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Medical Policy

Surgery Section

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 07/01/2024
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 06/01/2024
Chemical Peels SUR12.50 09/01/2023

Cochlear Implant

SUR08 05/01/2024
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 05/01/2024
Dermabrasion or Microdermabrasion SUR12.04 07/01/2023

Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis

SUR230 06/01/2024
Dynamic Stabilization of the Spine SUR143 09/01/2023

Endometrial Ablation

SUR01 05/01/2024
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 06/01/2024
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

Policy Version Effective 8/1/2024:
Knee Surgeries

SUR229 05/01/2024
Laser Trabeculotomy and Trabeculostomy SUR227 08/01/2023
Laser Treatment for Port Wine Stains SUR12.34 07/01/2024
Leadless Cardiac Pacemakers SUR217 07/01/2024
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 05/01/2024
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 05/01/2024

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 07/01/2024

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 06/01/2024
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 07/01/2024

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 07/01/2024
Surgical Treatments for Lymphedema and Lipedema SUR220 07/09/2024
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 07/01/2024
Transciliary Fistulization for the Treatment of Glaucoma SUR150 01/01/2024

Transcutaneous Bone-Conduction and Bone-Anchored Hearing Aids

SUR121 05/01/2024

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 07/01/2024

Ultrasound Guidance for Facet Joint Injection

SUR135 12/01/2023

Vagus Nerve Stimulation

SUR74 06/01/2024

Varicose Vein Treatment

SUR104 07/01/2024

Ventral (Including Incisional) Hernia Repair

Policy Version Effective 10/1/2024:
Anterior Abdominal Wall (Including Incisional) Hernia Repair

SUR12.03 07/01/2024
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