Patient-specific instrumentation has been developed as an alternative to conventional cutting guides for joint arthroplasty. Patient-specific cutting guides are constructed with the aid of preoperative 3-dimensional computed tomography or magnetic resonance imaging scans and proprietary planning software. The goals of patient-specific instrumentation are to increase surgical efficiency and to improve implant alignment and clinical outcomes.

Radiofrequency ablation (RFA) of the renal sympathetic nerves is thought to decrease both the afferent sympathetic signals from the kidney to the brain and the efferent signals from the brain to the kidney. This procedure decreases sympathetic activation, decreases vasoconstriction, and decreases activation of the renin-angiotensin system. Radiofrequency ablation of the renal sympathetic nerves may act as a nonpharmacologic treatment for hypertension and has been proposed as a treatment option for patients with uncontrolled hypertension despite the use of anti-hypertensive medications.

This evidence review addresses orthopedic implants that are constructed by additive manufacturing, commonly known as 3-dimensional (3D) printing. Three situations are considered: 3D printing of standard-sized implants, 3D printing of patient-matched implants for individuals who have typical bone and joint anatomy, and custom 3D-printed implants for patients who have a bone or joint deformity. For individuals who have typical bone and joint anatomy and are undergoing standard orthopedic procedures who receive a standard-sized 3D printed implant, the evidence includes a randomized controlled trial and systematic review. Relevant outcomes include symptoms, functional outcomes, and quality of life. There is limited data on the performance of orthopedic implants produced by additive manufacturing. 3D-printed implants are often manufactured with titanium and permit greater porosity than traditional manufacturing techniques. The literature on solid titanium implants has suggested greater subsidence compared with polyetheretherketone interbody spacers for spinal fusion and greater bone resorption compared with cobalt-chromium femoral stems in total hip arthroplasty. Other evidence suggests that porous titanium implants produced by 3D-printing may improve osteointegration and reduce aseptic loosening. Due to these conflicting findings, clinical trials are needed to evaluate how 3D-printed implants perform over the long-term compared with conventionally manufactured devices. The evidence is insufficient to determine the effects of the technology on health outcomes. For individuals who have typical bone and joint anatomy and are undergoing standard orthopedic procedures who receive a patient-matched 3D printed implant, the evidence includes no comparative studies. Relevant outcomes include symptoms, functional outcomes, and quality of life. Studies are needed to determine whether patient-matched implants improve outcomes compared with conventional implants. It is noted that other methods for the customization of orthopedic procedures, specifically patient-specific cutting guides and sex-specific implants, have failed to demonstrate improvements in health outcomes. Demonstration of improvement in key outcome measures is needed to justify the greater resource utilization (eg, time, imaging) of patient-matched 3D printed devices. The evidence is insufficient to determine the effects of the technology on health outcomes. For individuals who have a bone or joint deformity requiring a custom orthopedic implant who receive a custom 3D printed implant, the evidence includes case series. Relevant outcomes include symptoms, functional outcomes, and quality of life. The largest case series with the longest follow-up is from outside of the U. S. The most commonly reported indications are for revision total hip arthroplasty with severe acetabular defects, reconstruction following orthopedic tumor resection, and spinal abnormalities. These cases would require a custom process for design and manufacturing, even with traditional manufacturing methods. Therefore, the design and manufacturing of a single implant with 3D printing is an advantage of this technology. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

There are various surgical approaches to treat atrial fibrillation (AF) that work by interrupting abnormal electrical activity in the atria. Open surgical procedures, such as the Cox maze procedure were first developed for this purpose and are now generally performed in conjunction with valvular or coronary artery bypass graft surgery. Surgical techniques have evolved to include minimally invasive approaches that use epicardial radiofrequency ablation, a thoracoscopic or mediastinal approach, and hybrid catheter ablations/open procedures.

A variety of procedures are being developed to resurface articular cartilage defects. Autologous chondrocyte implantation (ACI) involves harvesting chondrocytes from healthy tissue, expanding the cells in vitro, and implanting the expanded cells into the chondral defect. Second- and third-generation techniques include combinations of autologous chondrocytes, scaffolds, and growth factors.

Chronic rhinosinusitis (CRS) is a common chronic condition associated with significant morbidity. Functional endoscopic sinus surgery (FESS) involves the removal of varying amounts of tissue and the opening of sinus ostia to treat CRS.

Before a transrectal ultrasound-guided biopsy, a magnetic resonance imaging (MRI) scan can be used to pinpoint the location of suspicious lesions in the prostate. Use of MRI permits a targeted biopsy (as opposed to a blind biopsy, which is the current standard of care). The use of an MRI-guided prostate biopsy serves 2 functions: (1) to identify areas in the prostate that could harbor a high-grade tumor; and (2) to divert attention from any clinically insignificant cancers not needing treatment. In accomplishing the secondary function, patients are placed into 1 of 2 categories: those only needing active surveillance and those needing definitive intervention.

Benign prostatic hyperplasia (BPH) is a common condition in older individuals that can lead to increased urinary frequency, an urgency to urinate, a hesitancy to urinate, nocturia, and a weak stream when urinating. The prostatic urethral lift (PUL) procedure involves the insertion of 1 or more permanent implants into the prostate, which retracts prostatic tissue and maintains an expanded urethral lumen. Use of temporarily implanted nitinol devices for benign prostatic hyperplasia is addressed separately in evidence review 7.01.175.

Vertebral artery diseases, including atherosclerotic stenosis, dissections, and aneurysms, can lead to ischemia of the posterior cerebral circulation. Conventional management of extracranial vertebral artery diseases may include medical therapy (eg, antiplatelet or anticoagulant medications), medications to reduce atherosclerotic disease risk (eg, statins), and/or surgical revascularization. Endovascular therapies have been investigated as an alternative to conventional management.

