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 |
|---|---|---|---|---|
| 07.001.163 | Cryoablation for Chronic Rhinitis | Mar 2026 | Chronic rhinitis is a common medical condition that encompasses allergic rhinitis, nonallergic rhinitis, and... | View |
| 07.001.164 | Liposuction for Lipedema and Lymphedema | Aug 2025 | Lipedema is a disorder characterized by a large amount of subcutaneous fat in the extremities, typically the... | View |
| 07.001.165 | Laser Interstitial Thermal Therapy for Neurological Conditions | Jan 2026 | Laser interstitial thermal therapy (litt) involves the introduction of a laser fiber probe to deliver thermal... | View |
| 07.001.166 | Uterus Transplantation for Absolute Uterine Factor Infertility | Sep 2025 | Absolute uterine factor infertility is a condition in which an individual is unable to achieve pregnancy due... | View |
| 07.001.167 | Remote Electrical Neuromodulation for Migraines | Nov 2025 | Migraine attacks due to episodic or chronic migraine require acute management. some individuals may also... | View |
| 07.001.168 | Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation | Sep 2025 | Atrial fibrillation (af) is the most common type of cardiac arrhythmia. stroke associated with af is... | View |
| 07.001.169 | Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia | Jan 2026 | Benign prostatic hyperplasia (bph) is a common condition in older individuals that can lead to increased... | View |
| 07.001.170 | Lithotripsy for Salivary Stones | Sep 2025 | The major salivary glands, parotid (front and behind the ear), submandibular (both sides of the jaw), and... | View |
| 07.001.171 | Laser Surgery of the Prostate for Benign Prostatic Hypertrophy | Sep 2025 | Benign prostatic hyperplasia (bph) is a common, noncancerous, and benign enlargement of the prostate gland.... | View |
| 07.001.172 | Suture Button Suspensionplasty Fixation System for Thumb Carpometacarpal Osteoarthritis | Nov 2025 | In the thumb, the most common site for arthritis to develop is in the joint at the base of the thumb, also... | View |
| 07.001.173 | Fractional Laser Treatment of Burn and Traumatic Scars for Functional Improvement | Feb 2026 | Hypertrophic scars and keloids are cutaneous lesions resulting from abnormal wound healing. there is no gold... | View |
| 07.001.174 | Peripheral Nerve Injury Repair Using Synthetic Conduits or Processed Nerve Allografts | Feb 2026 | Peripheral nerve injuries are common traumatic events for which the conventional treatment is the... | View |
| 07.001.175 | Intramedullary Limb-Lengthening Systems | Feb 2026 | Intramedullary limb-lengthening systems (ills) have been introduced as an alternative to the circular... | View |
| 07.001.176 | Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung | Jan 2026 | Irreversible electroporation produces high-frequency electric pulses to create an electric current that... | 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 |
| 07.001.182 | Intracoronary Drug Delivery Ballon Procedures | Feb 2026 | Drug-coated balloons (dcbs) deliver antiproliferative agents directly to the coronary vessel wall via a... | View |
| 07.001.183 | Prostate Artery Embolization for Benign Prostatic Hyperplasia | Feb 2026 | Prostate arterial embolization (pae) has been investigated as a minimally invasive alternative to... | View |
| 07.002.001 | Intravenous Sedation | Nov 2019 | Adequate sedation and analgesia are important parts of many diagnostic and therapeutic procedures. several... | View |