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Manual Section: Surgical and Related Services

List of Approved Procedures Policy Number: 10020

Purpose: To list approved procedures. I. From time to time, procedures will be added as technical advances occur and a reasonable prospect of discharge home on the day of surgery persists. Preliminary evaluation of new procedures will be done by the Medical Director. A. ENT LIST OF APPROVED PROCEDURES: Adenoidectomy Antral puncture/window Arch bar removal Bronchoscopy Cervical node biopsy Cleft lip repair Closed reduction nasal fracture Closed reduction mandibular fracture Cyst excision Endoscopic Sinus Surgery with or without image guidance Eyelid repair for Ectropion, Entropion & Ptosis Esophagoscopy Esophageal dilatation Ethmoidectomy Facial plastics Foreign body excision Fistulectomy Hyoid myotomy Incision and Drainage of Abscess Inner ear – labyrinthectomy Laryngoscopy Laryngeal polypectomy Lesion excision Myringotomy with or without tubes Mass excision Mastoidectomy, simple Nasal cauterization Nasal fracture, closed/open Nasal polypectomy Neck dissection, limited Neck Lift/Platysmaplasty Ossicular reconstruction Palatal biopsy Palatopharyngoplasty Parotidectomy Reduction inferior turbinate fracture Rhytidectomy Septoplasty Septorhinoplasty Stapendotomy Submaxillary gland excision Submucous resection Sinus irrigation Thyroglossal duct cyst Tonsillar tag excision Tumors – Benign and Malignant Tympanomastoidectomy Tympanoplasty Upper and lower lid blepheroplasties Uvulopalatopharyngoplasty Video Stroboscopy Vocal cord biopsy Zygoma arch reduction B. GASTROENTEROLOGY: Colonoscopy Endoscopic ultrasound Esophagogastroduodenoscopy (EGD) Esophageal motility studies Percutaneous endoscopic gastrostomy EGD with stent placement, removal or exchange EGD with balloon dilation EGD with pyloric injections Moderate Sedation Use of argon coagulation C. ORTHOPEDICS LIST OF APPROVED PROCEDURES: Amputations – Fingers and Toes Arthrodesis Arthroplasty of small joints Arthroscopy, operative, diagnostic any joint Arthroscopy – diagnostic – shoulder, knee, wrist or ankle Arthroscopic shoulder rotator cuff repairs including subacromial decompression and repairs of all tendons, muscles and ligaments of the shoulder joint Arthrotomy, meniscectomy Bone graft Bone cyst excision Bunionectomy Bursectomy Carpal tunnel decompression (Endoscope-assisted carpal tunnel release) Cast application Cast change with/without X-ray Cast removal Condylectomy Closed reduction with/without X-ray of fractures and dislocations Debridement Drainage – Bone/Joints Excision simple lesion Foot and Ankle – All procedures except triple arthrodesis Exostosis excision Fasciectomy Fiberoptic Arthroscopy – Diagnostic/Surgical Finger joint replacement Ganglionectomy Hammertoe repair Hand surgery Incision and drainage – Abscess Injection Block Joint manipulation Joint replacements – MCP/MTP Joint resection Knee — All ligament repair and/or reconstruction Metatarsal head excision Micro-laminectomy (with diskectomy) Morton’s neuroma excision Nerve block Nerve repair or graft Neurolysis, Transposition Repair Neurectomy (pain relief) Open reduction fracture Osteotomy Orthopedic hardware placement/removal Patellar shaving Peripheral nerve repair Plantar wart excision Repair minor/complex lacerations Release of tendon sheath Silastic Implants of pharangeal joints Skin Flaps- local Skin grafting Small vessel repair Spinal surgery – laminectomy – discectomy – lumbar – cervical Synovectomy Tendon transplants Tendon release Tendon repair – Extensor of