Approximately one-third of individuals with epilepsy do not respond to typical first-line therapy with antiepileptic medications. Seizures that occur in these individuals are referred to as refractory or drug-resistant. In individuals with refractory epilepsy, combination antiepileptic therapy often results in increased risk of adverse events. Other nonpharmacologic treatment options are available, including surgical approaches, ketogenic diet, and responsive neurostimulation. One responsive neurostimulation device, the NeuroPace RNS System, has U.S. Food and Drug Administration (FDA) approval for the treatment of refractory focal (formerly partial) epilepsy. Summary – Intro Responsive neurostimulation for the treatment of epilepsy involves the use of 1 or more implantable electric leads that serve both a seizure detection and neurostimulation function. The device is programmed using a proprietary algorithm to recognize seizure patterns from electrocorticography output and to deliver electrical stimulation with the goal of terminating a seizure. The NeuroPace RNS System has U.S. FDA approval for the treatment of refractory focal (formerly partial) epilepsy. For individuals who have refractory focal epilepsy who receive responsive neurostimulation, the evidence includes an industry-sponsored randomized controlled trial, which was used for FDA approval of the NeuroPace RNS System, as well as several published follow-up analyses.. Relevant outcomes are symptoms, morbid events, quality of life, and treatment-related mortality and morbidity. The randomized controlled trial was well-designed and well-conducted; it reported that responsive neurostimulation is associated with improvements in mean seizure frequency in individuals with refractory focal epilepsy, with an absolute difference in change in seizure frequency of about 20% between groups; however, the percentage of treatment responders with at least a 50% reduction in seizures did not differ from sham control. Overall, the results suggested a modest reduction in seizure frequency in a subset of individuals. The number of adverse events reported in the available studies is low, although the data on adverse events were limited because of small study samples. Generally, individuals who are candidates for responsive neurostimulation are severely debilitated and have few other treatment options, so the benefits are likely high relative to the risks. In particular, individuals who are not candidates for resective epilepsy surgery and have few treatment options may benefit from responsive neurostimulation. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome. Additional Information Not applicable. >

Steroid-eluting sinus stents are devices used postoperatively following endoscopic sinus surgery (ESS) or for treatment of recurrent sinonasal polyposis following ESS. These devices maintain patency of the sinus openings in the postoperative period, and/or serve as a local drug delivery vehicle. Reducing postoperative inflammation and maintaining patency of the sinuses may be important in achieving optimal sinus drainage and may impact recovery from surgery and/or reduce the need for additional surgery.

Radiofrequency (RF) coblation is being evaluated for the treatment of plantar fasciitis, lateral epicondylitis, and various musculoskeletal tendinopathies. When utilized for tenotomy, bipolar RF energy is directed into the tendon to generate a controlled, low-temperature field of ionizing particles that break organic bonds, ablating or debriding target tissue with the goal of relieving pain and restoring function.

Rhinoplasty Rhinoplasty is a procedure to correct congenital anatomical deformities acquired in the nostrils. <a id="

Articular cartilage damage, either from a focal lesion or diffuse osteoarthritis (OA), can result in disabling pain. Cartilage is a hydrogel, comprised mostly of water with collagen and glycosaminoglycans, that does not typically heal on its own. There is a need for improved treatment options. In 2016, a synthetic polyvinyl alcohol hydrogel disc received marketing approval by the U.S. Food and Drug Administration for the treatment of degenerative or posttraumatic arthritis in the first metatarsophalangeal (MTP) joint. If proven successful for the treatment of the MTP joint, off-label use is likely.

Eustachian tube dysfunction (ETD) occurs when the functional valve of the eustachian tube fails to open and/or close properly. This failure is frequently due to inflammation and can cause symptoms such as muffled hearing, ear fullness, tinnitus, and vertigo. Chronic obstructive ETD can lead to hearing loss, otitis media, tympanic membrane perforation, and cholesteatomas. Balloon dilation of the eustachian tube (BDET) is a procedure intended to improve patency by inflating a balloon in the cartilaginous part of the eustachian tube to cause local dilation.

Sports-related groin pain, commonly known as athletic pubalgia or sports hernia, is characterized by disabling, activity-dependent, lower abdominal and groin pain not attributable to any other cause. Athletic pubalgia is most frequently diagnosed in high-performance male athletes, particularly those who participate in sports that involve rapid twisting and turning such as soccer, hockey, and football. For patients who fail conservative therapy, surgical repair of any defects identified in the muscles, tendons, or nerves has been proposed.

As part of the treatment of localized breast cancer, breast-conserving surgery is optimally achieved by attaining tumor-free margins around the surgical resection site. Handheld radiofrequency spectroscopy for intraoperative assessment of surgical margins (eg, MarginProbe) is intended to increase the probability that the surgeon will achieve clear margins in the initial procedure, thus avoiding the need for a second surgery to excise more breast tissue.

Migraine is a common headache disorder that is treated using various medications, which can be taken at the onset of an attack and/or for migraine prophylaxis. Other treatments include behavioral treatments and botulinum toxin injections. Surgical deactivation of trigger sites is another proposed treatment. Surgical deactivation is based on the theory that migraine headaches arise due to inflammation of the trigeminal nerve branches in the head and neck and that specific trigger sites can be identified in individual patients. Surgical deactivation has also been proposed for other types of headaches (eg, tension headaches).

Moderate-to-severe sensorineural hearing loss is often treated with external acoustic hearing aids, while conductive hearing loss can be treated with acoustic or bone-conduction hearing aids when surgical or medical interventions do not correct hearing loss. Semi-implantable and fully implantable middle ear hearing aids detect sound and transduce signals directly to the ossicles in the middle ear and have been used as an alternative to external acoustic hearing aids.

For low- or intermediate-risk prostate cancer, radiation therapy is an option. Because the rectum lies in close proximity to the prostate, the risk of rectal toxicity is high. One approach is to push the rectum away from the prostate, increasing the space between the 2 and reducing the radiation dose to the rectum. A variety of biomaterials, including polyethylene glycol hydrogels (eg, SpaceOAR™System), hyaluronic acid hydrogels (Barrigel Injectable Gel), or absorbable balloon implants (BioProtect Balloon Implant™ System), have been evaluated as perirectal spacers.

Following a mastectomy, patients often experience pain and irradiated skin; as an adjunct to reconstructive breast surgery, surgeons will sometimes graft autologous fat to the breast. Adipose-derived stem cells (ADSCs) have been proposed as a supplement to the fat graft in an attempt to improve graft survival; however, whether ADSCs play a role in tumorigenesis is still relatively unknown.

Nasal valve collapse (NVC) is a readily identifiable cause of nasal obstruction. Specifically, the internal nasal valve represents the narrowest portion of the nasal airway with the upper lateral nasal cartilages present as supporting structures. The external nasal valve is an area of potential dynamic collapse that is supported by the lower lateral cartilages. Damaged or weakened cartilage will further decrease airway capacity and increase airflow resistance and may be associated with symptoms of obstruction. Patients with NVC may be treated with nonsurgical interventions in an attempt to increase the airway capacity but severe symptoms and anatomic distortion are treated with surgical cartilage graft procedures. The placement of an absorbable implant to support the lateral nasal cartilages has been proposed as an alternative to more invasive grafting procedures in patients with severe nasal obstruction. The concept is that the implant may provide support to the lateral nasal wall prior to resorption and then stiffen the wall with scarring as it is resorbed.

