Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   

Policy #
Policy Bulletin Title
MA11.010a
Abortion
MA11.072
Application and Removal of Tattoos
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MA11.105f
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
MA11.011c
Artificial Hearts and Ventricular Assist Devices (VADs)
MA11.044f
Artificial Intervertebral Disc Insertion
MA11.082c
Autologous Chondrocyte Implantation (ACI)/Carticel® and Other Cell-based Treatments of Focal Articular Cartilage Lesions
MA11.100e
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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MA11.047c
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
MA11.049c
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
MA11.006b
Bronchial Thermoplasty
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MA11.054c
Cataract Surgery
MA11.060c
Catheter Ablation of Cardiac Arrhythmias
MA11.103a
Chemical Peels
MA11.039d
Cochlear Implantation
MA11.112
Composite Tissue Allotransplantation of the Hand(s) and Face
MA11.088b
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
MA11.022a
Cryosurgical Ablation of the Prostate Gland
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MA11.014e
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.005c
Deep Brain Stimulation (DBS)
MA11.102g
Denervation of the Spinal Nerves for Chronic Pain
MA11.065d
Endometrial Ablation
MA11.012d
Endovascular Grafts for Abdominal Aortic Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
MA11.062
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
MA11.026e
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
MA11.079c
Evaluation and Treatment of Erectile Dysfunction (ED)
MA11.087b
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
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MA11.046b
Hair Transplants and Cranial Prostheses (Wigs)
MA11.002h
Hematopoietic Stem Cell Transplantation
MA11.023i
Hyaluronan Acid Therapies for Osteoarthritis of the Knee
MA11.107c
Implantable Steroid-Eluting Sinus Stents
MA11.007a
Islet Cell Transplantation
MA11.067d
Labiaplasty
MA11.070a
Lipectomy and Liposuction
MA11.048c
Lumbar Interspinous Process Decompression System
MA11.095a
Lysis of Epidural Adhesions
MA11.091b
Manipulation Under Anesthesia
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MA11.081a
Meniscal Allograft Transplantation
MA11.080a
Mentoplasty or Genioplasty
MA11.098
Migraine Deactivation Surgery
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MA11.018c
Mohs' Micrographic Surgery (MMS)
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MA11.032e
Multiple Surgical Reduction Guidelines
MA11.021a
Non-Surgical Spinal Decompression Therapy
MA11.101
Nucleoplasty
MA11.083a
Orthognathic Surgery
MA11.086b
Osteochondral Allograft Transplantation
MA11.084b
Osteochondral Autograft Transplantation Procedure
MA11.058a
Otoplasty Otoplasty or Non-Surgical External Ear Molding
MA11.066b
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
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MA11.073c
Panniculectomy, Abdominoplasty, Abdominal Lipectomy, and Other Excisions of Redundant Skin
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MA11.113b
Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound
MA11.096b
Percutaneous Discectomy
MA11.097d
Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis
MA11.025
Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
MA11.013b
Percutaneous Left Atrial Appendage (LAA) Closure for Non-Valvular Atrial Fibrillation (NVAF)
MA11.056e
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting and Extracranial- Intracranial (EC-IC) Arterial Bypass Surgery
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MA11.024d
Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation
MA11.063a
Photocoagulation of Macular Drusen
MA11.109a
Procedures for the Treatment of Acne
MA11.055c
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
MA11.077e
Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
MA11.016a
Prostate Mapping Biopsy
MA11.052b
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
MA11.030e
Reconstructive Breast Surgery
MA11.069b
Reduction Mammoplasty
MA11.008d
Refractive Keratoplasty
MA11.043
Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens
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MA11.076c
Removal of Breast Implants
MA11.075a
Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
MA11.028e
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
MA11.078b
Scar Revision
MA11.071a
Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
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MA11.068d
Sentinel Lymph Node Biopsy and Mapping
MA11.099a
Septoplasty, Rhinoplasty, and Septorhinoplasty
MA11.033b
Solid Organ Transplantation and Procurement Cost of Organs and Tissues
MA11.031g
Spinal Cord and Dorsal Root Ganglion Stimulation
MA11.029f
Spinal Discectomy
MA11.108c
Spinal Fusion
MA11.041b
Spinal Laminectomy
MA11.110
Surgery for Gynecomastia
MA11.004g
Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
MA11.090
Surgical Treatment of Femoroacetabular Impingement
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MA11.036c
Surgical Treatment of Nails
MA11.093a
Surgical Treatments of Athletic Pubalgia
MA11.027c
Transcatheter Aortic Valve Replacement (TAVR) and Transcatheter Mitral Valve Repair (TMVR)
MA11.040b
Transcatheter Closure of Cardiac Septal Defects
MA11.106e
Treatment of Gender Dysphoria
MA11.050
Treatment of Medical and Surgical Complications
MA11.051a
Treatment of Obesity and Bariatric Surgery for Treatment of Morbid Obesity
MA11.001i
Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence
MA11.017f
Trigger Point Injections
ma11.057a
Use of a Robotic-Assisted Surgical System
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MA11.037d
Use of an Operating Microscope During a Surgical Procedure
MA11.045c
Uterine Artery Embolization
MA11.019d
Vagus Nerve Stimulation (VNS)
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MA11.015i
Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds









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