Medical Policies - Surgical

Accidental Dental Services Commercial - Surgical 19

Anterior Cervical Discectomy and Fusion or Posterior Cervical Foraminotomy with or without Partial Discectomy for Cervical Radiculopathy Commercial - Surgical 117

Anterior Cervical Discectomy and Fusion or Posterior Cervical Foraminotomy with or without Partial Discectomy for Cervical Radiculopathy Medicaid - Surgical 117

Bariatric Services Commercial - Surgical 32

Bariatric Services Medicaid - Surgical 32

Benign Prostatic Hypertrophy Treatments as an Alternative to Transurethral Resection of the Prostate (TURP) Commercial - Surgical 83

Benign Prostatic Hypertrophy Treatments as an Alternative to Transurethral Resection of the Prostate (TURP) Medicaid - Surgical 83

Breast Procedures Commercial - Surgical 10

Breast Procedures Medicaid - Surgical 10

Capsular Plication of the Hip Commercial - Surgical 232

Capsular Plication of the Hip Medicaid - Surgical 232

Capsular Plication of the Hip Medicare - Surgical 232

Cervical Laminectomy Commercial - Surgical 122

Cervical Laminectomy Medicaid - Surgical 122

Cervical Laminectomy Medicare - Surgical 122

Coccygectomy Commercial - Surgical 114

Coccygectomy Medicaid - Surgical 114

Coccygectomy Medicare - Surgical 114

Cochlear Implants, Bone Attached Hearing Aid Implants, Auditory Brain Stem Implants Commercial - Surgical 20

Cochlear Implants, Bone Attached Hearing Aid Implants, Auditory Brain Stem Implants Medicaid - Surgical 20

Computer Assisted Navigation Commercial - Surgical 233.pdf

Computer Assisted Navigation Medicaid - Surgical 233.pdf

Computer Assisted Navigation Medicare - Surgical 233.pdf

Core Decompression for Avascular Necrosis of the Knee, Ankle, Elbow and Shoulder Commercial - Surgical 214

Core Decompression for Avascular Necrosis of the Knee, Ankle, Elbow and Shoulder Medicaid - Surgical 214

Core Decompression for Avascular Necrosis of the Knee, Ankle, Elbow and Shoulder Medicare - Surgical 214

Corneal Procedures Commercial - Surgical 55

Corneal Procedures Medicaid - Surgical 55

Cosmetic and Reconstructive Surgery Commercial - Surgical 03

Cosmetic and Reconstructive Surgery Medicaid - Surgical 03

Cryoablation Commercial - Surgical 82

Cryoablation Medicaid - Surgical 82

Cryoablation Medicare Surgical 82

Cytoreductive Surgery (Tumor Debulking) Commercial - Surgical 02

Cytoreductive Surgery (Tumor Debulking) Medicaid - Surgical 02

Cytoreductive Surgery (Tumor Debulking) Medicare - Surgical 02

Deep Brain Stimulation Commercial - Surgical 74

Deep Brain Stimulation Medicaid - Surgical 74

Dermatologic Conditions Commercial - Surgical 09

Dermatologic Conditions Medicaid - Surgical 09

Endometrial Ablation Commercial - Surgical 15

Endometrial Ablation Medicaid - Surgical 15

Endometrial Ablation Medicare - Surgical 15

Eyelid Procedures and Brow Lift - Surgical 13

Eyelid Procedures and Brow Lift Medicaid - Surgical 13

Gastrointestinal Procedures Commercial - Surgical 205

Gastrointestinal Procedures Medicaid - Surgical 205

Gender Affirming Surgery Commercial - Surgical 108

Gender Affirming Surgery Medicaid - Surgical 108

Hand and Foot Surgeries Commercial - Surgical 52

Hand and Foot Surgeries Medicaid - Surgical 52

Hand and Foot Surgeries Medicare - Surgical 52

Headache Treatments Commercial - Surgical 103

Headache Treatments Medicaid - Surgical 103

Heart-Lung Transplantation Commercial - Surgical 28

Heart-Lung Transplantation Medicaid - Surgical 28

Hematopoietic Stem Cell Transplantation (HSCT) Commercial - Surgical 08

Hematopoietic Stem Cell Transplantation (HSCT) Medicaid - Surgical 08

Hyperhidrosis Treatments Commercial - Surgical 107

Hyperhidrosis Treatments Medicaid - Surgical 107

Hyperhidrosis Treatments Medicare - Surgical 107

Intestinal Transplant with or without Combined Liver Transplant or Other Visceral Organs Commercial - Surgical 92

