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 |
|---|---|---|---|---|
| 07.001.099 | Hip Resurfacing | May 2026 | Hip resurfacing is an alternative to total hip arthroplasty (also known as hip replacement) for patients with... | View |
| 07.001.101 | Subtalar Arthroereisis | May 2026 | Arthroereisis is a surgical procedure that purposely limits movement across a joint. subtalar arthroereisis... | View |
| 07.001.103 | Transcatheter Aortic Valve Implantation For Aortic Stenosis | Sep 2026 | Aortic stenosis is narrowing of the aortic valve opening, resulting in obstruction of blood flow from the... | View |
| 07.001.104 | Transcatheter Pulmonary Valve Implantation | Jul 2026 | Transcatheter pulmonary valve implantation (tpvi) is a less invasive alternative to open surgical pulmonary... | View |
| 07.001.105 | Electromagnetic Navigational Bronchoscopy | Jul 2026 | Electromagnetic navigation bronchoscopy (enb) is intended to enhance standard bronchoscopy by providing a... | View |
| 07.001.107 | Surgical Treatment Of Bilateral Gynecomastia | Mar 2026 | Gynecomastia, a benign proliferation of the glandular tissue of the male breast, is caused by an increase in... | View |
| 07.001.114 | Bioengineered Skin And Soft Tissue Substitutes | May 2026 | Bioengineered skin and soft tissue substitutes may be derived from human tissue (autologous or allogeneic),... | View |
| 07.001.115 | Vertical Expandable Prosthetic Titanium Rib | May 2026 | The vertical expandable prosthetic titanium rib is a curved rod placed vertically in the chest to help shape... | View |
| 07.001.118 | Percutaneous Electrical Nerve Stimulation And Pecutaneous Neuromodulation Therapy | Apr 2026 | Percutaneous electrical nerve stimulation (pens), percutaneous neuromodulation therapy (pnt), and restorative... | View |
| 07.001.120 | Facet Arthroplasty | May 2026 | Facet arthroplasty refers to the implantation of a spinal prosthesis to restore posterior element structure... | View |
| 07.001.123 | Hydrogel Spacer use During Radiotherapy for Prostate Cancer | Sep 2026 | For low- or intermediate-risk prostate cancer, radiation therapy is an option. because the rectum lies in... | View |
| 07.001.124 | Semi-Implantable And Fully Implantable Middle Ear Hearing Aids | Mar 2026 | Moderate-to-severe sensorineural hearing loss is often treated with external acoustic hearing aids, while... | View |
| 07.001.125 | Surgical Deactivation Of Headache Trigger Sites | Mar 2026 | Migraine is a common headache disorder that is treated using various medications, which can be taken at the... | View |
| 07.001.126 | Handheld Radiofrequency Spectroscopy For Intraoperative Assessment Of Surgical Margins During Breast-Conserving Surgery | Mar 2026 | As part of the treatment of localized breast cancer, breast-conserving surgery is optimally achieved by... | View |
| 07.001.127 | Surgery For Groin Pain In Athletes | Mar 2026 | Sports-related groin pain, commonly known as athletic pubalgia or sports hernia, is characterized by... | View |
| 07.001.128 | Balloon Dilation Of The Eustachian Tube | Mar 2026 | Eustachian tube dysfunction (etd) occurs when the functional valve of the eustachian tube fails to open... | View |
| 07.001.134 | Steroid-Eluting Sinus Stents | Mar 2026 | Steroid-eluting sinus stents are devices used postoperatively following endoscopic sinus surgery (ess) or for... | View |
| 07.001.139 | Peripheral Subcutaneous Field Stimulation | May 2026 | ... | View |
| 07.001.143 | Responsive Neurostimulation For The Treatment Of Refractory Focal Epilepsy | May 2026 | Approximately one-third of individuals with epilepsy do not respond to typical first-line therapy with... | View |
| 07.001.151 | Prostatic Urethral Lift | Sep 2026 | Benign prostatic hyperplasia (bph) is a common condition in older individuals that can lead to increased... | View |