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Medical Policies

 

7.0 Surgery

7.01 Surgery Introduction 
Spinal Surgery Guidelines

Lumbar Fusion Guidelines can now be located in Policy 7.01.141

Cervical Fusion Guidelines

Laminectomy, Hemi-Laminectomy and Diskectomy Guidelines

Medically
Necessary
and
Investigational

 

For Blue Cross of Idaho`s definition of medically necessary and investigational, please click here. 
7.01.01 Acupuncture
7.01.03 Implantable Bone-Conduction and Bone-Anchored Hearing Aids 
7.01.05 Cochlear Implant 
7.01.07 Electrical Bone Growth Stimulation of the Appendicular Skeleton 
7.01.09 Prophylactic Mastectomy 
7.01.10 Embryonic Mesencephalic Transplantation for the Treatment of Parkinson's Disease 
7.01.11 Ilizarov Bone-Lengthening Procedure 
7.01.13 Surgical Treatment of Bilateral Gynecomastia 
7.01.14 Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures) 
7.01.15 Meniscal Allografts and Other Meniscal Implants 
7.01.16 Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinson’s Disease 
7.01.18 Automated Percutaneous and Endoscopic Discectomy  
7.01.19 Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
7.01.20 Vagus Nerve Stimulation 
7.01.21 Reduction Mammaplasty for Breast-Related Symptoms 
7.01.22 Reconstructive Breast Surgery/Management of Breast Implants 
7.01.23 Tissue Pressure Measurement 
7.01.25 Spinal Cord Stimulation 
7.01.26 Infrared Coagulation for Hemorrhoids 
7.01.27 Cerebellar Stimulation/Pacemaker 
7.01.28 Selective Posterior Rhizotomy for the Spasticity of Cerebral Palsy 
7.01.29 Percutaneous Electrical Nerve Stimulation (PENS) or Percutaneous Neuromodulation Therapy (PNT)  
7.01.36 Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae 
7.01.37 Electrophrenic Pacemaker 
7.01.40 Laser Treatment of Port Wine Stains 
7.01.41 Implantable Infusion Pump 
7.01.44 Implantable Cardioverter Defibrillators (ICD) 
7.01.47 Bariatric Surgery 
7.01.48 Autologous Chondrocyte Transplantation and Other Cell-based Treatments of Focal Articular Cartilage Lesions  
7.01.50 Placental/Umbilical Cord Blood as a Source of Stem Cells 
7.01.54 Transmyocardial Revascularization 
7.01.56 Laser-Assisted Tonsillectomy 
7.01.58 Intra-Operative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring)
7.01.60 Dynamic Cardiomyoplasty 
7.01.61 Transcatheter Closure of Patent Ductus Arteriosus 
7.01.62 Minimally Invasive Coronary Artery Bypass Graft Surgery 
7.01.63 Deep Brain Stimulation 
7.01.67 Endovascular Grafts for Abdominal Aortic Aneurysms 
7.01.68 Extracranial Carotid Angioplasty/Stenting 
7.01.69 Sacral Nerve Neuromodulation/Stimulation 
7.01.71 Lung Volume Reduction Surgery for Severe Emphysema 
7.01.72 Percutaneous Intradiscal Electrothermal Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty
7.01.73 Gastric Electrical Stimulation 
7.01.75 Cryosurgical Ablation of Primary or Metastatic Liver Tumors 
7.01.77 Total Ankle Replacement 
7.01.78 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions 
7.01.79 Cryoablation of Prostate Cancer 
7.01.80 Hip Resurfacing 
7.01.81 Nerve Graft in Association with Radical Prostatectomy 
7.01.82 Thermal Capsulorrhaphy as a Treatment of Joint Instability 
7.01.84 Semi-Implantable and Fully Implantable Middle Ear Hearing Aids 
7.01.85 Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures 
7.01.86 Endovascular Stent Grafts for Disorders of the Thoracic Aortic 
7.01.87 Artificial Intervertebral Disc: Lumbar Spine  
7.01.88 Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the Knee 
7.01.89 Extracorporeal Shock Wave Lithotripsy for Pancreatic Stones 
7.01.91 Radiofrequency Ablation of Primary or Metastatic Liver Tumors 
7.01.92 Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors 
7.01.93 Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) 
7.01.95 Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 
7.01.96 Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure 
7.01.98 Minimally Invasive Hip and Total Knee Arthroplasty 
7.01.100 Bone Morphogenetic Protein 
7.01.101 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
7.01.102 Periurethral Bulking Agents as a Treatment of Vesicoureteral Reflux
7.01.103 Surgical Ventricular Restoration
7.01.104 Subtalar Arthroereisis
7.01.105 Balloon Sinuplasty for Treatment of Chronic Sinusitis
7.01.106 Posterior Tibial Nerve Stimulation for Voiding Dysfunction
7.01.107 Interspinous Distraction Devices (Spacers)
7.01.108 Artificial Intervertebral Disc: Cervical Spine 
7.01.109