Facet arthroplasty refers to the implantation of a spinal prosthesis to restore posterior element structure and function as an adjunct to neural decompression. This procedure is proposed as an alternative to posterior spinal fusion for patients with facet arthrosis, spinal stenosis, and spondylolisthesis.

Surgery and radiotherapy for breast cancer can lead to lymphedema and are some of the most common causes of secondary lymphedema. There is no cure for lymphedema. However, physiologic microsurgical techniques such as lymphaticovenular anastomosis or vascularized lymph node transfer have been developed that may improve lymphatic circulation, thereby decreasing symptoms and risk of infection. This review focuses on physiologic microsurgical interventions and will not consider reductive (also known as excisional or ablative) surgical interventions such as liposuction.

Percutaneous electrical nerve stimulation (PENS), percutaneous neuromodulation therapy (PNT), and restorative neurostimulation therapy (ReActiv8) combine the features of electroacupuncture and transcutaneous electrical nerve stimulation. Percutaneous electrical nerve stimulation is performed with needle electrodes while PNT uses very fine needle-like electrode arrays placed near the painful area to stimulate peripheral sensory nerves in the soft tissue. ReActiv8 is an implantable electrical neurostimulation system that stimulates the nerves that innervate the lumbar multifidus muscles.

Morton neuroma is a common and painful compression0001 neuropathy of the dorsal foot that is also referred to as intermetatarsal neuroma, interdigital neuroma, interdigital neuritis, and Morton metatarsalgia. Morton neuroma has been treated with conservative measures (pads, orthotics, drugs) or surgery. Minimally invasive procedures, including intralesional alcohol injection, radiofrequency ablation (RFA) and cryoablation, have been investigated as alternatives to open surgery. These methods have also been used to treat other peripheral neuromas.

Routine foot care is defined as any service that treats preventively medical conditions with foot involvement among them: a neuropathic clinical alteration, induced by sustained hyperglycemia, in which with or without coexistence of ischemia and previous traumatic trigger produces injury and / or ulceration of the foot. There are three types of foot involvement: no injuries, at risk and active. This classification is carried out with a comprehensive clinical examination of the foot. Risk factors for peripheral vascular diseases are evaluated, including hypertension, hyperlipidemia, diabetes mellitus, metabolic syndrome, obesity, smoking and sedentary lifestyle. Similarly, there are many medical and surgical specialties such as podiatry, general surgery, orthopedic surgery, family medicine and dermatology that as an essential part of their practice can deal with surgical medical problems of the foot. This document is aimed at defining the policy of Triple S related to routine foot care. <a id="

The vertical expandable prosthetic titanium rib is a curved rod placed vertically in the chest to help shape the thoracic cavity. It is being evaluated in skeletally immature pediatric individuals with thoracic insufficiency syndrome to support thorax and lung development and in pediatric individuals with scoliosis without thoracic insufficiency syndrome to slow or correct curve progression.

Bioengineered skin and soft tissue substitutes may be derived from human tissue (autologous or allogeneic), nonhuman tissue (xenographic), synthetic materials, or a composite of these materials. Bioengineered skin and soft tissue substitutes are being evaluated for a variety of conditions, including breast reconstruction and healing lower-extremity ulcers and severe burns. Acellular dermal matrix (ADM) products are also being evaluated for soft tissue repair. Note that amniotic and placental products are reviewed in evidence review 7.01.149.

Radiofrequency ablation (RFA) and cryoneurolysis of nerves have been proposed as treatments for several different types of pain. RFA has been used to treat a number of clinical pain syndromes such as trigeminal neuralgia as well as cervical and lumbar pain. This review evaluates the application of RFA and cryoneurolysis in peripheral sites distant from the spine.

Blepharoplasty is done to remove excess skin tissue of the upper eyelid. The repair of blepharoptosis corrects the weakness of the levator palpebrae muscle. This weakness results in the drooping of the upper eyelid with possible obstruction of the upper visual field if the abnormality is severe enough. Many cases of mild ptosis do not result in significant compromise of the superior visual field. Aging or disease (less frequently) can result in excess skin of the upper eyelid protruding above the eyelashes and restricting the superior visual field. Blepharoplasty is performed more often for aesthetic reasons, but it may be medically necessary if vision deteriorates. There are many causes of ptosis and pseudoptosis, including congenital disorders; muscle, nervous, disorders and mechanics; complications due to eye surgery, tumors of the eyelids and brain, and age-related changes that damage the eyelid muscles. Many common medical disorders have been associated with ptosis including diabetes, stroke, and myasthenia gravis. If congenital ptosis is treated in children, amblyopia (lazy eye) can develop ptosis. Ptosis repair typically involves reconstructive procedures in the levator muscle and the connective tissues of the eyelid. <a id="

Vagus nerve blocking therapy for obesity consists of an implantable device that delivers electrical stimulation to branches of the vagus nerve on the anterior abdominal wall. The intent is to intermittently block signals to the intra-abdominal vagus nerve to disrupt hunger sensations and induce feelings of satiety. For individuals with obesity who receive vagus nerve blocking therapy, the evidence includes 2 sham-controlled randomized trials. Relevant outcomes are change in disease status, morbid events, quality of life, and treatment-related morbidity. The primary efficacy outcome (at least a 10% difference between groups at 12 months) was not met for either trial. In the first trial, Vagal Blocking for Obesity Control (EMPOWER), the observed difference in excess weight loss between groups at 12 months was 1%. In the more recent trial to Evaluate the Safety and Efficacy of vBloc Therapy Delivered by the Maestro Rechargeable System for the Treatment of Obesity (ReCharge), the observed difference in excess weight loss between groups at 12 months was 8.5%; a post hoc analysis found this difference statistically significant, but the magnitude of change may not be viewed as clinically significant according to investigators’ original trial design decisions. Post hoc analyses of longer-term data have been published and are subject to various biases, including missing data and unblinding at 12 months. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Laminectomy is a surgical procedure in which a portion of the vertebra (the lamina) is removed to decompress the spinal cord. Removal of the lamina creates greater space for the spinal cord and the nerve roots, thus relieving compression on these structures. Laminectomy is typically performed to alleviate compression due to spinal stenosis or a space-occupying lesion.

