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Medical Policy

Surgery Section

Policy Name Date Modified
Aqueous Shunts for Glaucoma 09/01/2012
Artificial Intervertebral Disc 05/01/2013
Autologous Fat Grafting to the Breast and Adipose-derived Stem Cells 01/01/2013
Automated Percutaneous and Endoscopic Discectomy 10/01/2012
Balloon Catheter Dilation for Treatment of Sinusitis 10/01/2012
Bariatric Surgery 04/09/2013
Baroreflex Stimulation Devices 12/01/2012
Bronchial Thermoplasty 01/01/2013
Cochlear Implant 12/01/2012
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure 03/01/2013
Cosmetic and Reconstructive Surgery 10/01/2012
Cryosurgical Ablation of Miscellaneous Solid Organ and Breast Tumors 02/01/2013
Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty™) 10/01/2012
Deep Brain Stimulation 06/01/2012
Dynamic Stabilization of the Spine 08/01/2012
Electromagnetic Navigation Bronchoscopy 07/01/2012
Endobronchial Valves 01/01/2013

Endometrial Ablation

04/01/2013
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus 03/01/2013
Endovascular Angioplasty and/or Stenting for Intracranial Arterial Disease (Atherosclerotic and Aneurysms) 08/01/2012
Extracranial Carotid Angioplasty/Stenting 12/01/2012
Femoroacetabular Impingement Surgery 04/01/2013
Gastric Electrical Stimulation 09/17/2012
Gastric Reflux Surgery 03/01/2013
Hip Resurfacing 03/01/2013
Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis 04/01/2013

Implantable Bone Conduction and Bone-Anchored Hearing Aids

09/01/2012
Implantable Cardioverter Defibrillator 02/01/2013
Interspinous Distraction Devices (Spacers) 08/01/2012
Knee Arthroscopy in Patients with Osteoarthritis 12/01/2012
Lumbar Spinal Fusion 04/16/2013
Lysis of Epidural Adhesions 12/01/2012
Mechanical Embolectomy for Treatment of Acute Stroke 03/01/2013
Meniscal Allografts and Collagen Meniscus Implants 03/01/2013
MRI-Guided Focused Ultrasound (MRgFUS) for the Treatment of Uterine Fibroids and Other Tumors 04/01/2013
Nerve Graft in Association with Radical Prostatectomy 11/01/2012
Occipital Nerve Stimulation 05/01/2013
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (MAZE and Related Procedures) 09/17/2012
Orthognathic Surgery 03/01/2013
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome 08/01/2012
Percutaneous Axial Anterior Lumbar Fusion 01/01/2013

Percutaneous Angioplasty and Stenting of Veins

05/01/2013

Percutaneous Intradiscal Electrothermal Annuloplasty (IDET) and Percutaneous Intradiscal Radiofrequency Thermocoagulation

Policy Effective 9/1/2013:
Percutaneous Intradiscal Electrothermal Annuloplasty (IDET) and Percutaneous Intradiscal Radiofrequency Thermocoagulation

05/0/2013
Percutaneous Neuromodulation Therapy (PNT) 10/01/2012

Percutaneous Vertebroplasty and Vertebral Augmentation (e.g., Kyphoplasty)

11/01/2012
Photocoagulation of Macular Drusen 06/01/2012
Plugs for Fistula Repair 08/01/2012
Posterior Tibial Nerve Stimulation for Voiding Dysfunction 03/01/2013
Pulsed Radiofrequency for Chronic Spinal Pain 03/01/2013
Radiofrequency Ablation of Tumors (RFA) 11/01/2012
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants 10/01/2012
Reduction Mammaplasty 10/01/2012
Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction 03/01/2013
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer 03/01/2013

Spinal Cord Stimulation for Treatment of Pain

04/01/2013
Spinous Process Fixation Orthosis 04/01/2013
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 01/01/2013
Subtalar Arthroereisis 12/01/2012

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

04/01/2013
Surgical Ventricular Restoration 03/01/2013
Surgical Treatments for Hyperhidrosis 06/01/2012
Thermal Capsulorrhaphy as a Treatment of Joint Instability 05/01/2013
Total Facet Arthroplasty 10/01/2012
Transanal Endoscopic Microsurgery (TEMS) 05/01/2013
Transanal Radiofrequency Treatment of Fecal Incontinence 03/01/2013
Transciliary Fistulization for the Treatment of Glaucoma 01/01/2013
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) 03/01/2013
Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization 08/01/2012
Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence 03/01/2013
Vagus Nerve Stimulation 01/01/2013
Varicose Vein Treatment 05/01/2013
Ventricular Assist Devices and Total Artificial Hearts 04/01/2013
Vertical Expandable Titanium Prosthetic Rib 08/01/2012
Wireless Pressure Sensors in Endovascular Aneurysm Repair 07/01/2012