Medical Policies - Surgical
Accidental Dental Services Commercial - Surgical 19
PDF, 220 KB
PDF, 220 KB
Allogeneic Hematopoietic Stem Cell Transplantation Commercial - Surgical 213
PDF, 234 KB
PDF, 234 KB
Allogeneic Hematopoietic Stem Cell Transplantation Medicaid - Surgical 213
PDF, 284 KB
PDF, 284 KB
Anterior Cervical Discectomy and Fusion or Posterior Cervical Foraminotomy with or without Partial Discectomy Commercial - Surgical 117
PDF, 241 KB
PDF, 241 KB
Anterior Cervical Discectomy and Fusion or Posterior Cervical Foraminotomy with or without Partial Discectomy for Cervical Radiculopathy Medicaid - Surgical 117
PDF, 308 KB
PDF, 308 KB
Anterior Cervical Discectomy and Fusion or Posterior Cervical Foraminotomy with or without Partial Discectomy Medicare - Surgical - 117
PDF, 282 KB
PDF, 282 KB
Artificial Disc Replacement and Treatment Commercial - Surgical 35
PDF, 200 KB
PDF, 200 KB
Artificial Disc Replacement and Treatment Medicaid - Surgical 35
PDF, 294 KB
PDF, 294 KB
Autologous Hematopoietic Stem Cell Transplantation (HSCT) Commercial - Surgical 08
PDF, 204 KB
PDF, 204 KB
Autologous Hematopoietic Stem Cell Transplantation (HSCT) Medicaid - Surgical 08
PDF, 278 KB
PDF, 278 KB
Bariatric Services Commercial - Surgical 32
PDF, 248 KB
PDF, 248 KB
Bariatric Services Medicaid - Surgical 32
PDF, 311 KB
PDF, 311 KB
Benign Prostatic Hypertrophy Treatments as an Alternative to Transurethral Resection of the Prostate (TURP) Commercial - Surgical 83
PDF, 317 KB
PDF, 317 KB
Benign Prostatic Hypertrophy Treatments as an Alternative to Transurethral Resection of the Prostate (TURP) Medicaid - Surgical 83
PDF, 329 KB
PDF, 329 KB
Blepharoplasty Commercial - Surgical 13
PDF, 189 KB
PDF, 189 KB
Blepharoplasty Medicaid - Surgical 13
PDF, 268 KB
PDF, 268 KB
Blepharoptosis Repair Commercial - Surgical 211
PDF, 223 KB
PDF, 223 KB
Blepharoptosis Repair Medicaid - Surgical 213
PDF, 292 KB
PDF, 292 KB
Breast Procedures Commercial - Surgical 10
PDF, 263 KB
PDF, 263 KB
Breast Procedures Medicaid - Surgical 10
PDF, 391 KB
PDF, 391 KB
Brow Lift Commercial - Surgical 212
PDF, 164 KB
PDF, 164 KB
Brow Lift Medicaid - Surgical 212
PDF, 258 KB
PDF, 258 KB
Capsular Plication of the Hip Commercial - Surgical 232
PDF, 188 KB
PDF, 188 KB
Capsular Plication of the Hip Medicaid - Surgical 232
PDF, 261 KB
PDF, 261 KB
Capsular Plication of the Hip Medicare - Surgical 232
PDF, 229 KB
PDF, 229 KB
Cervical Laminectomy Commercial - Surgical 122
PDF, 189 KB
PDF, 189 KB
Cervical Laminectomy Medicaid - Surgical 122
PDF, 282 KB
PDF, 282 KB
Cervical Laminectomy Medicare - Surgical 122
PDF, 242 KB
PDF, 242 KB
Coccygectomy Commercial - Surgical 114
PDF, 160 KB
PDF, 160 KB
Coccygectomy Medicaid - Surgical 114
PDF, 286 KB
PDF, 286 KB
Coccygectomy Medicare - Surgical 114
PDF, 193 KB
PDF, 193 KB