Gynecomastia, a benign proliferation of the glandular tissue of the male breast, is caused by an increase in the ratio of estrogen to androgen activity. It is categorized as physiologic (occurring normally during infancy, puberty, and older age) or pathologic (due to drugs or disorders such as androgen deficiency, testicular tumors, hyperthyroidism, and chronic kidney disease). In adult men seeking consultation for gynecomastia, approximately 40 percent of cases of gynecomastia are due to persistent pubertal gynecomastia or medications and 25 percent are idiopathic Surgical removal of the breast tissue, using either surgical excision or liposuction, may be considered if conservative therapies are not effective or possible.

Electromagnetic navigation bronchoscopy (ENB) is intended to enhance standard bronchoscopy by providing a 3-dimensional roadmap of the lungs and real-time information about the position of the steerable probe during bronchoscopy. The purpose of ENB is to allow navigation to distal regions of the lungs, so that suspicious lesions can be biopsied and to allow fiducial markers placement.

Transcatheter pulmonary valve implantation (TPVI) is a less invasive alternative to open surgical pulmonary valve replacement or reconstruction for right ventricular outflow tract (RVOT) obstruction. Percutaneous pulmonary valve replacement may be indicated for congenital pulmonary stenosis. Pulmonary stenosis or regurgitation in a patient with congenital heart disease who has previously undergone RVOT surgery are additional indications. Patients with prior congenital heart disease repair are at risk of needing repeated reconstruction procedures.

Aortic stenosis is narrowing of the aortic valve opening, resulting in obstruction of blood flow from the left ventricle into the ascending aorta. Patients with untreated, symptomatic severe aortic stenosis have a poor prognosis. Valve replacement is an effective treatment for severe aortic stenosis. Transcatheter aortic valve implantation (TAVI), also known as transcatheter aortic valve replacement (TAVR), is being evaluated as an alternative to open surgery for patients with aortic stenosis and to nonsurgical therapy for patients with a prohibitive risk for surgery.

Lumbar spinal fusion (arthrodesis) is a surgical technique that involves fusing 2 or more lumbar vertebrae using local bone, autologous bone taken from the iliac crest of the patient, allogeneic donor bone, or bone graft substitutes. There are numerous potential indications for lumbar spinal fusion. Spinal fusion can be performed as a single procedure or in conjunction with other spinal surgeries. For example, lumbar spinal fusion can be performed in combination with discectomy for either herniated discs or degenerative disc disease, or in combination with decompression surgery of the spinal canal for spinal stenosis.

Arthroereisis is a surgical procedure that purposely limits movement across a joint. Subtalar arthroereisis or extraosseous talotarsal stabilization is designed to correct excessive talar displacement and calcaneal eversion by reducing pronation across the subtalar joint. Extraosseous talotarsal stabilization is also being evaluated as a treatment of talotarsal joint dislocation. It is performed by placing an implant in the sinus tarsi, which is a canal located between the talus and the calcaneus.

Cryosurgical ablation (CSA) involves the freezing of target tissues, often by inserting a probe through which coolant is circulated into the tumor. CSA can be performed as an open surgical technique or percutaneously or laparoscopically, typically with ultrasound guidance.

Hip resurfacing is an alternative to total hip arthroplasty (also known as hip replacement) for patients with advanced arthritis of the hip. Total hip resurfacing describes the placement of a shell that covers the femoral head together with implantation of an acetabular cup in patients with painful hip joints. Partial hip resurfacing is considered a treatment option for avascular necrosis with collapse of the femoral head. Available prostheses are metal-on-metal devices.

A wound is a disruption of the normal structure and function of the skin and skin architecture. An acute wound has normal wound physiology, and healing is anticipated to progress through the normal stages of wound healing, whereas a chronic wound is defined as one that is physiologically impaired. To ensure proper healing, the wound bed needs to be well vascularized, free of devitalized tissue, clear of infection, and moist. Wound dressings should eliminate dead space, control exudate, prevent bacterial overgrowth, ensure proper fluid balance, be cost-efficient, and be manageable for the patient and/or nursing staff. Wounds that demonstrate progressive healing as evidenced by granulation tissue and epithelialization can undergo closure or coverage. All wounds are colonized with microbes; however, not all wounds are infected. Debridement is the removal of infected, contaminated, damaged tissue, devitalized, necrotic tissue, and foreign material from a wound. <a id="

The ductus arteriosus is the vascular remnant of the left sixth aortic arch, connecting the main pulmonary artery to the aorta. A patent ductus arteriosus (PDA) is the persistent opening of the channel beyond its expected time of closure during the first few days of life. Catheter-based techniques have been developed to close PDAs to eliminate the need for general anesthesia, a thoracotomy, and an extended hospital stay and convalescence associated with open surgical PDA closure. The use of percutaneous closure devices has become the procedure of choice for closure of patent ductus arteriosus in suitable patients. The evidence base for percutaneous closure of PDAs consists of a large number of case series that report high success rates with low rates of adverse events. A few nonrandomized comparative trials compare outcomes of different devices and techniques, and one such study reports better outcomes with a thoracoscopic approach compared to a percutaneous approach. However, these nonrandomized studies are not adequately rigorous to form conclusions because there is a high likelihood of selection bias, resulting in populations that are not comparable. Based on the evidence that percutaneous closure achieves high success rates and avoids the morbidity of open surgery, this technique may be considered medically necessary. <a id="

An integrated system providing magnetic resonance-guided focused ultrasound (MRgFUS) treatment is proposed as a noninvasive therapy for uterine fibroids and pain palliation of bone metastases. MRgFUS is also being investigated as a treatment of other benign and malignant tumors as well as essential tremors.

Standard electro-surgical instruments and lasers use thermal energy. Other methods to break down tissues have been developed to address the problem of high temperature and damage to surrounding tissues. Coblation is a non-thermal method where the tissue volume is removed through a molecular dissociation similar to the laser exempt. Coblation uses the fluid between the instrument (electrode) and the tissue as a conductor. When electric current is applied to this fluid it becomes charged particles and is called the plasma layer. These charged particles are accelerated by the plasma creating enough energy to break the molecular bonds within the cell. This produces the disintegration of the cells molecule by molecule. In this way, the volume of tissue is reduced. Assisted surgery by coblation uses a continuous mode of operation rather than the pulse mode used by lasers. The purpose of using a continuous mode is to allow coagulation in small vessels, hemostasis in larger vessels and decrease in collagen. Coaling uses relatively low temperatures compared to laser, thus reducing damage to adjacent tissues. <a id="

A laparoscopically implanted ring composed of interlinked titanium beads with magnetic cores has been developed for the treatment of gastroesophageal reflux disease (GERD). The device is placed around the esophagus at the level of the gastroesophageal junction and is being evaluated in patients who have GERD symptoms, despite maximal medical therapy.

