| Policy Name |
Policy ID Number |
Date Modified |
| Ablation for the Treatment of Chronic Rhinitis |
SUR224 |
01/01/2024 |
Ablation of Primary and Metastatic Liver Tumors |
SUR204 |
03/01/2024 |
| Adipose-derived
Stem Cell Enrichment in Autologous Fat Grafting to the Breast |
SUR182 |
01/01/2024 |
Artificial Intervertebral
Disc |
SUR127 |
04/01/2024 |
| Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions |
SUR87 |
09/01/2023 |
| Automated Percutaneous
and Percutaneous Endoscopic Discectomy |
SUR145 |
11/01/2023 |
| Balloon Dilation of the Eustachian Tube |
SUR206 |
07/01/2023 |
| Balloon Ostial Dilation
for Treatment of Sinusitis |
SUR153 |
11/01/2023 |
Bariatric
Surgery |
SUR58 |
02/01/2024 |
| Baroreflex Stimulation Devices |
SUR183 |
11/01/2023 |
Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair |
SUR12.05 |
07/01/2023 |
| Bronchial
Thermoplasty |
SUR178 |
12/01/2023 |
| Bronchial Valves |
SUR184 |
07/01/2023 |
| Chemical Peels |
SUR12.50 |
09/01/2023 |
Cochlear Implant |
SUR08 |
12/01/2023 |
| Coronary Intravascular Lithotripsy |
SUR233 |
01/01/2024 |
Cosmetic
and Reconstructive Procedures |
SUR12 |
04/01/2024 |
Cryosurgical
Ablation of Miscellaneous Solid Tumors Outside of the Liver |
SUR132 |
02/01/2024 |
| Decompression
of Intervertebral Discs Using Laser Energy (Laser Discectomy)
or Radiofrequency Energy (Nucleoplasty™) |
SUR131 |
11/01/2023 |
| Deep
Brain Stimulation |
SUR84 |
07/01/2023 |
| Dermabrasion or Microdermabrasion |
SUR12.04 |
07/01/2023 |
Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis |
SUR230 |
01/01/2024 |
| Dynamic Stabilization of the Spine |
SUR143 |
09/01/2023 |
Endometrial
Ablation |
SUR01 |
02/01/2024 |
| Extracranial Carotid Angioplasty and Stenting |
SUR93 |
11/01/2023 |
Femoroacetabular
Impingement Surgery |
SUR160 |
03/01/2024 |
| Focal Laser Ablation of Prostate Cancer |
SUR222 |
08/01/2023 |
Gastric Electrical Stimulation |
SUR111 |
01/01/2024 |
| Gastroesophageal Reflux Surgery |
SUR186 |
04/01/2024 |
Hypoglossal Nerve Stimulation |
SUR215 |
01/01/2024 |
Hysterectomy |
SUR218 |
11/01/2023 |
| Image-Guided
Minimally Invasive Decompression (IG-MSD)
for Spinal Stenosis |
SUR176 |
02/01/2024 |
Implantable Peripheral
Nerve Stimulation and Peripheral Subcutaneous Field Stimulation |
SUR205 |
01/01/2024 |
| Implantable Sinus Devices for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinonasal Polyposis |
SUR198 |
11/01/2023 |
| Interspinous and Interlaminar Stabilization and Distraction
Devices (Spacers) |
SUR155 |
09/01/2023 |
| Interspinous
Fixation (Fusion) Devices |
SUR172 |
03/01/2024 |
| Intracardiac Ischemia Monitoring |
SUR208 |
11/01/2023 |
| Intraosseous Radiofrequency Ablation of the Basivertebral Nerve |
SUR225 |
03/01/2024 |
| Knee Surgeries |
SUR229 |
07/01/2023 |
| Laser Trabeculotomy and Trabeculostomy |
SUR227 |
08/01/2023 |
| Laser Treatment for Port Wine Stains |
SUR12.34 |
07/01/2023 |
| Leadless Cardiac Pacemakers |
SUR217 |
01/01/2024 |
| Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation |
SUR195 |
03/01/2024 |
Lumbar Spinal Fusion |
SUR187 |
02/01/2024 |
| Lysis of Epidural Adhesions |
SUR94 |
12/01/2023 |
| Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) |
SUR190 |
05/01/2023 |
| Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation |
SUR139 |
11/01/2023 |
| Mastectomy as a Treatment of Gynecomastia |
SUR12.06 |
07/01/2023 |
| Microwave Tumor Ablation |
SUR189 |
01/01/2024 |
Minimally Invasive Treatments of Nasal Valve Collapse or Obstruction |
SUR209 |
03/01/2024 |
| Nerve
Graft with Radical Prostatectomy |
