BlueCross BlueShield of Tennessee Medical Policy Manual

General Surgery

• Ablation Procedure for Peripheral Neuromas
• Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast
• Angioplasty or Stenting for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
• Aqueous Shunts and Stents for Glaucoma
• Artificial Intervertebral Disc
• Autologous Chondrocyte Implantation (ACI)
• Automated Percutaneous and Endoscopic Discectomy
• Axial Lumbosacral Interbody Fusion
• Balloon and Self-Expanding Absorptive Ostial Dilation for Treatment of Rhinosinusitis
• Breast Augmentation / Mammaplasty (Non-Cancerous)
• Breast Implant Removal
• Breast Reconstructive and Symmetry Surgery Following Mastectomy
• Browplasty
• Bulking Agents for the Treatment of Vesicoureteral Reflux (VUR) and Incontinence
• Cardioverter Defibrillators
• Cryosurgical Ablation of Solid Tumors
• Diagnosis and Treatment of Sacroiliac Joint Pain
• Donor Lymphocyte Infusion for Hematologic Malignancies Treated with an Allogeneic Hematopoietic Stem-Cell Transplant
• Endometrial Ablation
• Endothelial Keratoplasty
• Epidural Steroid Injections for Treatment of  Back Pain
• Facelift, Facial Thread Lift
• Facet Arthroplasty
• Facet Joint Injections

• Facet Joint Neurotomy

• Fetal Surgery for Prenatally Diagnosed Malformations
• Functional Neuromuscular Electrical Stimulation
• Gender Reassignment Surgery
• Hair Transplantation
• Hand and/or Face Transplantation (Composite Tissue Allotransplantation)
• Hematopoietic Stem Cell Transplantation for Central Nervous System Embryonal and Ependymoma Tumors
• Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas
• Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults
• Implantable Hypoglossal Nerve Stimulation
• Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
• Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers); Interspinous Fixation (Fusion) Devices
• Intervertebral Disc Decompression using Radiofrequency Coblation (Nucleoplasty) or Laser Energy (Laser Discectomy)
• Intestinal Transplantation
• Intradiscal Annuloplasty and Intraosseous Radiofrequency Ablation for Treatment of Back Pain
• Intraocular Radiation Therapy for Age-Related Macular Degeneration
• Intrastromal Corneal Ring Segments (ICRS) for Vision Correction
• Laparoscopic and Endoscopic Therapies for Gastroesophageal Reflux (GERD)
• Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids
• Laser Assisted Uvulopalatoplasty (LAUP)
• LASIK (laser in situ keratomileusis)
• Lipectomy and Liposuction for Lymphedema
• Liposuction
• Liposuction and Lipectomy for Lipedema
• Lysis of Epidural Adhesions
• Manipulation Under Anesthesia (MUA) of the Musculoskeletal System
• Mastectomy for Gynecomastia
• Meniscal Allografts and Synthetic Meniscus Implants
• Mentoplasty (Chin Augmentation, Genioplasty)
• Microwave Ablation for Oncologic Tumors
• Minimally Invasive Endoscopic Procedures for Weight Loss
• Nerve Graft with Radical Prostatectomy
• Neuromuscular Electrical Stimulation
• Orthognathic Surgery
• Orthopedic Applications of Stem Cell Therapy
• Osteochondral Allografting
• Osteochondral Autografting (OCG)
• Otoplasty and External Ear Reconstruction
• Palatal Implants for the Treatment of Obstructive Sleep Apnea or Snoring
• Pancreas/Pancreas-Kidney/Pancreatic Islet Cell Transplantation
• Percutaneous Arteriovenous Fistula (pAVF)
• Percutaneous Electrical Nerve Stimulation (PENS), Percutaneous Neuromodulation Therapy (PNT) and Percutaneous Electrical Nerve Field Stimulation (PENFS)
• Percutaneous Sacroplasty
• Percutaneous Vertebroplasty, Kyphoplasty, and Mechanical Vertebral Augmentation
• Peripheral Subcutaneous Field Stimulation for the Treatment of Pain
• Plugs for Anal Fistula Repair
• Prolotherapy for Musculoskeletal Disorders
• Radioembolization for Primary Tumors and Metastatic Tumors to the Liver
• Radiofrequency Ablation for Nasal Obstruction and Rhinitis
• Radiofrequency Tissue Volume Reduction (RFTVR) for the Treatment of Upper Airway Obstruction
• Reduction Mammaplasty (Non-Cancerous)Obstruction
• Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
• Rhinoplasty
• Saturation Biopsy for Diagnosis and Staging of Prostate Cancer
• Spinal Cord Stimulation / Peripheral Subcutaneous Field Stimulation for the Treatment of Pain
• Stem Cell Therapy for Peripheral Artery Disease
• Steroid-Eluting and Non-Steroid-Eluting Sinus Stents
• Surgical Deactivation of Headache Trigger Sites
• Surgical Treatment of Femoroacetabular Impingement
• Surgical Ventricular Restoration
• Total Ankle Replacement
• Transcatheter Hepatic Arterial Chemoembolization
• Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
• Treatments for Athletic Groin Pain
• Vulvectomy

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