Interspinous fixation (fusion) devices are being developed to aid in the stabilization of the spine. They are evaluated as alternatives to pedicle screw and rod constructs in combination with interbody fusion. Interspinous fixation devices are also being evaluated for stand-alone use in individuals with spinal stenosis and/or spondylolisthesis.

Both invasive and noninvasive electrical bone growth stimulators have been investigated as an adjunct to spinal fusion surgery, with or without associated instrumentation, to enhance the probability of obtaining a solid spinal fusion. Noninvasive devices have also been investigated in patients who are at normal risk of failed fusion and to treat a failed fusion.

Microwave ablation (MWA) is a technique to destroy tumors and soft tissue using microwave energy to create thermal coagulation and localized tissue necrosis. Microwave ablation is used to treat tumors not amenable to resection and to treat individuals ineligible for surgery due to age, comorbidities, or poor general health. Microwave ablation may be performed as an open procedure, laparoscopically, percutaneously, or thoracoscopically under image guidance (eg, ultrasound, computed tomography, magnetic resonance imaging) with sedation, or local or general anesthesia. This technique is also referred to as microwave coagulation therapy.

Septoplasty Nasal septoplasty is a procedure to correct anatomical deformity or deviation of the nasal septum. Its purpose is to restore the structure, returning the nasal function. Resulting cosmetic improvement, if any, is incidental. Because the nasal septum is deviated in most adults, there is a potential for overuse in asymptomatic individuals. The primary indication for the surgical treatment of a diverted septum is obstruction of air nasal passages. Corrective surgery is also used as treatment of recurrent epistaxis associated to septal deviation or sinusitis where the deviation represents a contributing factor, and occasionally, is necessary as an approach to enter to other anatomical regions such as the sphenoid, sella turcica, or pituitary gland. In addition, Septoplasty can be used as a response to trauma (nasal trauma) or in addition to the repair of cleft palate. <a id="

Description – Intro Lung volume reduction surgery (LVRS) is proposed as a treatment option for patients with severe emphysema who have failed optimal medical management. The procedure involves the excision of diseased lung tissue to reduce symptoms and improve quality of life.

Image-guided minimally invasive decompression describes a percutaneous procedure for decompression of the central spinal canal in patients with spinal stenosis and hypertrophy of the ligamentum flavum. In this procedure, a specialized cannula and surgical tools (mild®) are used under fluoroscopic guidance for bone and tissue sculpting near the spinal canal. Image-guided minimally invasive lumbar decompression is proposed as an alternative to existing posterior decompression procedures.

Autologous fat grafting to the breast has been used as an adjunct to reconstructive breast surgery, for postmastectomy pain and in irradiated skin. Adipose-derived stem cells (ADSCs) have been proposed as a supplement to the fat graft in an attempt to improve graft survival. Fat grafting to the breast has gained popularity with the development of improved harvesting and transplanting techniques. As an adjunct to reconstructive surgery, reported complication rates have been low; however, the clinical effectiveness, interference with screening mammography and the oncologic safety of fat grafting to the breast is still unclear. The use of adipose-derived stem cells (ADSCs) in conjunction with fat grafting to the breast represents a potential new advance in the field of regenerative medicine. Although there is a possible role that these stem cells could play a role in graft survival through both adipogenesis and angiogenesis, a complete understanding of the mechanisms of interactions among adipose stem cells and growth factors is lacking, as is the understanding of any possible role they may have in tumorigenesis. The way to control ADSC differentiation and the fate of the stem cells also remains unknown. Controlled prospective trials are needed to further investigate the many unanswered questions relating to the application of autologous fat grafting to the breast, with or without the use of ADSCs in conjunction with this procedure. The impact of fat grafting to the breast and the use of ADSCs on net health outcome is unknown and therefore, is considered to be investigational. <a id="

Surgery guided by images is a system of three-dimensional mapping that combines computerized tomography and information in real time to locate exactly the position of the operative instruments by means of infrared or electromagnetic probes. In this way, the otolaryngologist "navigates" through the nasal passages in a more precise way when performing functional endoscopic paranasal sinuses surgery (FESS). In 2005, image-guided surgery (IGS) expanded from the field of neurosurgery, where it was originally used, to the surgery of paranasal sinuses, spine and orthopedic surgery. As the otolaryngologists were gaining experience, its use has been generalized, particularly in the following indications: • Surgery of the paranasal sinuses in the absence of normal anatomy • Revision of surgery of paranasal sinuses • Disease that is extending to the base of the skull • Disease extending to frontal or sphenoid sinuses • Surgery near the lamina papyracea. • Presence of orbital pathology Image-guided surgery provides the surgeon a more detailed view of the extra and intracranial structures such as: areas near the eyes, brain, arteries and major veins, and nerves that can be found during FESS. This technology is particularly useful in revision procedures of FESS where the effects of scarring may be present and common anatomical reference points are not already present or in such complex cases that the anatomy is distorted. FDA has approved for the process 510 (k) several systems for this purpose, namely: • InstaTrak 3000Plus System (GE OEC Medical Systems, Salt Lake City, UT) • StealthStation System (Surgical Navigation Technologies, Broomfield, CO) • VectorVision Cranial/ENT (BrainLAB AG, Heimstetten, Germany) • Stryker Navigation System ENT Module (Stryker Corporation, Kalamazoo, MI) • Fusion Compact Navigation System ( Medtronics,Lousville Colorado) <a id="

Bronchial valves are synthetic devices deployed with bronchoscopy into ventilatory airways of the lung to control airflow. They have been investigated for use in individuals who have prolonged bronchopleural air leaks and in individuals with lobar hyperinflation from severe or advanced emphysema.

Studies have generally found that laser treatment can be effective at lightening port wine stains. The preponderance of evidence is on the pulsed dye laser; there is insufficient evidence from comparative studies that 1 type of laser results in more lightening than another. There is insufficient evidence that adding topical angiogenesis inhibitor to laser therapy results in better outcomes than lasers alone. There was 1 positive RCT and 1 negative RCT. No comparative studies were identified on lasers combined with any other treatments. Thus, laser treatment may be considered medically necessary in certain situations for patients with port wine stains and combination treatment is considered investigational.