Hand Flexor of Hand Proximal to Wrist Distal to Ankle Proximal to Ankle Tenotomy Total or partial joint replacement of knee or hip Ulnar nerve release/transfer Stump revision Syndactyly release Z-plasty D. OPHTHALMOLOGIC APPROVED LIST OF PROCEDURES: Biopsy of conjunctiva, eyelid, cornea Canthus excision/plasty Cataract extraction, with/without lens implant Chalazion excision Conjunctival surgery Corneal/sclera laceration repair Cryopexy Cryotherapy Cyst excision Entropion Ectropion Enucleation Epiretinal membrane dissection Glaucoma surgery including shunt procedures Examination under anesthesia Intraocular lens implant repositioning and exchange Iridectomy Keratotomy Lacrimal duct probing and/or reconstruction Limbal relaxing incision Lid and ocular adnexal surgery including plastics procedures Macular hole repair Pars plana lensectomy Phacoemulsification Pingueculum excision Posterior Vitrectomy Primary repair of retinal detachment Pterygium excision Removal of Intraocular foreign body Retinal surgery including sclera buckle Retina and vitreous surgery Revision of sclera buckle Strabismus surgery Superficial corneal surgery Retrobulbar or peribulbar injections Use of vitreous substitutes Vitrectomy E. GENERAL SURGERY LIST OF APPROVED PROCEDURES: Anal Fistulectomy Anal ulcer, papillae, crypts Axillary Dissection Lipoma excision Basal cell excision Breast biopsy, incised and excised Biopsy lymph node, skin, subcutaneous, muscle lesions with/without frozen section Bronchoscopy – rigid tube/fiberoptic Common bileduct exploration Condyloma excision Correction congenital anomalies – breast Cyst excision Esophagogastroduodenoscopy Excision simple or malignant lesion Excision – Benign or Malignant Lesions – Breast Flexible fiberoptic colonoscopy Flexible procto-sigmoidoscopy Foreign body excision with/without X-ray Ganglionectomy Gynecomastia excision Hematoma drainage Hemorrhoidectomy including stapled hemorrhoidectomy Herniorrhaphy, adult, pediatric, inguinal, umbilical, ventral, femoral Herniorrhaphy, laparoscopic inguinal/umbilical Placement of indwelling central venous access devices and removal Incision and Drainage – Abscess – Breast Laparoscopic appendectomy (incidental or interval) Laparoscopic biopsy, liver, peritoneal structures Laparoscopic cholecystectomy and cholangiogram Laparoscopic Nissen fundoplication Liver biopsy Mass excision Mastectomy, partial Mastectomy, simple Mastectomy, modified radical Mastectomy, reconstruction Minor burn treatment Minor laceration repair Muscle biopsy Neck tumors Node drainage of excision – superficial/deep Orchiopexy Parotidectomy Pilonidal cystectomy/ I&D Pleurocentesis Polypectomy – simple/endoscopic Radiofrequency ablation of varicose veins Rectal polypectomy Rectal dilatation Repair complex lacerations Rigid procto-sigmoidoscopy Sentinel lymph node biopsy Sigmoidoscopy Sinus tract excision Skin grafts Skin Flaps – local/distal Sphincter repair Suture removal Thoracentesis Thyroidectomy, partial or total Toe or digital amputations Tumor excision Varicose vein ligation with/without stripping Varicocelectomy wound closure, secondary F. UROLOGY LIST OF APPROVED PROCEDURES: Bladder tumor Circumcision Cystoscopy with or without stent placement Cystometric studies Hydrocelectomy Internal urethrotomy Laparoscopic varix ligation Meatotomy Modified Pereyra procedure Orchiectomy Orchiopexy Penile condylomata excision Penile pros. Insertion Prostate biopsy Retrograde pyelography Scrotal exploration Spermatic vein ligation Spermatocele ligation Stone manipulation Testicular biopsy Transurethral resection