Cochlear Implants, Bone Attached Hearing Aid Implants, Auditory Brain Stem Implants Commercial - Surgical 20
PDF, 207 KB
PDF, 207 KB
Cochlear Implants, Bone Attached Hearing Aid Implants, Auditory Brain Stem Implants Medicaid - Surgical 20
PDF, 278 KB
PDF, 278 KB
Computer Assisted Navigation Commercial - Surgical 233.pdf
PDF, 207 KB
PDF, 207 KB
Computer Assisted Navigation Medicaid - Surgical 233.pdf
PDF, 251 KB
PDF, 251 KB
Computer Assisted Navigation Medicare - Surgical 233.pdf
PDF, 242 KB
PDF, 242 KB
Core Decompression for Avascular Necrosis of the Knee, Ankle, Elbow and Shoulder Commercial - Surgical 214
PDF, 163 KB
PDF, 163 KB
Core Decompression for Avascular Necrosis of the Knee, Ankle, Elbow and Shoulder Medicaid - Surgical 214
PDF, 255 KB
PDF, 255 KB
Core Decompression for Avascular Necrosis of the Knee, Ankle, Elbow and Shoulder Medicare - Surgical 214
PDF, 214 KB
PDF, 214 KB
Corneal remodeling, Corneal Keratectomy, Keratoplasties and Keratoprosthesis Commercial - Surgical 55
PDF, 244 KB
PDF, 244 KB
Corneal remodeling, Corneal Keratectomy, Keratoplasties and Keratoprosthesis Medicaid - Surgical 55
PDF, 310 KB
PDF, 310 KB
Cosmetic and Reconstructive Surgery Commercial - Surgical 03
PDF, 207 KB
PDF, 207 KB
Cosmetic and Reconstructive Surgery Medicaid - Surgical 03
PDF, 330 KB
PDF, 330 KB
Cryoablation Commercial - Surgical 82
PDF, 236 KB
PDF, 236 KB
Cryoablation Medicaid - Surgical 82
PDF, 303 KB
PDF, 303 KB
Cytoreductive Surgery (Tumor Debulking) Commercial - Surgical 02
PDF, 230 KB
PDF, 230 KB
Cytoreductive Surgery (Tumor Debulking) Medicaid - Surgical 02
PDF, 279 KB
PDF, 279 KB
Cytoreductive Surgery (Tumor Debulking) Medicare - Surgical 02
PDF, 268 KB
PDF, 268 KB
Deep Brain Stimulation Commercial - Surgical 74
PDF, 230 KB
PDF, 230 KB
Deep Brain Stimulation Medicaid - Surgical 74
PDF, 296 KB
PDF, 296 KB
Endometrial Ablation Commercial - Surgical 15
PDF, 181 KB
PDF, 181 KB
Endometrial Ablation Medicaid - Surgical 15
PDF, 276 KB
PDF, 276 KB
Endometrial Ablation Medicare - Surgical 15
PDF, 234 KB
PDF, 234 KB
Epidermal Nerve Fiber Density Testing Commercial - Surgical 98
PDF, 182 KB
PDF, 182 KB
Epidermal Nerve Fiber Density Testing Medicaid - Surgical 98
PDF, 309 KB
PDF, 309 KB
Epidermal Nerve Fiber Density Testing Medicare - Surgical 98
PDF, 233 KB
PDF, 233 KB
Facet Joint Procedures Commercial - Surgical 119
PDF, 266 KB
PDF, 266 KB
Facet Joint Procedures Medicaid - Surgical 119
PDF, 336 KB
PDF, 336 KB
Foot surgeries Commercial - Surgical 52
PDF, 239 KB
PDF, 239 KB
Foot Surgeries Medicaid - Surgical 52
PDF, 343 KB
PDF, 343 KB
Foot Surgeries Medicare - Surgical 52
PDF, 277 KB
PDF, 277 KB
Gastric Pacemakers - Gastric Electrical Stimulators Commercial - Surgical 95
PDF, 220 KB
PDF, 220 KB
Gastric Pacemakers - Gastric Electrical Stimulators Medicaid - Surgical 95
PDF, 296 KB
PDF, 296 KB
Gastric Pacemakers - Gastric Electrical Stimulators Medicare - Surgical 95