Femoroacetabular impingement results from localized compression within the joint as a result of an anatomic mismatch between the head of the femur and the acetabulum. Symptoms of impingement typically occur in young to middle-aged adults before the onset of osteoarthritis but may be present in younger patients with developmental hip disorders. The objective of surgical treatment of femoroacetabular impingement is to provide symptom relief and reduce further joint damage.

Occipital nerve stimulation delivers a small electrical charge to the occipital nerve intended to prevent migraines and other headaches in patients who have not responded to medications. The device consists of a subcutaneously implanted pulse generator (in the chest wall or abdomen) attached to extension leads that are tunneled to join electrodes placed across one or both occipital nerves at the base of the skull. Continuous or intermittent stimulation may be used.

Anal fistula plugs (AFPs) are biosynthetic devices used to promote healing and prevent the recurrence of anal fistulas. They are proposed as an alternative to procedures including fistulotomy, endorectal advancement flaps, seton drain placement, and use of fibrin glue in the treatment of anal fistulas.

Saturation biopsy of the prostate, in which more cores are obtained than by standard biopsy protocol, has been proposed in the diagnosis (for initial or repeat biopsy), staging, and management of individuals with prostate cancer.

Carotid artery angioplasty with stenting and transcarotid artery revascularization are treatments for carotid stenosis that are intended to prevent a future stroke. They are an alternative to medical therapy and a less-invasive alternative to carotid endarterectomy.

Facet denervation is used to treat neck and back pain originating in facet joints with degenerative changes. Diagnosis of facet joint pain is confirmed by response to nerve blocks. The goal of facet denervation is long-term pain relief. However, the nerves regenerate and, therefore, repeat procedures may be required.

Interspinous and interlaminar implants (spacers) stabilize or distract the adjacent lamina and/or spinous processes and restrict extension to reduce pain in patients with lumbar spinal stenosis and neurogenic claudication. Interspinous spacers are small devices implanted between the vertebral spinous processes. After implantation, the device is opened or expanded to distract (open) the neural foramen and decompress the nerves. Interlaminar spacers are implanted midline between the adjacent lamina and spinous processes to provide dynamic stabilization either following decompression surgery or as an alternative to decompression surgery.

Axial lumbosacral interbody fusion (also called presacral, transsacral, or paracoccygeal interbody fusion) is a minimally invasive technique designed to provide anterior access to the L4-S1 disc spaces for interbody fusion while minimizing damage to muscular, ligamentous, neural, and vascular structures. It is performed under fluoroscopic guidance.

In radiofrequency ablation (RFA), a probe is inserted into the center of a tumor; then, prong-shaped, non-insulated electrodes are projected into the tumor. Next, heat is generated locally by an alternating, high-frequency current that travels through the electrodes. The localized heat treats the tissue adjacent to the probe, resulting in a 3 cm to 5.5 cm sphere of dead tissue. The cells killed by RFA are not removed but are gradually replaced by fibrosis and scar tissue. If there is a local recurrence, it occurs at the edge and can sometimes be retreated. RFA may be performed percutaneously, laparoscopically, or as an open procedure.

Isolated Limb Perfusion (ILP)

When used as a therapeutic treatment of local recurrence of nonresectable melanoma (i.e., satellite lesions or “in transit” melanoma), isolated limb perfusion with melphalan may be considered medically necessary.

When used as an adjuvant treatment of surgically treated locally recurrent melanoma with no other evidence of disease, isolated limb perfusion with melphalan is considered investigational.

Isolated limb perfusion in conjunction with hyperthermia or isolated limb perfusion using melphalan in conjunction with tumor necrosis factor or interferon gamma is considered investigational.

When used as an adjuvant treatment of surgically treated primary malignant melanoma with no clinical evidence of disease, isolated limb perfusion with melphalan is considered not medically necessary.

Isolated Limb Infusion (ILI)

When used as a therapeutic treatment of local recurrence of nonresectable melanoma (i.e., satellite lesions or “in transit” melanoma), isolated limb infusion with melphalan may be considered medically necessary.

Isolated limb infusion in the treatment of melanoma is considered investigational for all other indications.

Nerve grafting at the time of radical prostatectomy, most commonly using the sural nerve, has been proposed to reduce the risk of postoperative erectile dysfunction.

Risk-reducing mastectomy is defined as the removal of the breast in the absence of malignant disease to reduce the risk of breast cancer occurrence.

Total disc replacement, using an artificial intervertebral disc designed for the lumbar spine, is proposed as an alternative to spinal fusion in patients with degenerative disc disease leading to disabling symptoms.

Transanal endoscopic microsurgery (TEM) is a minimally invasive approach for local excision of rectal lesions that cannot be directly visualized. It is an alternative to open or laparoscopic excision and has been studied in the treatment of both benign and malignant conditions of the rectum.

Wireless sensors implanted in an aortic aneurysm sac after endovascular repair are being investigated to measure postprocedural pressure. It is thought that low pressures may correlate with positive prognoses and high pressures may indicate the need for revision. For individuals who have received endovascular aneurysm repair who are monitored with wireless pressure sensors, the evidence consists of case series. Relevant outcomes are test accuracy and validity, resource utilization, and treatment-related morbidity. Evidence from small case series is insufficient to indicate whether use of this device improves clinical outcomes. Device performance over time, including the accuracy of the device in patients with various types of endoleaks, needs to be assessed. Work is also needed to determine the type and number of devices that might best for monitoring because sac compartmentalization might lead to a pressure-sensing device missing an endoleak. It also is not known whether there are serious long-term complications from this implanted device. Furthermore, the extent to which the device can reduce imaging requirements following endovascular aneurysm repair (which can be established using direct comparison to computed tomography) is undetermined. The evidence is insufficient to determine the effects of the technology on health outcomes. <a id="

Radiofrequency ablation (RFA) is a procedure in which a probe is inserted into the center of a tumor and heated locally by a high-frequency, alternating current that flows from electrodes. The local heat treats the tissue adjacent to the probe, resulting in a 3 to 5 cm sphere of dead tissue. The cells killed by RFA are not removed but are gradually replaced by fibrosis and scar tissue. If there is a local recurrence, it occurs at the edge of the treated tissue and, in some cases, is retreated. Radiofrequency ablation may be performed percutaneously, laparoscopically, or as an open procedure.

Several prosthetic devices are currently available for cervical disc arthroplasty. Cervical disc arthroplasty is proposed as an alternative to anterior cervical discectomy and fusion for patients with symptomatic cervical degenerative disc disease.