Intestinal Transplant with or without Combined Liver Transplant or Other Visceral Organs Medicaid - Surgical 92

Intraoperative Neurophysiological Monitoring Commercial - Surgical 40

Intraoperative Neurophysiological Monitoring Medicaid - Surgical 40

Leadless Cardiac Pacemaker Commercial - Surgical 126

Leadless Cardiac Pacemaker Medicaid - Surgical 126

Left Atrial Appendage Occlusion Commercial - Surgical 102

Left Atrial Appendage Occlusion Medicaid - Surgical 102

Lumbar Discectomy Commercial - Surgical 120

Lumbar Discectomy Medicaid - Surgical 120

Lumbar Discectomy Medicare - Surgical 120

Lumbar Fusion Commercial - Surgical 118

Lumbar Fusion Medicaid - Surgical 118

Lumbar Laminectomy Commercial - Surgical 121

Lumbar Laminectomy Medicaid - Surgical 121

Lumbar Laminectomy Medicare - Surgical 121

Medical Dental Surgery Commercial - Surgical 128

Nasal Implants Commercial Surgical 230

Nasal Implants Medicaid Surgical 230

Neurolysis and Nerve Re-Implantation for Pelvic Pain Commercial - Surgical 221

Neurolysis and Nerve Re-Implantation for Pelvic Pain Medicaid - Surgical 221

Neurolysis and Nerve Re-Implantation for Pelvic Pain Medicare - Surgical 221

Non-Oncology Embolization Commercial Surgical 235

Non-Oncology Embolization Medicaid Surgical 235

Non-Oncology Embolization Medicare Surgical 235

Open Treatment of Rib Fracture with Internal Fixation Commercial - Surgical 217

Open Treatment of Rib Fracture with Internal Fixation Medicaid - Surgical 217

Ophthalmic Procedures Commercial - Surgical 60

Ophthalmic Procedures Medicaid - Surgical 60

Oral Incontinence Treatments Commercial - Surgical 220

Oral Incontinence Treatments Medicaid - Surgical 220

Oral Incontinence Treatments Medicare - Surgical 220

Orthognathic Surgery Commercial - Surgical 34

Orthognathic Surgery Medicaid - Surgical 34

Ovarian Vein Embolization Commercial - Surgical 202

Ovarian Vein Embolization Medicaid - Surgical 202

Pancreas and Islet Cell Transplants Commercial - Surgical 27

Pancreas and Islet Cell Transplants Medicaid - Surgical 27

Pectus Surgery and Devices Commercial - Surgical 05

Pectus Surgery and Devices Medicaid - Surgical 05

Pectus Surgery and Devices Medicare - Surgical 05

Penile Prosthesis Surgery Commercial - Surgical 23

Percutaneous Antegrade Transseptal Transcatheter Mitral Valve Implantation Commercial - Surgical 136

Percutaneous Antegrade Transseptal Transcatheter Mitral Valve Implantation Medicaid - Surgical 136

Percutaneous Antegrade Transseptal Transcatheter Mitral Valve Implantation Medicare - Surgical 136

Percutaneous Spinal Augmentation Commercial - Surgical 231

Percutaneous Spinal Augmentation Medicaid - Surgical 231

Percutaneous Transluminal Coronary Lithotripsy Commercial - Surgical 132

Percutaneous Transluminal Coronary Lithotripsy Medicaid - Surgical 132

Percutaneous Transluminal Coronary Lithotripsy Medicare - Surgical 132

Sacroiliac Fusion, Open and Percutaneous Commercial - Surgical 116

Sacroiliac Fusion, Open and Percutaneous Medicaid - Surgical 116

Shoulder-Elbow Joint Resurfacing Arthroplasty with Allograft Tissue Commercial - Surgical 111