PDF, 247 KB
PDF, 247 KB
Gastrointestinal Procedures Commercial - Surgical 205
PDF, 207 KB
PDF, 207 KB
Gastrointestinal Procedures Medicaid - Surgical 205
PDF, 292 KB
PDF, 292 KB
Gender Affirming Surgery Commercial - Surgical 108
PDF, 291 KB
PDF, 291 KB
Gender Affirming Surgery Medicaid - Surgical 108
PDF, 331 KB
PDF, 331 KB
Genicular Nerve Ablation Commercial - Surgical 110
PDF, 198 KB
PDF, 198 KB
Genicular Nerve Ablation Medicaid - Surgical 110
PDF, 267 KB
PDF, 267 KB
Genicular Nerve Ablation Medicare - Surgical 110
PDF, 238 KB
PDF, 238 KB
Headache Treatments Commercial - Surgical 103
PDF, 241 KB
PDF, 241 KB
Headache Treatments Medicaid - Surgical 103
PDF, 342 KB
PDF, 342 KB
Heart-Lung Transplantation Commercial - Surgical 28
PDF, 186 KB
PDF, 186 KB
Heart-Lung Transplantation Medicaid - Surgical 28
PDF, 295 KB
PDF, 295 KB
Hip Resurfacing Arthroplasty Commercial - Surgical 62
PDF, 185 KB
PDF, 185 KB
Hip Resurfacing Arthroplasty Medicaid - Surgical 62
PDF, 277 KB
PDF, 277 KB
Hyperhidrosis Treatments Commercial - Surgical 107
PDF, 241 KB
PDF, 241 KB
Hyperhidrosis Treatments Medicaid - Surgical 107
PDF, 287 KB
PDF, 287 KB
Hyperhidrosis Treatments Medicare - Surgical 107
PDF, 244 KB
PDF, 244 KB
Intestinal Transplant with or without Combined Liver Transplant or Other Visceral Organs Commercial - Surgical 92
PDF, 188 KB
PDF, 188 KB
Intestinal Transplant with or without Combined Liver Transplant or Other Visceral Organs Medicaid - Surgical 92
PDF, 280 KB
PDF, 280 KB
Intraoperative Neurophysiological Monitoring Commercial - Surgical 40
PDF, 268 KB
PDF, 268 KB
Intraoperative Neurophysiological Monitoring Medicaid - Surgical 40
PDF, 302 KB
PDF, 302 KB
Knee Arthroscopy Medicaid - Surgical 135
PDF, 291 KB
PDF, 291 KB
Laparoscopic Uterosacral Nerve Ablation (LUNA) and Presacral Neurectomy (PSN) Commercial - Surgical 84
PDF, 166 KB
PDF, 166 KB
Laparoscopic Uterosacral Nerve Ablation (LUNA) and Presacral Neurectomy (PSN) Medicare - Surgical 84
PDF, 217 KB
PDF, 217 KB
Laparoscopic Uterosacral Nerve Ablation and Presacral Neurectomy Medicaid - Surgical 84
PDF, 257 KB
PDF, 257 KB
Laser Therapy for Skin Treatments Commercial - Surgical 58
PDF, 233 KB
PDF, 233 KB
Laser Therapy for Skin Treatments Medicaid - Surgical 58
PDF, 300 KB
PDF, 300 KB
Leadless Cardiac Pacemaker Commercial - Surgical 126
PDF, 188 KB
PDF, 188 KB
Leadless Cardiac Pacemaker Medicaid - Surgical 126
PDF, 255 KB
PDF, 255 KB
Left Atrial Appendage Occlusion Commercial - Surgical 102
PDF, 210 KB
PDF, 210 KB
Left Atrial Appendage Occlusion Medicaid - Surgical 102
PDF, 277 KB
PDF, 277 KB
Lumbar Disc Arthroplasty Commercial - Surgical 124
PDF, 194 KB
PDF, 194 KB
Lumbar Disc Arthroplasty Medicaid - Surgical 124
PDF, 262 KB
PDF, 262 KB
Lumbar Discectomy Commercial - Surgical 120
PDF, 213 KB
PDF, 213 KB
