BlueCross BlueShield of Tennessee Medical Policy Manual

General Surgery

• Ablation Procedure for Peripheral Neuromas
• Ablation Treatments for Barrett’s Esophagus
• Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast
• Angioplasty and 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 Ostial Dilation for Treatment of Chronic Sinusitis
• Bariatric Surgery
• Blepharoplasty
• 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 for the Treatment of Prostate Tumors
• Cryosurgical Ablation for the Treatment of Renal Tumors
• Cryosurgical Ablation of Miscellaneous Solid Tumors (e.g., Liver, Pancreas and Breast)
• Diagnosis and Treatment of Facet Joint Pain
• Diagnosis and Treatment of Sacroiliac Joint Pain
• Donor Lymphocyte Infusion for Hematologic Malignancies Treated with an Allogeneic Hematopoietic Stem-Cell Transplant
• Electromagnetic Navigation Bronchoscopy
• Endometrial Ablation
• Endothelial Keratoplasty
• Epidural Steroid Injections for Treatment of  Back Pain
• Facelift, Facial Thread Lift
• Facet Arthroplasty
• Fetal Surgery for Prenatally Diagnosed Malformations
• Gender Reassignment Surgery
• Hair Transplantation
• Hand and/or Face Transplantation (Composite Tissue Allotransplantation)
• Hematopoietic Stem Cell Transplantation for Autoimmune Diseases
• 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
• Hematopoietic Stem Cell Transplantation in the Treatment of Germ Cell Tumors
• Implantable Sinus Stents and Drug-eluting Implants for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease
• 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 for Treatment of Discogenic Back Pain
• Intraocular Radiation Therapy for Age-Related Macular Degeneration
• Intrastromal Corneal Ring Segments (ICRS) for Vision Correction
• Keratoprosthesis
• Laparoscopic and Endoscopic Therapies for Gastroesophageal Reflux (GERD)
• Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids
• Laser Assisted Uvulopalatoplasty (LAUP)
• LASIK (laser in situ keratomileusis)
• Liposuction
• 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 Procedures for Weight Loss
• Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Peroral Endoscopic Myotomy (POEM)
• Nerve Graft with Radical Prostatectomy
• Neuromuscular Electrical Stimulation
• Occipital Nerve Stimulation
• Orthognathic Surgery
• Orthopedic Applications of Stem Cell Therapy
• Osteochondral Allografting
• Osteochondral Autografting (OCG)
• Otoplasty and External Ear Reconstruction
• Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
• Palatal Implants for the Treatment of Obstructive Sleep Apnea or Snoring
• Pancreas/Pancreas-Kidney/Pancreatic Islet Cell Transplantation
• Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
• Percutaneous Tibial Nerve Stimulation (PTNS)
• Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
• Plugs for Anal Fistula Repair
• Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
• Prolotherapy for Musculoskeletal Disorders
• Prostatic Urethral Lift
• Radioembolization for Primary Tumors of the Liver and Metastatic Tumors to the Liver
• Radiofrequency Ablation of Tumors
• Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
• Radiofrequency Energy Transanal Treatment of Fecal Incontinence
• Radiofrequency Tissue Volume Reduction (RFTVR) for the Treatment of Upper Airway Obstruction
• Reduction Mammaplasty (Non-Cancerous)Obstruction
• Responsive Neurostimulation for the Treatment of Refractory Partial 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
• Stereotactic Radiosurgery of Central Nervous System (CNS) Lesions
• 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
• Treatment of Congenital Port Wine Stains and Hemangiomas
• Vagal Nerve Blocking Therapy for Treatment of Obesity
• Varicose Vein Treatments for the Lower Extremities
• Vulvectomy

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