Transmyocardial revascularization (TMR), also known as transmyocardial laser revascularization, is a surgical technique that attempts to improve blood flow to ischemic heart muscles by creating direct channels from the left ventricle into the myocardium. TMR may be performed via a thoracotomy or percutaneous TMR (PTMR).

Thermal capsulorrhaphy uses thermal energy to restructure collagen in the capsule or ligaments to reduce the capsule size. This procedure has primarily been evaluated for shoulder joint instability and proposed to treat capsular laxity in other joints. The literature does not support use of thermal capsulorrhaphy. The few available comparative studies do not support that this procedure is an efficacious treatment for shoulder instability. The case series report a high rate of unsatisfactory results and complications, raising the potential for a net harm. Because of the lack of efficacy and potential for harm, this procedure is considered not medically necessary. <a id="

Most commonly seen in children, vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder upward toward the kidney. The primary management strategies have been prophylactic antibiotics to reduce urinary tract infections and, for higher grade disease, surgical correction of the underlying reflux. Injection of periureteral bulking agents is proposed as an alternative to surgical intervention.

An auditory brainstem implant (ABI) is designed to restore some hearing in people with neurofibromatosis type 2 who are rendered deaf by bilateral removal of neurofibromas involving the auditory nerve. ABIs have also been studied to restore hearing for other non-neurofibromatosis indications.

Percutaneous tibial nerve stimulation (PTNS; also known as posterior tibial nerve stimulation) is an electrical neuromodulation technique used primarily for treating voiding dysfunction. Subcutaneous tibial nerve stimulation via an implantable peripheral neurostimulator is an alternate technique for treating urgency urinary incontinence associated with overactive bladder syndrome.

Balloon ostial dilation (BOD, also known as balloon sinuplasty) is proposed as an alternative to functional endoscopic sinus surgery (FESS) for individuals with chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis (RARS) who fail medical management. The procedure involves placing a balloon in the sinus ostium and inflating the balloon to stretch the opening. It can be performed as a stand-alone procedure or as an adjunctive procedure to FESS. This evidence review addresses BOD as a standalone procedure.

An implantable cardioverter defibrillator (ICD) is a device designed to monitor a patient's heart rate, recognize ventricular fibrillation or ventricular tachycardia, and deliver an electric shock to terminate these arrhythmias to reduce the risk of sudden death. A subcutaneous ICD (S-ICD), which lacks transvenous leads, is intended to reduce lead-related complications.

Percutaneous nephrostolithotomy (PCN) is an invasive procedure for removing upper urinary tract stones by means of forceps or wire basket devices. Percutaneous lithotripsy (PCL) is often used to break up large kidney stones to a more manageable size. A nephrostomy tract is first established by using a needle, catheter, dilators, and a nephrostomy tube under fluoroscopic guidance. After this has been accomplished, an endoscope is used to visualize the treatment area while lithotripsy instruments are inserted into the nephrostomy tube to break up the kidney stone. Stone fragments are removed by catheter suction, forceps, or a small basket; smaller fragments are sometimes left to pass spontaneously. General or local anesthesia may be appropriate. <a id="

Intraoperative neurophysiologic monitoring describes a variety of procedures used to monitor the integrity of neural pathways during high-risk neurosurgical, orthopedic, and vascular surgeries. It involves the detection of electrical signals produced by the nervous system in response to sensory or electrical stimuli to provide information about the functional integrity of neuronal structures. This evidence review does not address established neurophysiologic monitoring (ie, somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography of cranial nerves, electroencephalography, electrocorticography), during spinal, intracranial, or vascular procedures.

Surgical ventricular restoration is designed to restore or remodel the left ventricle to its normal, spherical shape and size in patients with akinetic segments of the heart, secondary to ischemic dilated cardiomyopathy.

Sensorineural, conductive, and mixed hearing loss may be treated with various devices, including conventional air-conduction or bone-conduction external hearing aids. Air-conduction hearing aids may not be suitable for patients with chronic middle ear and ear canal infections, atresia of the external canal, or an ear canal that cannot accommodate an ear mold. Bone-conduction hearing aids may be useful for individuals with conductive hearing loss, or (if used with contralateral routing of signal), for unilateral sensorineural hearing loss. Implantable, bone-anchored hearing aids (BAHAs) that use a percutaneous or transcutaneous connection to a sound processor have been investigated as alternatives to conventional bone-conduction hearing aids for patients with conductive or mixed hearing loss or for patients with unilateral single-sided sensorineural hearing loss.

Osteochondral grafts are used to repair full-thickness chondral defects involving a joint. In the case of osteochondral autografts, 1 or more small osteochondral plugs are harvested from non-weight-bearing sites, usually from the knee, and press fit into a prepared site in the lesion. Osteochondral allografts are typically used for larger lesions. Autologous or allogeneic minced cartilage, decellularized osteochondral allograft plugs, and reduced osteochondral allograft discs are also being evaluated as a treatment of articular cartilage lesions.

Electrothermal intradiscal annuloplasty therapies use radiofrequency energy sources to treat discogenic low back pain arising from annular tears. These annuloplasty techniques are designed to decrease pain arising from the annulus by thermocoagulating nerves in the disc and tightening annular tissue.

A cochlear implant is a device for treatment of severe-to-profound hearing loss in individuals who only receive limited benefit from amplification with hearing aids. A cochlear implant provides direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea.

Morbid obesity is defined as an increase in body weight above an optimal level resulting in significant complications and comorbidities with a reduction in longevity. For example, morbid obesity has a significant impact on the cardiovascular risk factors, incidence of diabetes, obstructive sleep apnea, and various types of cancer (in men: colon, rectum and prostate and in women: breast, uterus and ovary, among others). The first treatment for morbid obesity is diet with lifestyle modification. life, but this strategy only works in 5-10% who manage to reach and maintain the weight lost for more than three years. When conservative measures don't work there are surgical measures that can be considered in each particular case. In 1991, the NIH established two levels for candidates for surgery based on the index of body mass (BMI): 1. Those with a BMI of 40kg/m2 or greater would be candidates and 2. Those with a BMI of 35kg/m2 with cardiopulmonary comorbidities or diabetes they would also be candidates. After surgery and massive weight loss, some of these patients remain with deforming flaps, which are frequent areas of skin mycosis and infections and that make daily personal hygiene difficult. To these patients, many of whom have improved their diabetes, hypertension, apnea etc., they can be offered reconstructive surgery after bariatric surgery. The purpose of these procedures is focused on improving pre-existing diseases and improving the quality of life of the patient exclusively. It is not considered cosmetic surgery. <a id="

