Surgery Index - Blue Cross of Idaho

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Medical Policies

7.0

Surgery

7.01	Surgery Introduction
Spinal Surgery Guidelines	Lumbar 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 Hearing Aids
7.01.05	Cochlear Implant
7.01.06	Disposable Arthroscopy
7.01.07	Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
7.01.08	Extracorporeal Shock Wave Lithotripsy for Kidney Stones
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
7.01.12	Isolated Limb Perfusion for Malignant Melanoma
7.01.13	Surgical Treatment of Bilateral Gynecomastia
7.01.14	Maze Procedure
7.01.15	Meniscal Allografts and Collagen Meniscus Implants
7.01.16	Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinson’s Disease
7.01.17	Percutaneous Balloon Valvuloplasty
7.01.18	Percutaneous Discectomy
7.01.19	Periurethral Bulking Agents for the Treatment of Incontinence
7.01.20	Vagus Nerve Stimulation
7.01.21	Reduction Mammaplasty
7.01.22	Reconstructive Breast Surgery/Management of Breast Implants
7.01.23	Tissue Pressure Measurement
7.01.24	Vitrectomy
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
7.01.30	Percutaneous Nephrostolithotomy and Lithotripsy for Kidney Stones
7.01.31	Continent Ileostomy and Urostomy
7.01.32	Chemonucleolysis
7.01.33	Posterior Capsulotomy
7.01.34	Electrocorticography
7.01.35	Extracorporeal Shock Wave Lithotripsy for Gallstones
7.01.36	Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae
7.01.37	Electrophrenic Pacemaker
7.01.40	Laser Treatment of Congenital Port Wine Stain Hemangiomas
7.01.41	Implantable Infusion Pump
7.01.42	Endoscopic Laser for Gastrointestinal Bleeding
7.01.43	Adrenal-to-Brain Transplantation
7.01.44	Automatic Implantable Cardioverter Defibrillator (AICD)
7.01.45	Endoscopic Laser for Tracheobronchial Obstructions
7.01.46	Endoscopic Injection Sclerotherapy for Esophageal Varices
7.01.47	Bariatric Surgery
7.01.48	Autologous Chondrocyte Transplantation
7.01.49	Laser Prostatectomy
7.01.50	Placental and Umbilical Cord Blood as a Source of Stem Cells
7.01.51	Surgical Management of Obstructive Sleep Apnea Syndrome/Upper Airway Resistance Syndrome
7.01.52	Transurethral Microwave Thermotherapy
7.01.53	Transjugular Intrahepatic Portosystemic Shunt (TIPS)
7.01.54	Transmyocardial Revascularization
7.01.55	Treatment of Varicose Veins
7.01.56	Laser-Assisted Tonsillectomy
7.01.58	Intra-operative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring)
7.01.59	Transurethral Radiofrequency Needle Ablation of the Prostate
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
7.01.64	Ross Pulmonary Autograft
7.01.65	Chronic Pulmonary Thromboendarterectomy
7.01.66	Partial Left Ventriculectomy
7.01.67	Endovascular Grafts for Abdominal Aortic Aneurysms
7.01.68	Extracranial Carotid Angioplasty/Stenting
7.01.69	Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction
7.01.70	Free Vascularized Fibular Grafting for the Treatment of Osteonecrosis of the Hip
7.01.71	Lung Volume Reduction Surgery for Severe Emphysema
7.01.72	Percutaneous Intradiscal Electrothermal Annuloplasty (IDET) and Percutaneous Intradiscal Radiofrequency Thermocoagulation
7.01.73	Gastric Electrical Stimulation
7.01.74	Stimulation of the Sacral Anterior Root Combined with Posterior Sacral Rhizotomy in Patients with Spinal Cord Injury
7.01.75	Cryosurgical Ablation of Primary or Metastatic Liver Tumors
7.01.77	Total Ankle Replacement
7.01.78	Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
7.01.79	Cryoablation of Clinically Localized Prostate Cancer
7.01.80	Total Hip Resurfacing
7.01.81	Sural Nerve Graft in Association with Radical Prostatectomy
7.01.82	Thermal Capsulorrhaphy as a Treatment of Joint Instability
7.01.83	Auditory Brain Stem Implant
7.01.84	Semi-Implantable Middle Ear Hearing Aid for Moderate to Severe Sensorineural Hearing Loss
7.01.85	Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
7.01.86	Endovascular Stent Grafts for Thoracic Aortic Aneurysms or Dissections
7.01.87	Artificial Intervertebral Disc
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 (Laser Discectomy) or Radiofrequency (DISC Nucleoplasty™) Energy
7.01.94	Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
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	Minimally Invasive Surgery for Snoring, Obstructive Sleep Apnea Syndrome/Upper Airway Resistance Syndrome
7.01.102	Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
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 High-Intensity Ultrasound Ablation 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	Allograft Use in Breast Reconstructive Surgery
7.01.114	Reverse Shoulder Arthroplasty
7.01.115	Axial (Percutaneous) Lumbar Interbody Fusion
7.01.116	Radiofrequency 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
7.01.121	Saturation Biopsy for Diagnosis and Staging of Prostate Cancer
7.01.200	Surgical Correction of Pectus Excavatum
7.01.201	Orthognathic Surgery
7.02	Anesthesiology Introduction
7.03	Transplant Introduction
7.03.01	Kidney Transplant
7.03.02	Allogeneic Pancreas Transplant
7.03.04	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	Ventricular Assist Devices and Total Artificial Hearts
7.03.12	Islet Transplantation

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