocyte... | View |
| 07.001.157 | Open And Thoracoscopic Approaches To Treat Atrial Fibrillation And Atrial Flutter (Maze And Related Procedures) | Apr 2026 | There are various surgical approaches to treat atrial fibrillation (af) that work by interrupting abnormal... | View |
| 07.001.158 | Three-Dimensional Printed Orthopedic Implants | Sep 2020 | This evidence review addresses orthopedic implants that are constructed by additive manufacturing, commonly... | View |
| 07.001.159 | Radiofrequency Ablation Of The Renal Sympathetic Nerves As A Treatment For Resistant Hypertension | Aug 2025 | Radiofrequency ablation (rfa) of the renal sympathetic nerves is thought to decrease both the afferent... | View |
| 07.001.161 | Patient Specific Instrumentation (Eg Cutting Guides) For Joint Arthroplasty | May 2026 | Patient-specific instrumentation has been developed as an alternative to conventional cutting guides for... | View |
| 07.001.162 | Allograft Injection For Degenerative Disc Disease | Jun 2025 | Degeneration of the intervertebral discs is commonly observed in imaging and has been proposed to be a source... | View |
| 07.001.163 | Cryoablation for Chronic Rhinitis | Mar 2026 | Chronic rhinitis is a common medical condition that encompasses allergic rhinitis, nonallergic rhinitis, and... | View |
| 07.001.164 | Liposuction for Lipedema and Lymphedema | Aug 2025 | Lipedema is a disorder characterized by a large amount of subcutaneous fat in the extremities, typically the... | View |
| 07.001.165 | Laser Interstitial Thermal Therapy for Neurological Conditions | Jan 2026 | Laser interstitial thermal therapy (litt) involves the introduction of a laser fiber probe to deliver thermal... | View |
| 07.001.166 | Uterus Transplantation for Absolute Uterine Factor Infertility | Sep 2025 | Absolute uterine factor infertility is a condition in which an individual is unable to achieve pregnancy due... | View |
| 07.001.167 | Remote Electrical Neuromodulation for Migraines | Nov 2025 | Migraine attacks due to episodic or chronic migraine require acute management. some individuals may also... | View |
| 07.001.168 | Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation | Sep 2025 | Atrial fibrillation (af) is the most common type of cardiac arrhythmia. stroke associated with af is... | View |
| 07.001.169 | Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia | Jan 2026 | Benign prostatic hyperplasia (bph) is a common condition in older individuals that can lead to increased... | View |
| 07.001.170 | Lithotripsy for Salivary Stones | Sep 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 | Sep 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 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 2026 | Hypertrophic scars and keloids are cutaneous lesions resulting from abnormal wound healing. there is no gold... | View |