Lumbar Discectomy Medicaid - Surgical 120
PDF, 285 KB
PDF, 285 KB
Lumbar Discectomy Medicare - Surgical 120
PDF, 239 KB
PDF, 239 KB
Lumbar Fusion Commercial - Surgical 118
PDF, 230 KB
PDF, 230 KB
Lumbar Fusion Medicaid - Surgical 11
PDF, 301 KB
PDF, 301 KB
Lumbar Laminectomy Commercial - Surgical 121
PDF, 222 KB
PDF, 222 KB
Lumbar Laminectomy Medicaid - Surgical 121
PDF, 268 KB
PDF, 268 KB
Lumbar Laminectomy Medicare - Surgical 121
PDF, 249 KB
PDF, 249 KB
Medical Dental Surgery Commercial - Surgical 128
PDF, 281 KB
PDF, 281 KB
Nasal Implants Commercial - Surgical 230
PDF, 192 KB
PDF, 192 KB
Nasal Implants Medicaid - Surgical 230
PDF, 220 KB
PDF, 220 KB
Neurolysis and Nerve Re-Implantation for Pelvic Pain Commercial - Surgical 221
PDF, 162 KB
PDF, 162 KB
Neurolysis and Nerve Re-Implantation for Pelvic Pain Medicaid - Surgical 221
PDF, 256 KB
PDF, 256 KB
Neurolysis and Nerve Re-Implantation for Pelvic Pain Medicare - Surgical 221
PDF, 198 KB
PDF, 198 KB
Open Treatment of Rib Fracture with Internal Fixation Commercial - Surgical 217
PDF, 185 KB
PDF, 185 KB
Open Treatment of Rib Fracture with Internal Fixation Medicaid - Surgical 217
PDF, 269 KB
PDF, 269 KB
Ophthalmic Procedures Commercial - Surgical 60
PDF, 243 KB
PDF, 243 KB
Ophthalmic Procedures Medicaid - Surgical 60
PDF, 330 KB
PDF, 330 KB
Oral Incontinence Treatments Commercial - Surgical 220
PDF, 180 KB
PDF, 180 KB
Oral Incontinence Treatments Medicaid - Surgical 220
PDF, 277 KB
PDF, 277 KB
Oral Incontinence Treatments Medicare - Surgical 220
PDF, 208 KB
PDF, 208 KB
Orthognathic Surgery Commercial - Surgical 34
PDF, 224 KB
PDF, 224 KB
Orthognathic Surgery Medicaid - Surgical 34
PDF, 305 KB
PDF, 305 KB
Ovarian Vein Embolization Commercial - Surgical 202
PDF, 192 KB
PDF, 192 KB
Ovarian Vein Embolization Medicaid - Surgical 202
PDF, 257 KB
PDF, 257 KB
Pancreas and Islet Cell Transplants Commercial - Surgical 27
PDF, 222 KB
PDF, 222 KB
Pancreas and Islet Cell Transplants Medicaid - Surgical 27
PDF, 299 KB
PDF, 299 KB
Panniculectomy Commercial - Surgical 14
PDF, 207 KB
PDF, 207 KB
Panniculectomy Medicaid - Surgical 14
PDF, 259 KB
PDF, 259 KB
Pectus Surgery and Devices Commercial - Surgical 05
PDF, 233 KB
PDF, 233 KB
Pectus Surgery and Devices Medicaid - Surgical 05
PDF, 306 KB
PDF, 306 KB
Pectus Surgery and Devices Medicare - Surgical 05
PDF, 273 KB
PDF, 273 KB
Penile Prosthesis Surgery Commercial - Surgical 23
PDF, 246 KB
PDF, 246 KB
Percutaneous Antegrade Transseptal Transcatheter Mitral Valve Implantation Commercial - Surgical 136
PDF, 188 KB
PDF, 188 KB
Percutaneous Antegrade Transseptal Transcatheter Mitral Valve Implantation Medicaid - Surgical 136
PDF, 258 KB
PDF, 258 KB
Percutaneous Antegrade Transseptal Transcatheter Mitral Valve Implantation Medicare - Surgical 136
PDF, 239 KB
PDF, 239 KB
Percutaneous Spinal Augmentation Commercial - Surgical 231