Meniscal allografts and other meniscal implants (eg, collagen) are intended to improve symptoms and reduce joint degeneration in patients who have had a total or partial meniscus resection. For individuals who are undergoing partial meniscectomy who receive meniscal allograft transplantation, the evidence includes systematic reviews of mostly case series and a randomized controlled trial. The relevant outcomes are symptoms, functional outcomes, and quality of life. The systematic reviews concluded that most studies have shown statistically significant improvements in pain and function following the procedure. The benefits have also been shown to have a long-term effect (>10 years). Reviews have also reported acceptable complication and failure rates. There remains no evidence that meniscal allograft transplantation can delay or prevent the development of knee osteoarthritis. A limitation of the evidence is its reliance primarily on case series. Because the single randomized controlled trial, which enrolled a very small number of patients, pooled data from randomized and nonrandomized groups, results cannot be interpreted in a meaningful way. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. For individuals who are undergoing partial meniscectomy and concomitant repair of malalignment, focal chondral defects, and/or ligamentous insufficiency who receive meniscal allograft transplantation, the evidence includes a systematic review of case series as well as case series published after the systematic review. The relevant outcomes are symptoms, functional outcomes, and quality of life. The systematic review concluded that pain and function improved following the procedure. One of the series published after the review showed that patients with more severe cartilage damage experienced favorable outcomes similar to patients with less cartilage damage. Another series published subsequently reported an overall 9.7-year survival of the implant. A limitation of the evidence is its reliance primarily on case series. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. For individuals who are undergoing partial meniscectomy who receive collagen meniscal implants (CMIs), the evidence includes 2 systematic reviews primarily of case series. Relevant outcomes are symptoms, functional outcomes, and quality of life. The reviews reported overall positive results with the CMI, but the quality of the selected studies (RCTs, observational studies) was low. Radiologic evaluations have shown reductions in the size of the implant in a large portion of patients. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome Additional Information Not applicable.

Two recombinant human bone morphogenetic proteins (rhBMPs) have been extensively studied: recombinant human bone morphogenetic protein-2 (rhBMP-2), applied with an absorbable collagen sponge (Infuse), and recombinant human bone morphogenetic protein-7 (rhBMP-7), applied in putty (OP-1; not currently available in the U.S.). These protein products have been investigated as alternatives to bone autografting in a variety of clinical situations, including spinal fusions, internal fixation of fractures, treatment of bone defects, and reconstruction of maxillofacial conditions.

Shock wave lithotripsy — Extracorporeal Shock Wave Lithotripsy (ESWL)remains one of the most commonly used procedures for kidney stones worldwide [35]. SWL can be used to treat small- to medium-sized kidney stones but is not the ideal modality for the management of large or complex stones or stones located in the lower pole of the kidney. The dependent location of lower pole stones makes it more difficult for fragments produced by SWL to be cleared from the kidney. In addition, SWL should not be used in patients with obesity, who are pregnant, or with a bleeding diathesis SWL is generally performed on an outpatient basis with the patient under conscious sedation, general anesthesia, or regional anesthesia. SWL employs high-energy shock waves produced by an electrical discharge. The shock waves are transmitted through water and directly focused onto a kidney/ureteral stone with the aid of biplanar fluoroscopy. The change in tissue density between the soft kidney tissue and the hard stone causes a release of energy at the stone surface. This energy fragments the stone. The main limitations of SWL are the completeness of stone fragmentation as well as the completeness of fragment elimination. Alpha blockers (eg, tamsulosin) may be prescribed to facilitate stone passage following SWL. <a id="

Reconstructive surgery of the ear can be considered for injury, trauma or congenital conditions. Congenital anomalies result from errors in embryogenesis (malformations) or intrauterine events that affect embryonic and fetal growth (deformations and disruptions) [1]. The more complex the formation of a structure, the more opportunities for malformation. <a id="

Phototherapeutic keratectomy is considered for payment when used as an alternative to lamellar keratoplasty in the treatment of visual or irritative problems related to to corneal scars, opacities or dystrophies that extend beyond the layer epithelial.

Phototherapeutic keratectomy is not considered for payment under the following conditions:

Description

Tuberculosis of the eye
Keratoconjunctivitis due to Herpes zoster
Herpes simplex conjunctivitis
Measles keratoconjunctivitis
Keratoconjunctivitis epidemic
syphilitic interstitial keratitis
Keratitis or keratoconjunctivitis in exanthema
Triple-S, Inc. will cover phototherapeutic keratectomy only in those situations where it is recognized as medically necessary as specified in this policy, in those policies that specifically cover it.

None of the refractive keratoplasties are considered for payment. This is a generic term to designate all those surgical procedures that are performed into the cornea of ​​the human eye for the specific purpose of improving vision by changing the refractive index of the corneal surface. Refractive keratoplasty includes following surgeries:

Triple-S, Inc. will cover phototherapeutic keratectomy only in those situations where it is recognized as medically necessary as specified in this policy, in those policies that specifically cover it.

None of the refractive keratoplasties are considered for payment. This is a generic term to designate all those surgical procedures that are performed into the cornea of ​​the human eye for the specific purpose of improving vision by changing the refractive index of the corneal surface. Refractive keratoplasty includes following surgeries:

· Radial keratotomy (RK) is the surgical correction for myopia. The surgeon using a microscope, he makes microincisions in the cornea, in a radial way. When healing, the convexity of the central part of the cornea is reduced, improving vision.

· Refractive keratotomy (PRK) is the use of the “excimer” laser to reshape the cornea evaporating small particles of tissue from the cornea, enough to correct myopia, hyperopia or astigmatism. This process takes 10-20 minutes. The use of laser takes between 15-40 seconds.
· Computerized lamellar keratoplasty (ALK) in this procedure removes a slice of the most anterior part of the cornea. When repositioning and healing this increases the convexity of the cornea correcting the flattening of the cornea present in the hyperopic condition.

· Conductive keratoplasty (CK) reshapes the cornea with one or two circles parallel concentric using laser.

Deep brain stimulation involves the stereotactic placement of an electrode into a central nervous system nucleus (eg, hypothalamus, thalamus, globus pallidus, subthalamic nucleus). Deep brain stimulation is used as an alternative to permanent neuroablative procedures for control of essential tremor and Parkinson disease. Deep brain stimulation is also being evaluated for the treatment of a variety of other neurologic and psychiatric disorders.