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Final Policies - Surgical

Policy # Policy Title Print View
MP-004 Minimally Invasive Approaches to Vertebral Fractures
MP-018 Cochlear Implants
MP-022 Occlusion of Uterine Arteries Using Transcatheter Embolization or Laparoscopic Occlusion to Treat Uterine Fibroids
MP-023 Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease-GERD
MP-033 Total Artificial Hearts and Implantable Ventricular Assist Devices
MP-041 Percutaneous Intradiscal Electrothermal Annuloplasty (IDET), Radiofrequency Annuloplasty, Biacuplasty, and Intraosseous Basivertebral Nerve Ablation
MP-045 Management of Varicose Veins
MP-052 Chemical Peels
MP-053 Bariatric Surgery for Treatment of Morbid Obesity and GERD
MP-055 Bi-Ventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
MP-056 Reduction Mammaplasty
MP-058 Management of Excessive Skin and Subcutaneous Tissue
MP-070 Locoregional Therapies for Primary or Metastatic Liver Tumors
MP-090 Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
MP-109 Septoplasty, Rhinoplasty Repair
MP-110 Permanent Forms of Sterilization Using the Hysteroscope
MP-114 Gynecomastia Surgery
MP-116 Otoplasty
MP-118 Dermabrasion
MP-119 Radiofrequency Ablation of Solid Tumors Excluding Liver Tumors
MP-120 Intraductal Biopsy/Breast Duct Endoscopy
MP-125 Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the Knee
MP-137 Automated Percutaneous and Percutaneous Endoscopic Discectomy
MP-141 Treatment Modalities for Facetogenic Pain
MP-145 Implantable Bone Conduction and Bone-Anchored Hearing Aids (BAHA)
MP-146 Auditory Brain Stem Implant
MP-148 Gastric Electrical Stimulation
MP-150 Artificial Intervertebral Disc
MP-151 Lung Volume Reduction Surgery for Severe Emphysema
MP-153 Hip Resurfacing
MP-156 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
MP-158 Meniscal Allografts and Other Meniscus Implants
MP-159 Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction
MP-166 Nonpharmacologic Treatment of Rosacea
MP-168 Cardioverter Defibrillator: Implantable
MP-169 Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
MP-172 Ovarian and Internal Iliac Vein Endovascular Occlusion as Treatment of Pelvic Congestion Syndrome
MP-173 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
MP-174 Risk-Reducing Mastectomy
MP-178 Magnetic Resonance Guided Focused Ultrasound (MRgFUS)
MP-182 Axial Lumbar Interbody Fusion
MP-183 Stem-cell Therapy for Peripheral Arterial Disease
MP-185 Isolated Limb Perfusion/Infusion for Malignant Melanoma
MP-189 Bone Morphogenetic Protein
MP-208 Laparoscopic, Percutaneous, and Transcervical Techniques for the Myolysis of Uterine Fibroids
MP-218 Transcatheter Closure Devices for Septal Defects
MP-224 Extracorporeal Shock Wave Lithotripsy (ESWL) for Pancreatic Stones
MP-225 Balloon Ostial Dilation for Treatment of Sinusitis
MP-229 Computer-Assisted Navigation for Orthopedic Procedures
MP-235 Prolotherapy
MP-241 Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing, Orthopedic Applications, and Other Non-Orthopedic Conditions
MP-248 Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
MP-257 Surgical Ventricular Restoration
MP-259 Prophylactic Oophorectomy
MP-260 Vagus Nerve Stimulation
MP-263 Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
MP-282 Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
MP-292 Disposable Arthroscopy
MP-299 Vertical Expandable Prosthetic Titanium Rib
MP-300 Islet Transplantation
MP-303 Epidural Steroid Injections for Back Pain
MP-306 Intraoperative Neurophysiologic Monitoring
MP-313 Transanal Endoscopic Microsurgery (TEM)
MP-314 Occipital Neuralgia and Headache Treatment
MP-326 Natural Orifice Transluminal Endoscopic Surgery (NOTES)
MP-328 Spinal Cord and Dorsal Root Ganglion Stimulation
MP-339 Total Ankle Replacement
MP-345 Joint Manipulation Under Anesthesia (Excluding Spine)
MP-347 Deep Brain and Motor Cortex Stimulation
MP-357 Subtalar Arthroereisis
MP-360 Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
MP-361 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
MP-366 Shoulder Resurfacing
MP-367 Facet Arthroplasty
MP-370 Nerve Graft with Radical Prostatectomy
MP-372 Hematopoietic Cell Transplantation for Malignant Astrocytomas and Gliomas
MP-373 Heart/Lung Transplant
MP-374 Lung and Lobar Lung Transplant
MP-380 Small Bowel/Liver and Multivisceral Transplant
MP-383 Hematopoietic Cell Transplantation for Primary Amyloidosis
MP-384 Whole Gland Cryoablation of Prostate Cancer
MP-386 Allogeneic Pancreas Transplant
MP-387 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
MP-388 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
MP-390 Heart Transplant and Combined Heart-Kidney Transplantation
MP-391 Arthroscopic Debridement and Lavage as Treatment for Osteoarthritis of the Knee
MP-394 Laser Treatment of Active Acne
MP-396 Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
MP-397 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
MP-398 Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