Shoulder-Elbow Joint Resurfacing Arthroplasty with Allograft Tissue Medicaid - Surgical 111

Shoulder-Elbow Joint Resurfacing Arthroplasty with Allograft Tissue Medicare - Surgical 111

Skin and Tissue Substitutes Commercial - Surgical 73

Skin and Tissue Substitutes Medicaid - Surgical 73

Solid Organ Transplantations Commercial Surgical 236

Solid Organ Transplantations Medicaid Surgical 236

Spinal and Other Pain Management Procedures Commercial - Surgical 119

Spinal and Other Pain Management Procedures Medicaid - Surgical 119

Spinal Arthroplasty Commercial - Surgical 35

Spinal Arthroplasty Medicaid - Surgical 35

Spinal Cord Electrical Stimulator and Dorsal Motor Ganglion Stimulator Commercial Surgical 69

Spinal Cord Electrical Stimulator and Dorsal Motor Ganglion Stimulator Medicaid - Surgical 69

Sports Hernia Repair (Athletic Pubalgia Surgery) Commercial - Surgical 127

Sports Hernia Repair (Athletic Pubalgia Surgery) Medicare - Surgical 127

Sports Hernia Repair Medicaid - Surgical 127

Stereotactic Radiosurgery (SRS) and Stereotactic Body Radio Therapy (SBRT) Commercial - Surgical 88

Stereotactic Radiosurgery (SRS) and Stereotactic Body Radio Therapy (SBRT) Medicaid - Surgical 88

Subcutaneous Implantable Cardioverter Defibrillator Commercial - Surgical 106.pdf

Subcutaneous Implantable Cardioverter Defibrillator Medicaid - Surgical 106

Substernal Implantable Cardioverter-Defibrillator System Commercial - Surgical 130

Substernal Implantable Cardioverter-Defibrillator System Medicaid - Surgical 130

Substernal Implantable Cardioverter-Defibrillator System Medicaid - Surgical 130

Surgical Assisted Liposuction for Lymphedema Post-mastectomy Commercial - Surgical 131

Surgical Assisted Liposuction for Lymphedema Post-mastectomy Medicaid - Surgical 131

Surgical Assisted Liposuction for Lymphedema Post-mastectomy Medicare - Surgical 131

Surgical Treatments for Obstructive Sleep Apnea Commercial - Surigcal 18

Surgical Treatments for Obstructive Sleep Apnea Medicaid - Surgical 18

Thermal Capsulorrhaphy Commercial - Surgical 86

Thermal Capsulorrhaphy Medicaid - Surgical 86

Thermal Intradiscal Procedures (TIP) Commercial - Surgical 79

Thermal Intradiscal Procedures (TIP) Medicaid - Surgical 79

Tissue Transplantation of the Knee, Ankle and Talus Commercial - Surgical 39

Tissue Transplantation of the Knee, Ankle and Talus Medicaid - Surgical 39

Titanium Rib Implant-Device Commercial - Surgical 75

Titanium Rib Implant-Device Medicaid - Surgical 75

Titanium Rib Implant-Device Medicare - Surgical 75

Total Ankle Replacement Commercial - Surgical 96

Total Ankle Replacement Medicaid - Surgical 96

Total Ankle Replacement Medicare - Surgical 96

Transanal Endoscopic Microsurgery (TEM) Commercial - Surgical 41

Transanal Endoscopic Microsurgery (TEM) Medicaid - Surgical 41

Transvenous Implantable Cardioverter Defibrillator Commercial - Surgical 133

Transvenous Implantable Cardioverter Defibrillator Medicaid - Surgical 133

Treatment for Varicose Veins Commercial - Surgical 04

Treatment for Varicose Veins Medicaid - Surgical 04

Varicocele Embolization Commercial - Surgical 209

Varicocele Embolization Medicaid - Surgical 209

Vertebral Body Tethering Commercial - Surgical 123

Vertebral Body Tethering Medicaid - Surgical 123

Vertebral Body Tethering Medicare - Surgical 123