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 |
|---|---|---|---|---|
| 07.001.174 | Peripheral Nerve Injury Repair Using Synthetic Conduits or Processed Nerve Allografts | Feb 2026 | Peripheral nerve injuries are common traumatic events for which the conventional treatment is the... | View |
| 07.001.175 | Intramedullary Limb-Lengthening Systems | Feb 2026 | 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 | Jan 2026 | 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 2026 | Nasal obstruction is defined clinically as a patient symptom that presents as a sensation of reduced or... | View |
| 07.001.178 | Balloon Spacers for Treatment of Irreparable Rotator Cuffs of the Shoulder | May 2026 | Subacromial balloon spacer implantation represents a minimally invasive treatment modality for massive... | View |
| 07.001.181 | Treatment of Tarlov Cyst | Mar 2026 | Tarlov cysts (tc; perineural cyst, sacral perineural cyst, sacral meningeal cyst) are characterized as... | View |
| 07.001.182 | Intracoronary Drug Delivery Ballon Procedures | Feb 2026 | Drug-coated balloons (dcbs) deliver antiproliferative agents directly to the coronary vessel wall via a... | View |
| 07.001.183 | Prostate Artery Embolization for Benign Prostatic Hyperplasia | Feb 2026 | Prostate arterial embolization (pae) has been investigated as a minimally invasive alternative to... | View |
| 07.002.001 | Intravenous Sedation | Nov 2019 | Adequate sedation and analgesia are important parts of many diagnostic and therapeutic procedures. several... | View |
| 07.002.002 | Monitored Anesthesia Care | Dec 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 | Jan 2026 | Revascularization (either surgical or percutaneous) is a treatment option for certain individuals with lower... | View |
| 07.003.001 | Tratamiento del mal de Parkinson | Sep 2016 | ... | View |
| 07.003.002 | Placental And Umbilical Cord Blood As A Source Of Stem Cells | Mar 2021 | This evidence review addresses the collection, storage, and transplantation of placental and umbilical cord... | View |
| 07.003.003 | Isolated Small Bowel Transplant | Oct 2025 | A small bowel transplant may be performed as an isolated procedure or in conjunction with other visceral... | View |
| 07.003.004 | Transplante nomieloablativo de médula ósea o células germinales periféricas en e | Nov 2012 | ... | View |
| 07.003.005 | Allogeneic Pancreas Transplant | Oct 2025 | Transplantation of a healthy pancreas is a treatment for individuals with insulin-dependent diabetes.... | View |
| 07.003.006 | Liver Transplant And Combined Liver-Kidney Transplant | Dec 1969 | Liver transplantation is currently the treatment of last resort for individuals with end-stage liver disease.... | View |
| 07.003.007 | Heart Transplant | Oct 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 | Oct 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 | Oct 2025 | Heart/lung transplantation involves a coordinated triple operative procedure consisting of procurement of a... | View |