The “Last Review Date” set forth in the Medical Policy
is the most recent date the MPTAC has reviewed or revised the
policy. This is not necessarily coincident with the “Current Effective
Date” which is also
shown on the policy. For example, we may require lead time in order
to program a medical policy on our claims systems. In cases where a
new or revised policy results in the denial of benefits for services
which have historically been covered, we may opt to provide advance
notice of the changes prior to the policy taking effect. To confirm
the effective date of a particular policy for your state or region, please
contact your local health plan customer or provider service area.
The Office of Medical Policy & Technology Assessment has assigned
coordinators for each region in which our enterprise does business. Please contact
the applicable Medical Policy Regional Coordinator below according to your region for
assistance regarding medical policy.
East
Deb Crocker
Kathryn A. King
Central
Michelle Bostic
West
Linda Paradis
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Surgery
- SURG.00001 Carotid, Vertebral and
Intracranial Artery Angioplasty with or without Stent Placement
- SURG.00005 Partial Left Ventriculectomy
- SURG.00007 Vagus Nerve Stimulation
- SURG.00008 Mechanized Spinal Distraction
Therapy for Low Back Pain (VAX-D ® Therapy, DRS ® System, Accu-Spina
System TM IDD Therapy)
- SURG.00009 Refractive Surgery
- SURG.00010 Treatment of Urinary
Incontinence, Urinary Retention, and Sacral Nerve Stimulation
- SURG.00011 Wound Healing: Skin Substitutes
and Blood-Derived Growth Factors
- SURG.00014 Cochlear Implants and Auditory
Brainstem Implants
- SURG.00016 Stereotactic Radiofrequency
Pallidotomy
- SURG.00017 Stereotactic Radiosurgery
- SURG.00019 Transmyocardial
Revascularization
- SURG.00020 Implantable Bone Conduction
Hearing Aids
- SURG.00022 Lung Volume Reduction Surgery
- SURG.00023 Breast Procedures; including
Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00024 Surgery for Clinically Severe Obesity
- SURG.00025 Cryosurgical Ablation of Solid
Tumors
- SURG.00026 Deep Brain Stimulation
- SURG.00028 Surgery for Benign Prostatic
Hypertrophy (BPH)
- SURG.00032 Transcatheter Closure of Patent Ductus Arteriosus,
Foramen Ovale, Closure of a Fenestrated Fontan Procedure and Atrial and Ventricular Septal
Defects and Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
- SURG.00033 Implantable
Cardioverter-Defibrillator (ICD)
- SURG.00036 Fetal Surgery for Prenatally
Diagnosed Malformations
- SURG.00037 Treatment of Varicose Veins (Lower
Extremities)
- SURG.00043 Electrothermal Capsular
Shrinkage
- SURG.00044 Ductal Lavage and Fiberoptic
Ductoscopy
- SURG.00045 Extracorporeal Shock Wave
Therapy for Orthopedic Conditions
- SURG.00046 Gastric Electrical Stimulation
- SURG.00047 Transendoscopic Therapy for
Gastroesophageal Reflux Disease
- SURG.00048 Panniculectomy and
Abdominoplasty
- SURG.00049 Mandibular / Maxillary
(Orthognathic) Surgery
- SURG.00050 Radiofrequency Ablation to Treat
Tumors Outside the Liver
- SURG.00051 Hip Resurfacing
- SURG.00052 Intradiscal Decompression Procedures
(Percutaneous Intradiscal Electrothermal Coagulation [IDET] and Percutaneous
Intradiscal Radiofrequency Thermocoagulation [PIRFT])
- SURG.00053 Unicondylar Interpositional
Spacer
- SURG.00054 Endovascular / Endoluminal Repair
of Aortic Aneurysms
- SURG.00055 Artificial Intervertebral Discs
- SURG.00056 Transanal Radiofrequency
Treatment of Fecal Incontinence
- SURG.00057 Microwave Thermotherapy for
Primary Breast Cancer
- SURG.00058 Prophylactic Bilateral
Oophorectomy and Prophylactic Hysterectomy
- SURG.00059 Recombinant Human Bone Morphogenetic Protein
- SURG.00060 Implanted Spinal Cord
Stimulators (SCS)
- SURG.00061 Presbyopia-Correcting Intraocular Lenses
- SURG.00062 Ovarian and Internal Iliac Vein
Embolization as a Treatment of Pelvic Congestion Syndrome
- SURG.00063 Prophylactic Mastectomy
- SURG.00064 Cardiac Resynchronization
Therapy (CRT) with or without an Implantable Cardioverter Defibrillator
(CRT/ICD) for the Treatment of Heart Failure
- SURG.00065 Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
(i.e., Surgical Excision, Cryosurgical Ablation, Radiofrequency Ablation or Percutaneous Ethanol Injection)
- SURG.00066 Percutaneous Radiofrequency Neurolysis
- SURG.00067 Percutaneous Vertebroplasty and
Percutaneous Kyphoplasty
- SURG.00068 Implantable Infusion Pumps
- SURG.00069 Transpupillary Thermotherapy
- SURG.00070
Photocoagulation of Macular
Drusen
- SURG.00071 Percutaneous Techniques for Disc
Decompression including Automated Lumbar Discectomy, Laser Discectomy
and DISC Nucleoplasty
- SURG.00072 Lysis of Epidural Adhesions
Using Hypertonic Solutions
- SURG.00073 Epiduroscopy
- SURG.00074 Nasal Surgery for the Treatment
of Obstructive Sleep Apnea (OSA) (Including Radiofrequency Ablation of
Nasal Turbinates for Nasal Obstruction with or with out OSA)
- SURG.00075 Intervertebral Stabilization Devices (Dynesys® Spinal System,
SATELLITE™ Spinal System)
- SURG.00076 Sural Nerve Graft After
Prostatectomy
- SURG.00077 Laparoscopic and Percutaneous
MRI-Image Guided Techniques for Myolysis of as a Treatment of Uterine
Fibroids
- SURG.00079 Nasal Valve Suspension
- SURG.00080 Implanted Cerebral Thermal
Perfusion Probe for Monitoring Regional Cerebral Blood Flow
- SURG.00081 Total Ankle Replacement
- SURG.00082 Computer-Assisted
Musculoskeletal Surgical Navigational Orthopedic Procedures
- SURG.00084 Semi-Implantable Middle Ear
Hearing Aids as a Treatment of Hearing Loss
- SURG.00085 Mastectomy for Gynecomastia
- SURG.00086 Reduction Mammaplasty
- SURG.00087 Transciliary Fistulization
for the Treatment of Glaucoma
- SURG.00088 Coblation® Use for Musculoskeletal Conditions
- SURG.00089 Ballooon Sinuplasty
- SURG.00090 Radiofrequency Ablation for
Trigeminal Neuralgia
- SURG.00092 Interspinous Vertebral Devices
for Treatment of Spinal Stenosis
- SURG.00093 Treatment of Osteochondral Defects of the
Knee and Ankle
- SURG.00094
High Intensity Focused Ultrasound (HIFU) for
the Treatment of Prostate Cancer
- SURG.00095 Canaloplasty
- SURG.00096 Surgical Treatment of Migraine Headaches
-
SURG.00097 Vertebral Body Stapling for the Treatment
of Adolescent Idiopathic Scoliosis
-
SURG.00098 Mechanical Embolectomy for Treatment of Acute
Stroke
-
SURG.00099 Convection Enhanced Delivery of
Intraparenchymal Agents to the Brain
-
SURG.00100 Cryoablation for Plantar Fasciitis and
Plantar Fibroma
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Transplantation
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