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Surgery Section

Policy Name	Policy ID Number	Date Modified
Ablation of Primary and Metastatic Liver Tumors	SUR204	03/01/2023
Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast	SUR182	01/01/2023
Artificial Intervertebral Disc	SUR127	06/01/2023
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions	SUR87	09/01/2023
Automated Percutaneous and Percutaneous Endoscopic Discectomy	SUR145	11/01/2022
Balloon Dilation of the Eustachian Tube	SUR206	07/01/2023
Balloon Ostial Dilation for Treatment of Sinusitis	SUR153	12/01/2022
Bariatric Surgery	SUR58	07/01/2023
Baroreflex Stimulation Devices	SUR183	02/01/2023
Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair	SUR12.05	07/01/2023
Bronchial Thermoplasty	SUR178	12/01/2022
Bronchial Valves	SUR184	07/01/2023
Chemical Peels	SUR12.50	09/01/2023
Cochlear Implant Policy Version Effective 12/01/2023: Cochlear Implant	SUR08	09/01/2023
Cosmetic and Reconstructive Procedures	SUR12	08/01/2023
Cryoablation for Chronic Rhinitis	SUR224	02/01/2023
Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver	SUR132	02/01/2023
Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty™)	SUR131	11/01/2022
Deep Brain Stimulation	SUR84	07/01/2023
Dermabrasion or Microdermabrasion	SUR12.04	07/01/2023
Dynamic Stabilization of the Spine	SUR143	09/01/2023
Endometrial Ablation	SUR01	12/01/2022
Extracranial Carotid Angioplasty and Stenting	SUR93	01/01/2023
Femoroacetabular Impingement Surgery	SUR160	03/01/2023
Focal Laser Ablation of Prostate Cancer	SUR222	08/01/2023
Gastric Electrical Stimulation	SUR111	07/01/2023
Gastroesophageal Reflux Surgery	SUR186	04/01/2023
Hypoglossal Nerve Stimulation	SUR215	11/01/2022
New Policy Effective 11/01/2023: Hysterectomy	SUR218	08/01/2023
Image-Guided Minimally Invasive Decompression (IG-MSD) for Spinal Stenosis	SUR176	03/01/2023
Implantable Cardioverter Defibrillator	SUR17	08/01/2023
Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation	SUR205	08/01/2023
Implantable Sinus Devices for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinonasal Polyposis	SUR198	10/01/2022
Interspinous and Interlaminar Stabilization and Distraction Devices (Spacers)	SUR155	09/01/2023
Interspinous Fixation (Fusion) Devices	SUR172	04/01/2023
Intracardiac Ischemia Monitoring	SUR208	12/01/2022
Intraosseous Radiofrequency Ablation of the Basivertebral Nerve	SUR225	03/01/2023
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	07/01/2023
Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation	SUR195	03/01/2023
Lumbar Spinal Fusion	SUR187	02/01/2023
Lysis of Epidural Adhesions	SUR94	12/01/2022
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	11/01/2022
Mastectomy as a Treatment of Gynecomastia	SUR12.06	07/01/2023
Microwave Tumor Ablation	SUR189	02/01/2023
Minimally Invasive Treatments of Nasal Valve Collapse or Obstruction	SUR209	01/01/2023
Nerve Graft with Radical Prostatectomy	SUR117	09/01/2023
Occipital Nerve Stimulation	SUR174	05/01/2023
Orthognathic Surgery	SUR137	04/01/2023
Ovarian, Internal Iliac, and Gonadal Vein Embolization, Ablation, and Sclerotherapy	SUR147	07/01/2023
Panniculectomy	SUR12.01	07/01/2023
Pectus Excavatum and Carinatum Surgery	SUR12.02	07/01/2023
Percutaneous Angioplasty and Stenting of Veins	SUR109	07/01/2023
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	11/01/2022
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty	SUR107	08/01/2023
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia	SUR196	10/01/2022
Phrenic Nerve Stimulation for Central Sleep Apnea	SUR212	09/01/2023
Plugs for Enteric and Anorectal Fistula Repair	SUR175	09/01/2023
Pulsed Radiofrequency for Chronic Spinal Pain	SUR156	03/01/2023
Radiofrequency Ablation (RFA) of Tumors Other than Liver	SUR92	03/01/2023
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants	SUR40	12/01/2022
Reduction Mammaplasty	SUR60	11/01/2022
Responsive Neurostimulation	SUR216	04/01/2023
Retinal Prosthesis	SUR194	09/01/2023
Rhinoplasty	SUR12.28	09/01/2023
Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction	SUR134	04/01/2023
Sacroiliac Joint Fusion	SUR193	08/01/2023
Shoulder Surgeries	SUR228	05/01/2023
Spinal Cord and Dorsal Root Ganglion Stimulation	SUR45	08/01/2023
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites	SUR214	09/01/2023
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites	SUR213	08/01/2022
Subacromial Balloon Placement	SUR226	09/01/2023
Subtalar Arthroereisis	SUR144	12/01/2022
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome	SUR166	04/01/2023
Surgical Treatments for Hyperhidrosis	SUR165	05/01/2023
Surgical Treatments for Lymphedema and Lipedema	SUR220	10/01/2022
Surgical Ventricular Restoration	SUR149	11/01/2022
Temporary Implanted Nitinol Device (e.g., iTind) for Benign Prostatic Hyperplasia	SUR230	08/01/2023
Total Facet Arthroplasty	SUR171	10/01/2022
Transanal Hemorrhoidal Dearterialization	SUR219	03/01/2023
Transcatheter Aortic Valve Implantation for Aortic Stenosis	SUR201	07/01/2023
Transciliary Fistulization for the Treatment of Glaucoma	SUR150	12/01/2022
Transcutaneous Bone-Conduction and Bone-Anchored Hearing Aids	SUR121	05/01/2023
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)	SUR110	02/01/2023
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate	SUR210	03/01/2023
Ultrasound Guidance for Facet Joint Injection	SUR135	12/01/2022
Vagus Nerve Stimulation	SUR74	07/01/2023
Varicose Vein Treatment	SUR104	07/01/2023
Ventral (Including Incisional) Hernia Repair Policy Version Effective 12/01/2023: Ventral (Including Incisional) Hernia Repair	SUR12.03	09/01/2023
Ventricular Assist Devices and Total Artificial Hearts	SUR52	03/01/2023
Vertical Expandable Prosthetic Titanium Rib	SUR159	09/01/2023


	The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state. The Regence Group and each of its affiliate Plans are independent licensees of the Blue Cross and Blue Shield Association.