Surgery Table of Contents

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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


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