MRI-Guided Focused Ultrasound for the Treatment of Uterine Fibroids and Other Tumors

7.01.110

Vertical Expandable Prosthetic Titanium Rib

7.01.111

Wireless Pressure Sensors in Endovascular Aneurysm Repair

7.01.112 Transanal Endoscopic Microsurgery (TEMS)
7.01.113 Bio-Engineered Skin and Soft Tissue Substitutes  
7.01.114 Reverse Shoulder Arthroplasty  
7.01.116 Facet Joint Denervation
7.01.117 Arthroscopic Debridement and Lavage as Treatment for Osteoarthritis of the Knee
7.01.118  Surgical Treatment of Femoroacetabular Impingement 
7.01.119  Shoulder Resurfacing 
7.01.120  Facet Arthroplasty 
7.01.121  Saturation Biopsy for Diagnosis and Staging of Prostate Cancer 
7.01.122  Electromagnetic Navigation Bronchoscopy 
7.01.123  Plugs for Fistula Repair 
7.01.124  Treatment of Varicose Veins/Venous Insufficiency  
7.01.125  Occipital Nerve Stimulation 
7.01.127  Bronchial Thermoplasty 
7.01.126  Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis 
7.01.128  Endobronchial Valves 
7.01.129  Autologous Fat Grafting to the Breast and Adipose-derived Stem Cells
7.01.130 Axial Lumbosacral Interbody Fusion
7.01.131 Transcatheter Pulmonary Valve Implantation
7.01.132 Transcatheter Aortic-Valve Implantation for Aortic Stenosis
7.01.133 Microwave Tumor Ablation
7.01.134 Transcatheter Pulmonary Valve Implantation
7.01.135 Surgical Deactivation of Headache Trigger Sites
7.01.136 Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
7.01.137 Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)
7.01.138 Interspinous Fixation (Fusion) Devices
7.01.139 Peripheral Subcutaneous Field Stimulation
7.01.140 Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery
7.01.141 Lumbar Fusion Guidelines
7.01.142 Surgery for Athletic Pubalgia
7.01.144 Patient-Specific Cutting Guides and Custom Knee Implants
7.01.201 Orthognathic Surgery
7.02 Anesthesiology Introduction
7.02.01  Monitored Anesthesia Care (MAC)  
7.03 Transplant Introduction
7.03.01 Kidney Transplant
7.03.02 Allogeneic Pancreas Transplant
7.03.04

Isolated Small Bowel Transplant 

7.03.05 Small Bowel/Liver and Multivisceral Transplant
7.03.06 Liver Transplant
7.03.07 Lung and Lobar Lung Transplant
7.03.08 Heart/Lung Transplant
7.03.09 Heart Transplant
7.03.11 Total Artificial Hearts and Implantable Ventricular Assist Devices
7.03.12 Islet Transplantation