SUR117 |
09/01/2023 |
| Occipital
Nerve Stimulation |
SUR174 |
04/01/2024 |
| Orthognathic Surgery |
SUR137 |
03/01/2024 |
Ovarian, Internal Iliac, and Gonadal Vein Embolization, Ablation, and Sclerotherapy |
SUR147 |
07/01/2023 |
| Panniculectomy |
SUR12.01 |
07/01/2023 |
Pectus Excavatum and Carinatum Treatment |
SUR12.02 |
04/01/2024 |
Percutaneous
Angioplasty and Stenting of Veins |
SUR109 |
02/01/2024 |
| Percutaneous Axial Lumbosacral Interbody Fusion (LIF) |
SUR157 |
09/01/2023 |
Percutaneous
Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty |
SUR118 |
06/01/2023 |
| Percutaneous Neuromodulation
Therapy (PNT) and Percutaneous Electrical Nerve Stimulation (PENS) |
SUR44 |
11/01/2023 |
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty |
SUR107 |
08/01/2023 |
| Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia |
SUR196 |
10/01/2023 |
| Phrenic Nerve Stimulation for Central Sleep Apnea |
SUR212 |
01/01/2024 |
| Plugs for Enteric and Anorectal Fistula Repair |
SUR175 |
09/01/2023 |
| Pulsed
Radiofrequency for Chronic Spinal Pain |
SUR156 |
03/01/2024 |
Radiofrequency Ablation and Injection of Sacroiliac Joint Nerves |
SUR231 |
01/01/2024 |
| Radiofrequency
Ablation (RFA) of Tumors Other than Liver |
SUR92 |
01/01/2024 |
Reconstructive
Breast Surgery/Mastopexy, and Management of Breast
Implants |
SUR40 |
12/01/2023 |
Reduction Mammaplasty |
SUR60 |
10/01/2023 |
| Responsive Neurostimulation |
SUR216 |
03/01/2024 |
| Retinal Prosthesis |
SUR194 |
09/01/2023 |
Rhinoplasty |
SUR12.28 |
09/01/2023 |
Sacral
Nerve Neuromodulation (Stimulation) for Pelvic Floor
Dysfunction |
SUR134 |
03/01/2024 |
| Sacroiliac Joint Fusion |
SUR193 |
01/01/2024 |
| Shoulder Surgeries |
SUR228 |
04/01/2024 |
Spinal
Cord and Dorsal Root Ganglion Stimulation |
SUR45 |
01/01/2024 |
| Stereotactic
Radiosurgery and Stereotactic Body Radiation
Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites |
SUR214 |
01/01/2024 |
| Stereotactic
Radiosurgery and Stereotactic Body Radiation
Therapy of Intracranial, Skull Base, and Orbital Sites |
SUR213 |
01/01/2024 |
| Subacromial Balloon Placement |
SUR226 |
09/01/2023 |
| Subcutaneous Tibial Nerve Stimulation |
SUR154 |
01/01/2024 |
| Subtalar Arthroereisis |
SUR144 |
12/01/2023 |
Surgeries for Snoring, Obstructive Sleep Apnea
Syndrome, and Upper Airway Resistance Syndrome |
SUR166 |
01/01/2024 |
Surgical
Treatments for Hyperhidrosis |
SUR165 |
05/01/2023 |
| Surgical Treatments for Lymphedema and Lipedema |
SUR220 |
10/01/2023 |
| Surgical Ventricular Restoration |
SUR149 |
10/01/2023 |
| Total Facet Arthroplasty |
SUR171 |
10/01/2023 |
| Transanal Hemorrhoidal Dearterialization |
SUR219 |
03/01/2024 |
Transcatheter Aortic Valve Implantation for Aortic Stenosis |
SUR201 |
07/01/2023 |
| Transciliary Fistulization
for the Treatment of Glaucoma |
SUR150 |
01/01/2024 |
Transcutaneous Bone-Conduction
and Bone-Anchored Hearing Aids |
SUR121 |
01/01/2024 |
Transesophageal Endoscopic
Therapies for Gastroesophageal Reflux Disease
(GERD) |
SUR110 |
01/01/2024 |
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate |
SUR210 |
04/01/2024 |
Ultrasound Guidance for Facet Joint Injection |
SUR135 |
12/01/2023 |
Vagus Nerve Stimulation |
SUR74 |
01/01/2024 |
Varicose Vein Treatment |
SUR104 |
12/01/2023 |
Ventral (Including Incisional) Hernia Repair |
SUR12.03 |
12/01/2023 |
| Ventricular Assist Devices
and Total Artificial Hearts |
SUR52 |
03/01/2024 |
| Vertebral Body Tethering and Stapling |
SUR232 |
01/01/2024 |
| Vertical Expandable Prosthetic Titanium
Rib |
SUR159 |
09/01/2023 |
