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Medical Policy

Surgery Section

Policy Name Policy ID Number Date Modified
Ablation for the Treatment of Chronic Rhinitis M-SUR224 01/01/2024

Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast

M-SUR182 01/01/2024

Automated Percutaneous and Percutaneous Endoscopic Discectomy

M-SUR145 11/01/2023
Balloon Dilation of the Eustachian Tube M-SUR206 07/01/2023
Balloon Ostial Dilation for Treatment of Sinusitis M-SUR153 12/01/2023
Baroreflex Stimulation Devices M-SUR183 11/01/2023
Blepharoplasty, Eyelid Surgery, and Brow Lift M-SUR12.05 06/01/2023
New Policy Effective 04/01/2024:
Coronary Intravascular Lithotripsy
M-SUR233 01/01/2024

Cosmetic and Reconstructive Procedures

M-SUR12 10/01/2023
Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty™) M-SUR131 11/01/2023
Deep Brain Stimulation (DBS) M-SUR84 07/01/2023

Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis

M-SUR230 01/01/2024
Dynamic Stabilization of the Spine M-SUR143 09/01/2023

Femoroacetabular Impingement (FAI) Surgery

M-SUR160 03/01/2024
Focal Laser Ablation of Prostate Cancer M-SUR222 08/01/2023

Gastric Electrical Stimulation

M-SUR111 01/01/2024

Gastroesophageal Reflux Surgery

M-SUR186 04/01/2023
Hypoglossal Nerve Stimulation M-SUR215 10/01/2023
Image-Guided Minimally Invasive Decompression (IG-MSD) for Spinal Stenosis M-SUR176 02/01/2024
Interspinous and Interlaminar Stabilization and Distraction Devices (Spacers) M-SUR155 11/01/2023

Interspinous Fixation (Fusion) Devices

M-SUR172 03/01/2024

Intracardiac Ischemia Monitoring

M-SUR208 11/01/2023
Intraosseous Radiofrequency Ablation of the Basivertebral Nerve M-SUR225 02/01/2024

Laser Trabeculotomy and Trabeculostomy

Policy Version Effective 05/01/2024:
Micro-Invasive Glaucoma Surgery (MIGS) and Laser Trabeculectomy and Trabeculostomy

M-SUR227 03/01/2024
Leadless Pacemakers M-SUR217 01/01/2024
Lung Volume Reduction Surgery (LVRS, or Reduction Pneumoplasty) M-SUR31 12/01/2023
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) M-SUR190 05/01/2023

Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation

M-SUR139 10/01/2023
Minimally Invasive Treatments of Nasal Valve Collapse M-SUR209 03/01/2024

Nerve Graft with Radical Prostatectomy

M-SUR117 09/01/2023

Occipital Nerve Stimulation (ONS)

M-SUR174 01/01/2024

Orthognathic Surgery

M-SUR137 03/01/2024

Percutaneous Axial Lumbosacral Fusion (LIF)

M-SUR157 09/01/2023
Percutaneous Neuromodulation Therapy (PNT) and Percutaneous Electrical Nerve Stimulation (PENS) M-SUR44 09/01/2023

Percutaneous Transluminal Angioplasty (PTA) and Stenting

M-SUR207 12/01/2023

Peripheral Nerve Stimulation (PNS) and Peripheral Nerve Field Stimulation (PNFS)

M-SUR205 01/01/2024
Phrenic Nerve Stimulation for Central Sleep Apnea M-SUR212 01/01/2024

Plugs for Enteric and Anorectal Fistula Repair

M-SUR175 09/01/2023
Pressure Ulcer Treatment by Musculocutaneous or Free Flap M-SUR223 10/01/2023

Radiofrequency Ablation (RFA) of Tumors Other Than the Liver

M-SUR92 01/01/2024
Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants M-SUR40 03/01/2024
Reduction Mammaplasty (Mammoplasty) M-SUR60 10/01/2023
Responsive Neurostimulation M-SUR216 03/01/2024

Sacral Nerve Stimulation (Neuromodulation) for Pelvic Floor Dysfunction

M-SUR134 03/01/2024
Sacroiliac Joint Fusion M-SUR193 01/01/2024
Subacromial Balloon Placement M-SUR226 09/01/2023
Subcutaneous Tibial Nerve Stimulation (STNS) M-SUR154 01/01/2024
Subtalar Arthroereisis M-SUR144 12/01/2023

Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome

M-SUR166 02/01/2024
Surgical Treatments for Lymphedema and Lipedema M-SUR220 10/01/2023

Surgical Ventricular Restoration

M-SUR149 10/01/2023
Total Facet Arthroplasty M-SUR171 10/01/2023
Transcatheter Heart Valve Procedures M-SUR221 11/01/2023

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

M-SUR110 02/01/2024
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate M-SUR210 03/01/2024

Vagus Nerve Stimulation (VNS)

M-SUR74 01/01/2024
Varicose Vein Treatment M-SUR104 07/01/2023
Ventricular Assist Devices and Total Artificial Hearts M-SUR52 03/01/2024
Vertebral Body Tethering and Stapling M-SUR232 01/01/2024