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 |
|---|---|---|---|---|
| 06.001.015 | Stereotactic Radiosurgery And Stereotactic Body Radiotherapy | Sep 2026 | Stereotactic radiosurgery (srs) and stereotactic body radiotherapy (sbrt) are highly precise radiotherapy... | View |
| 06.001.018 | Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine | May 2026 | Percutaneous vertebroplasty, percutaneous balloon kyphoplasty, radiofrequency kyphoplasty, and mechanical... | View |
| 06.001.046 | Optical Coherence Tomography Of The Anterior Eye Segment | Apr 2026 | Escription optical coherence tomography is a noninvasive, high-resolution imaging method that can be used to... | View |
| 06.001.062 | Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve | Jul 2026 | Invasive coronary angiography (ica) is clinically useful in stable ischemic heart disease when there is... | View |
| 07.001.005 | Decompression Of The Intervertebral Disc Using Laser Energy (Laser Discectomy) Or Radiofrequency Coblation (Nucleoplasty) | May 2026 | Laser energy (laser discectomy) and radiofrequency coblation (nucleoplasty) are being evaluated for... | View |
| 07.001.007 | Gastric Electrical Stimulation | Mar 2026 | Gastric electrical stimulation (ges) is performed using an implantable device designed to treat chronic... | View |
| 07.001.009 | Computer-Assisted Navigation For Orthopedic Procedure | May 2026 | Computer-assisted navigation in orthopedic procedures describes the use of computer-enabled tracking systems... | View |
| 07.001.014 | Reduction Mammaplasty For Breast-Related Symptoms | Mar 2026 | Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. macromastia... | View |
| 07.001.015 | Reconstructive Breast Surgery/Management Of Breast Implants After Mastectomy | Jul 2026 | Reconstructive breast surgery is defined as a surgical procedure that is designed to restore the normal... | View |
| 07.001.018 | Electrical Bone Growth Stimulation Of The Appendicular Skeleton | May 2026 | In the appendicular skeleton, electrical stimulation with either implantable electrodes or noninvasive... | View |
| 07.001.025 | Sacral Nerve Neuromodulation/Stimulation | May 2026 | Sacral nerve neuromodulation, also known as sacral nerve stimulation, involves the implantation of a... | View |
| 07.001.026 | Bronchial Thermoplasty | Jul 2026 | Bronchial thermoplasty is a potential treatment option for individuals with severe persistent asthma. it... | View |
| 07.001.028 | Injectable Bulking Agents For The Treatment Of Urinary And Fecal Incontinence | Apr 2026 | Bulking agents are injectable substances used to increase tissue bulk. they can be injected periurethrally to... | View |
| 07.001.029 | Spinal Cord And Dorsal Root Ganglion Stimulation | May 2026 | Spinal cord stimulation delivers low-voltage electrical stimulation to the dorsal columns of the spinal cord... | View |
| 07.001.030 | Vagus Nerve Stimulation | Mar 2026 | Stimulation of the vagus nerve can be performed using a pulsed electrical stimulator implanted within the... | View |
| 07.001.031 | Deep Brain Stimulation | May 2026 | Deep brain stimulation involves the stereotactic placement of an electrode into a central nervous system... | View |
| 07.001.037 | Bone Morphogenetic Protein | May 2026 | Two recombinant human bone morphogenetic proteins (rhbmps) have been extensively studied: recombinant human... | View |
| 07.001.039 | Meniscal Allografts And Other Meniscal Implants | May 2026 | Meniscal allografts and other meniscal implants (eg, collagen) are intended to improve symptoms and reduce... | View |
| 07.001.041 | Cochlear Implant | Mar 2026 | A cochlear implant is a device for treatment of severe-to-profound hearing loss in individuals who only... | View |
| 07.001.042 | Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, And Biacuplasty | May 2026 | Electrothermal intradiscal annuloplasty therapies use radiofrequency energy sources to treat discogenic low... | View |