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Medical Policy

Surgery Section

Policy Name Date Modified

Ablation of Primary and Metastatic Liver Tumors

03/01/2019

Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

03/01/2019
Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast 03/01/2019

Artificial Intervertebral Disc

10/01/2018
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions 01/01/2019
Automated Percutaneous and Percutaneous Endoscopic Discectomy 09/01/2018
Balloon Dilation of the Eustachian Tube 10/01/2018
Balloon Ostial Dilation for Treatment of Sinusitis 10/01/2018

Bariatric Surgery

12/01/2018
Baroreflex Stimulation Devices 11/01/2018
Blepharoplasty and Brow Ptosis Repair 10/01/2018
Bronchial Thermoplasty 11/01/2018
Chemical Peels 10/01/2018

Cochlear Implant

01/01/2019

Cosmetic and Reconstructive Surgery

01/01/2019

Cryosurgical Ablation of Miscellaneous Solid Organ. Pulmonary, and Breast Tumors

03/01/2019
Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty™) 09/01/2018
Deep Brain Stimulation 01/01/2019
Dermabrasion/Microdermabrasion 01/01/2019
Dynamic Stabilization of the Spine 07/01/2018
Electromagnetic Navigation Bronchoscopy 05/01/2018
Endobronchial and Intrabronchial Valves 05/01/2018

Endometrial Ablation

10/01/2018
Extracranial Carotid Angioplasty/Stenting 12/01/2018

Femoroacetabular Impingement Surgery

02/01/2019
Gastric Electrical Stimulation 01/01/2019
Gastroesophageal Reflux Surgery 03/01/2019
Image-Guided Minimally Invasive Spinal Decompression (IG-MSD) for Spinal Stenosis 03/01/2018

Implantable Cardioverter Defibrillator

10/01/2018

Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin

01/01/2019
Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinonasal Polyposis 12/01/2018
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) 07/01/2018
Interspinous Fixation (Fusion) Devices 03/01/2019
Intracardiac Ischemia Monitoring 01/01/2019
Laser Treatment for Port Wine Stains 10/01/2018
Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation 02/01/2019

Lumbar Spinal Fusion

11/01/2018
Lysis of Epidural Adhesions 11/01/2018
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) 03/01/2018
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation 09/01/2018
Mastectomy as a Treatment of Gynecomastia 01/01/2019
Microwave Tumor Ablation 01/01/2019
Nerve Graft with Radical Prostatectomy 09/01/2018
Occipital Nerve Stimulation 01/01/2019
Orthognathic Surgery 02/01/2019

Ovarian, Internal Iliac, and Gonadal Vein Embolization, Ablation, and Sclerotherapy

06/01/2018
Panniculectomy 10/01/2018
Pectus Excavatum 10/01/2018

Percutaneous Angioplasty and Stenting of Veins

10/01/2018
Percutaneous Axial Lumbosacral Interbody Fusion (LIF) 01/01/2019

Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty

04/01/2018
Percutaneous Neuromodulation Therapy (PNT) 09/01/2018

Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

06/01/2018
Peripheral Subcutaneous Field Stimulation 06/01/2018
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia 08/01/2018
Plugs for Enteric and Anorectal Fistula Repair 06/01/2018
Pulsed Radiofrequency for Chronic Spinal Pain 02/01/2019
Radiofrequency Ablation of Tumors (RFA) 02/01/2019
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants 12/01/2018

Reduction Mammaplasty

12/16/2018
Retinal Prosthesis 01/01/2019
Rhinoplasty 10/01/2018

Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction

02/01/2019
Sacroiliac Joint Fusion 03/22/2019

Spinal Cord and Dorsal Root Ganglion Stimulation

01/01/2019
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 02/15/2019
Subtalar Arthroereisis 01/01/2019

Surgeries for Snoring and Obstructive Sleep Apnea Syndrome

02/01/2019
Surgical Ventricular Restoration 08/01/2018
Surgical Treatments for Hyperhidrosis 05/01/2018
Total Facet Arthroplasty 09/01/2018
Transanal Radiofrequency Treatment of Fecal Incontinence 02/01/2019
Transciliary Fistulization for the Treatment of Glaucoma 11/01/2018

Transcutaneous Bone-Conduction and Bone-Anchored Hearing Aids

01/01/2019

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

03/01/2019
Policy Effective 4/1/2019:
Transurethral Water Vapor Thermal Therapy of the Prostate
01/01/2019

Ultrasound Guidance for Facet Joint Injection

11/01/2018
Vagus Nerve Blocking Therapy for Obesity 05/01/2018

Vagus Nerve Stimulation

01/01/2019

Varicose Vein Treatment

01/01/2019
Ventral Hernia Repair 10/01/2018
Ventricular Assist Devices and Total Artificial Hearts 03/01/2019
Vertical Expandable Prosthetic Titanium Rib 07/01/2018