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Medical Policy

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


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:

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


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