MP-399 Plugs for Anal Fistula Repair
MP-400 Electromagnetic Navigational Bronchoscopy
MP-401 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
MP-402 Hematopoietic Cell Transplantation for Hodgkin Lymphoma
MP-403 Hematopoietic Cell Transplantation for Solid Tumors of Childhood
MP-404 Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
MP-406 Percutaneous Electrical Nerve Stimulation Applications
MP-410 Fetal Surgery for Prenatally Diagnosed Malformations
MP-411 Peripheral Nerve Stimulation of the Head and Neck for Treatment of Pain
MP-412 Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors
MP-414 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
MP-415 Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
MP-417 Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus
MP-419 Image-Guided Minimally Invasive Decompression for Spinal Stenosis
MP-420 Lysis of Epidural Adhesions
MP-421 Surgical Treatment of Femoroacetabular Impingement
MP-429 Cryoablation of Tumors (Excluding Liver or Prostate Tumors)
MP-430 Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitutes Used with Autologous Bone Marrow)
MP-434 Bronchial Thermoplasty
MP-437 Kidney Transplant
MP-439 Placental/Umbilical Cord Blood as a Source of Stem Cells
MP-442 Implantable Infusion Pump for Pain and Spasticity
MP-454 Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux
MP-455 Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
MP-458 Bronchial Valves
MP-469 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
MP-476 Adipose-derived Stem Cells in Autologous Fat Grafting to the Breast
MP-479 Isolated Small Bowel Transplant
MP-480 Baroreflex Stimulation Devices
MP-483 Transcatheter Aortic-Valve Implantation for Aortic Stenosis
MP-485 Hematopoietic Cell Transplantation for Autoimmune Diseases
MP-486 Transcatheter Pulmonary Valve Implantation
MP-488 Wireless Pressure Sensors in Endovascular Aneurysm Repair
MP-489 Liver Transplant and Combined Liver-Kidney Transplant
MP-496 Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant
MP-503 Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension
MP-506 Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD)
MP-507 Surgical Deactivation of Headache Trigger Sites
MP-512 Microwave Tumor Ablation
MP-514 Interspinous Fixation (Fusion) Devices
MP-517 Lumbar Spinal Fusion Surgery
MP-518 Hematopoietic Stem-Cell Transplantation for Breast Cancer
MP-520 Confocal Laser Endomicroscopy
MP-521 Composite Tissue Allotransplantation (CTA) of the Hand and Face
MP-527 Bio-Engineered Skin and Soft Tissue Substitutes
MP-537 Peroral Endoscopic Myotomy (POEM) for Treatment of Esophageal Achalasia and Gastroparesis
MP-552 Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery
MP-555 Sacroiliac Joint Fusion
MP-558 Diagnosis and Treatment of Sacroiliac Joint Pain
MP-560 Surgery for Groin Pain in Athletes
MP-561 Transcatheter Mitral Valve Repair or Replacement
MP-574 Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
MP-576 Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
MP-579 Endovascular Therapies for Extracranial Vertebral Artery Disease
MP-596 Focal Treatments for Prostate Cancer
MP-597 Amniotic Membrane and Amniotic Fluid
MP-598 Vagus Nerve Blocking Therapy for Treatment of Obesity
MP-610 Prostatic Urethral Lift
MP-611 Transmyocardial Revascularization
MP-612 Irreversible Electroporation (IRE)
MP-617 High Resolution Anoscopy
MP-618 Neural Therapy
MP-621 Surgical Treatment of Snoring and Obstructive Sleep Apnea
MP-623 Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain
MP-631 Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
MP-637 Endovascular Stent Grafts for Thoracic Aortic Aneurysms or Dissections
MP-645 Endovascular Stent Grafts for Abdominal Aortic Aneurysms
MP-703 Leadless Cardiac Pacemakers
MP-704 Balloon Dilation of the Eustachian Tube
MP-705 Knee Arthroplasty
MP-712 Endoscopic Ultrasonography for the Upper Gastrointestinal Tract
MP-713 Liposuction for Lymphedema
MP-716 Patient-Specific Instrumentation for Joint Arthroplasty
MP-717 Three-Dimensional Printed Orthopedic Implants
MP-719 Surgical Treatments for Lymphedema
MP-728 Laser Interstitial Thermal Therapy (LITT) for Neurological Disorders
MP-730 Phrenic Nerve Stimulation for Central Sleep Apnea
MP-733 Cryosurgical Ablation of Primary or Metastatic Liver Tumors
MP-734 Internal Fixation of Rib Fractures
MP-737 Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies
MP-739 Trigger Point Injections
MP-740 Dry Needling of Trigger Points for Myofascial Pain
MP-741 Allograft Injection for Degenerative Disc Disease
MP-744 Cryoablation, Radiofrequency Ablation and Laser Ablation for Treatment of Chronic Rhinitis
MP-745 Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions
MP-747 Uterus Transplantation for Absolute Uterine Factor Infertility
MP-751 Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation
MP-753 Cardiac Contractility Modulation
MP-754 Annular Closure Devices
MP-757 Axillary Reverse Mapping for Prevention of Lymphedema