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 |
|---|---|---|---|---|
| 07.001.155 | 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 |
| 07.001.161 | 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 |
| 07.001.163 | Cryoablation for Chronic Rhinitis | Mar 2026 | Chronic rhinitis is a common medical condition that encompasses allergic rhinitis, nonallergic rhinitis, and... | View |
| 07.001.166 | Uterus Transplantation for Absolute Uterine Factor Infertility | Sep 2026 | Absolute uterine factor infertility is a condition in which an individual is unable to achieve pregnancy due... | View |
| 07.001.168 | Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation | Sep 2026 | Atrial fibrillation (af) is the most common type of cardiac arrhythmia. stroke associated with af is... | 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 |
| 07.001.184 | Permanently Implanted Prostatic Devices for Benign Prostatic Hyperplasia | Sep 2026 | Benign prostatic hyperplasia (bph) is a common condition in older individuals that can lead to lower urinary... | View |
| 07.001.186 | Navigated Transcranial Magnetic Stimulation for Preoperative Neurosurgical Mapping | Sep 2026 | Navigated transcranial magnetic stimulation (ntms) is a noninvasive method of mapping functional cortical... | View |
| 07.001.187 | Genicular Artery Embolization | Sep 2026 | Osteoarthritis (oa) of the knee is a progressive degenerative joint disease and the most common form of... | View |
| 07.001.188 | Urethral Drug-Coated Balloon for Urethral Stricture and Benign Prostatic Hyperplasia | Sep 2026 | Urethral stricture disease is a fibrotic narrowing of the urethral lumen, most commonly involving the... | View |
| 07.003.003 | Isolated Small Bowel Transplant | Sep 2026 | A small bowel transplant may be performed as an isolated procedure or in conjunction with other visceral... | View |
| 07.003.005 | Allogeneic Pancreas Transplant | Sep 2026 | 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 | Sep 2026 | Liver transplantation is currently the treatment of last resort for individuals with end-stage liver disease.... | View |
| 07.003.007 | Heart Transplant | Sep 2026 | 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 | Sep 2026 | 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 2026 | Heart/lung transplantation involves a coordinated triple operative procedure consisting of procurement of a... | View |