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 |
|---|---|---|---|---|
| 07.001.079 | Occipital Nerve Stimulation | May 2026 | Occipital nerve stimulation delivers a small electrical charge to the occipital nerve intended to prevent... | View |
| 07.001.080 | Surgical Treatment Of Femoroacetabular Impingement | May 2026 | Femoroacetabular impingement results from localized compression within the joint as a result of an anatomic... | View |
| 07.001.081 | Laser Treatment Of Wine Stains | Mar 2026 | Destruction of cutaneous vascular proliferative lesions (cvpls) involves the use of laser or other... | View |
| 07.001.082 | Bronchial Valves | Jul 2025 | Bronchial valves are synthetic devices deployed with bronchoscopy into ventilatory airways of the lung to... | View |
| 07.001.083 | Surgery Of Paranasal Sinuses Guided By Images | Nov 2020 | Surgery guided by images is a system of three-dimensional mapping that combines computerized tomography and... | View |
| 07.001.084 | Fusion Vertebral Lumbar minimamente Invasiva | Aug 2017 | ... | View |
| 07.001.085 | Autologous Fat Grafting To The Breast And Adipose-Derived Stem Cells | Oct 2020 | Autologous fat grafting to the breast has been used as an adjunct to reconstructive breast surgery, for... | View |
| 07.001.086 | Image-Guided Minimally Invasive Decompression For Spinal Stenosis | May 2026 | Image-guided minimally invasive decompression describes a percutaneous procedure for decompression of the... | View |
| 07.001.088 | Lung Volume Reduction Surgery For Severe Emphysema | Jul 2025 | Description – intro lung volume reduction surgery (lvrs) is proposed as a treatment option for patients... | View |
| 07.001.089 | Septoplasty | Nov 2021 | Septoplasty nasal septoplasty is a procedure to correct anatomical deformity or deviation of the nasal... | View |
| 07.001.090 | Microwave Tumor Ablation | Jan 2026 | Microwave ablation (mwa) is a technique to destroy tumors and soft tissue using microwave energy to create... | View |
| 07.001.091 | Electrical Stimulation Of The Spine As An Adjunct To Spinal Fusion Procedures | May 2026 | Both invasive and noninvasive electrical bone growth stimulators have been investigated as an adjunct to... | View |
| 07.001.092 | Interspinous Fixation (Fusion) Devices | May 2026 | Interspinous fixation (fusion) devices are being developed to aid in the stabilization of the spine. they are... | View |
| 07.001.094 | Magnetic Esophageal Sphincter Augmentation To Treat Gastroespphageal Reflux Disease | Dec 2025 | A laparoscopically implanted ring composed of interlinked titanium beads with magnetic cores has been... | View |
| 07.001.095 | Coblation Assisted Tonsilectomy | Nov 2021 | Standard electro-surgical instruments and lasers use thermal energy. other methods to break down tissues have... | View |
| 07.001.096 | Magnetic Resonance-Guided Focused Ultrasound | Aug 2025 | An integrated system providing magnetic resonance-guided focused ultrasound (mrgfus) treatment is proposed as... | View |
| 07.001.097 | Transcatheter Closure Of Patent Ductus Arteriosus | Jun 2019 | The ductus arteriosus is the vascular remnant of the left sixth aortic arch, connecting the main pulmonary... | View |
| 07.001.098 | Debridment | Oct 2025 | A wound is a disruption of the normal structure and function of the skin and skin architecture. an acute... | View |
| 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 |
| 07.001.100 | Cryosurgical Ablation Of Primary Or Metastatic Liver Tumors | Oct 2025 | Cryosurgical ablation (csa) involves the freezing of target tissues, often by inserting a probe through which... | View |