PDF, 196 KB
PDF, 196 KB
Percutaneous Spinal Augmentation Medicaid - Surgical 231
PDF, 298 KB
PDF, 298 KB
Percutaneous Transluminal Coronary Lithotripsy Commercial - Surgical 132
PDF, 161 KB
PDF, 161 KB
Percutaneous Transluminal Coronary Lithotripsy Medicaid - Surgical 132
PDF, 242 KB
PDF, 242 KB
Percutaneous Transluminal Coronary Lithotripsy Medicare - Surgical 132
PDF, 188 KB
PDF, 188 KB
Sacroiliac Fusion, Open and Percutaneous Commercial - Surgical 116
PDF, 194 KB
PDF, 194 KB
Sacroiliac Fusion, Open and Percutaneous Medicaid - Surgical 116
PDF, 264 KB
PDF, 264 KB
Shoulder-Elbow Joint Resurfacing Arthroplasty with Allograft Tissue Commercial - Surgical 111
PDF, 213 KB
PDF, 213 KB
Shoulder-Elbow Joint Resurfacing Arthroplasty with Allograft Tissue Medicaid - Surgical 111
PDF, 278 KB
PDF, 278 KB
Shoulder-Elbow Joint Resurfacing Arthroplasty with Allograft Tissue Medicare - Surgical 111
PDF, 251 KB
PDF, 251 KB
Skin and Tissue Substitutes Commercial-Surgical 73
PDF, 421 KB
PDF, 421 KB
Skin and Tissue Substitutes Medicaid - Surgical 73
PDF, 478 KB
PDF, 478 KB
Skin and Tissue Substitutes Medicare - Surgical 73
PDF, 413 KB
PDF, 413 KB
Skin Lesions-Keloids-Warts-Dermoscopy Commercial - Surgical 09
PDF, 245 KB
PDF, 245 KB
Skin Lesions-Keloids-Warts-Dermoscopy Medicaid - Surgical 09
PDF, 294 KB
PDF, 294 KB
Spinal Cord Electrical Stimulator and Dorsal Motor Ganglion Stimulator Commercial Surgical 69
PDF, 272 KB
PDF, 272 KB
Spinal Cord Electrical Stimulator and Dorsal Motor Ganglion Stimulator Medicaid - Surgical 69
PDF, 340 KB
PDF, 340 KB
Sports Hernia Repair (Athletic Pubalgia Surgery) Commercial - Surgical 127
PDF, 162 KB
PDF, 162 KB
Sports Hernia Repair (Athletic Pubalgia Surgery) Medicare - Surgical 127
PDF, 212 KB
PDF, 212 KB
Sports Hernia Repair Medicaid - Surgical 127
PDF, 232 KB
PDF, 232 KB
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radio Therapy (SBRT) Commercial - Surgical 88
PDF, 229 KB
PDF, 229 KB
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radio Therapy (SBRT) Medicare - Surgical 88
PDF, 281 KB
PDF, 281 KB
Stereotactic Radiosurgery and Stereotactic Body Radio Therapy Medicaid - Surgical 88
PDF, 310 KB
PDF, 310 KB
Subcutaneous Implantable Cardioverter Defibrillator Commercial - Surgical 106.pdf
PDF, 210 KB
PDF, 210 KB
Subcutaneous Implantable Cardioverter Defibrillator Medicaid - Surgical 106
PDF, 279 KB
PDF, 279 KB
Substernal Implantable Cardioverter-Defibrillator System Commercial - Surgical 130.pdf
PDF, 198 KB
PDF, 198 KB
Substernal Implantable Cardioverter-Defibrillator System Medicaid - Surgical 130
PDF, 243 KB
PDF, 243 KB
Substernal Implantable Cardioverter-Defibrillator System Medicare - Surgical 130
PDF, 224 KB
PDF, 224 KB
Surgical Assisted Liposuction for Lymphedema Post-mastectomy Commercial - Surgical 131
PDF, 180 KB
PDF, 180 KB
Surgical Assisted Liposuction for Lymphedema Post-mastectomy Medicaid - Surgical 131
PDF, 276 KB
PDF, 276 KB
Surgical Assisted Liposuction for Lymphedema Post-mastectomy Medicare - Surgical 131
PDF, 232 KB
PDF, 232 KB
Surgical Treatments for Obstructive Sleep Apnea Commercial - Surigcal
PDF, 256 KB
PDF, 256 KB
Surgical Treatments for Obstructive Sleep Apnea Medicaid - Surgical 18
PDF, 329 KB
PDF, 329 KB
Thermal Capsulorrhaphy Commercial - Surgical 86
PDF, 194 KB
PDF, 194 KB
Thermal Capsulorrhaphy Medicaid - Surgical 86
PDF, 263 KB
PDF, 263 KB
Thermal Capsulorrhaphy Medicare - Surgical 86
PDF, 232 KB
PDF, 232 KB
Thermal Intradiscal Procedures (TIP) Commercial - Surgical 79
PDF, 191 KB
PDF, 191 KB
Thermal Intradiscal Procedures (TIP) Medicaid - Surgical 79
PDF, 242 KB
PDF, 242 KB
Tissue Transplantation of the Knee, Ankle and Talus Commercial - Surgical 39
PDF, 208 KB
PDF, 208 KB
Tissue Transplantation of the Knee, Ankle and Talus Medicaid - Surgical 39
PDF, 317 KB
PDF, 317 KB
Titanium Rib Implant-Device Commercial - Surgical 75
Titanium Rib Implant-Device Medicaid - Surgical 75
PDF, 248 KB
PDF, 248 KB
Titanium Rib Implant-Device Medicare - Surgical 75
PDF, 229 KB
PDF, 229 KB
Total Ankle Replacement Commercial - Surgical 96
PDF, 251 KB
PDF, 251 KB
Total Ankle Replacement Medicaid - Surgical 96
PDF, 300 KB
PDF, 300 KB
Total Ankle Replacement Medicare - Surgical 96
PDF, 254 KB
PDF, 254 KB
Transanal Endoscopic Microsurgery (TEM) Commercial - Surgical 41
PDF, 164 KB
PDF, 164 KB
Transanal Endoscopic Microsurgery (TEM) Medicaid - Surgical 41
PDF, 237 KB
PDF, 237 KB
Transvenous Implantable Cardioverter Defibrillator Commercial - Surgical 133
PDF, 242 KB
PDF, 242 KB
Transvenous Implantable Cardioverter Defibrillator Medicaid - Surgical 133
PDF, 295 KB
PDF, 295 KB
Transvenous Phrenic Nerve Stimulation for Central Sleep Apnea Commercial - Surgical 134
PDF, 227 KB
PDF, 227 KB
Uterus Transplant Commercial - Surgical 125
PDF, 161 KB
PDF, 161 KB
Uterus Transplant Medicaid - Surgical 125
PDF, 233 KB
PDF, 233 KB
Uterus Transplant Medicare - Surgical 125
PDF, 213 KB
PDF, 213 KB
Varicocele Embolization Commercial - Surgical 209
PDF, 206 KB
PDF, 206 KB
Varicocele Embolization Medicaid - Surgical 209
PDF, 250 KB
PDF, 250 KB
Varicose Vein Treatments - Vulvar and Scrotal Commercial - Surgical 04
PDF, 241 KB
PDF, 241 KB
Varicose Vein Treatments-Vulvar and Scrotal Varicosity Treatments Medicaid - Surgical 04
PDF, 335 KB
PDF, 335 KB
Vertebral Body Tethering Commercial - Surgical 123
PDF, 203 KB
PDF, 203 KB
Vertebral Body Tethering Medicaid - Surgical 123
PDF, 254 KB
PDF, 254 KB
Vertebral Body Tethering Medicare - Surgical 123
PDF, 213 KB
PDF, 213 KB
Vestibular Implants Commercial - Surgical 129
PDF, 190 KB
PDF, 190 KB
Vestibular Implants Medicaid - Surgical 129
PDF, 243 KB
PDF, 243 KB
Vestibular Implants Medicare - Surgical 129
PDF, 216 KB
PDF, 216 KB