bladder tumor Undescended testes repair Vasectomy Vasovasostomy Varicocelectomy G. GYN LIST OF APPROVED PROCEDURES: Bartholin cystectomy and marsupialization Bladder neck suspension Cervical polypectomy Cervical cerclage Cervical biopsy – LEEP, conization Colporrhaphy, anterior Colporrhaphy, posterior Condyloma Acuminata removal Culdocentesis Colpotomy Cyst excision Cystoscopy Dilatation and Curettage Elective interruption of pregnancy (13 weeks or less) Enterocele vaginal repair Examination under anesthesia Fistulectomy Hymenotomy/ectomy Hysteroscopy, operative: – Lysis of endometrial adhesions (Asherman’s syndrome) – Resection/division/ablation of uterine septum Total laparoscopic hysterectomy +/- BSO Supra cervical hysterectomy +/- BSO Vaginal mesh placement Sacrospinous vault suspension Laparoscopic lymph node dissection Laparoscopy, diagnostic Laparoscopy-assisted bladder neck suspension Laparoscopy with/without CO2 Laser: – Diagnostic, including tubal dye studies – Biopsy of ovary, endometriotic implants, fibroids – Treatment: Cystectomy (all adnexal types) Adnexectomy (oophorectomy) Salpingostomy/Salpingectomy (ectopic pregnancy, not ruptured) Myomectomy Oophorectomy Tuboplasty Lysis of adhesions – Resection of myomas – Resection/excision of polyps – Foreign body retrieval, e.g. IUD – Endometrial ablation – Cannulation/dilation of fallopian tubes – Laparoscopic-Assisted Vaginal Hysterectomy +/- BSO – Appendectomy – Omental biopsy – Adhesiolysis Laser Treatment of condylomata/venereal warts in lower GYN tract, perineal and anal regions LEEP Modified Pereyra procedure Ovarian cystectomy Pelvic reconstruction procedures Pudendal block Termination of pregnancy, elective or therapeutic Tubal ligation, fulguration Tubal re-anastomosis (mini-lap) Use of subtotal morcelator Vaginal Hysterectomy Vaginal Stenosis Release Vaginal web excision Vaginoplasty Vulvar biopsy H. ORAL/DENTAL LIST OF APPROVED PROCEDURES: Alveoloplasty Biopsy Bone trim Cystectomy Exam under anesthesia, TMJ manipulation Exostosis excision Fistula closure Full/partial periodontal surgery Fractures, closed reduction Gingivectomy Incision and drainage Minor salivary gland surgery Oral lesion excision Oral cavity reconstruction Osteotomy, minor Palatal repair, minor Relocation mandibular dislocation Removal wires, bars, splints Soft tissue tumor excision Tooth extraction Wiring fracture jaw Zygoma reduction, closed I. PLASTICS APPROVED LIST OF PROCEDURES: Abdominoplasty Arm lift Basal cell excision Biopsy soft tissue Blepharoplasty Breast reconstruction/revision Breast Capsulorrhaphy Burn Treatment – Minor Capsulectomy Capsulotomy Carpal tunnel decompression Cartilage, Bone fascia graft Chemical peel Chin implant Cleft earlobe repair Cleft lip repair Contracture release Closed reduction nasal fracture Correction congenital anomalies – breast Cyst excision Debridement Dermabrasion Digital reconstruction, minor Dressing change Endoscopic carpal tunnel release Eyelid repair for ectropion, entropion & ptosis Face lift/Rhytidectomy Face peel Fat Harvesting and injection Flap revision/release Foreign material implant Ganglion excision Hair transplant Hand surgery Incision and drainage Integumentary System/Foreign body removal Keloid resection Laceration repair Lesion excision Lip reconstruction Lipectomy, abdomen Liposuction Laceration repair Lesion excision Lip reconstruction Lipectomy, abdomen Liposuction Laceration repair Lesion excision Lip reconstruction Lipectomy, abdomen Liposuction Mammoplasty, augmentation Mammoplasty, reduction Mass excision Mentoplasty Minor Anesthesia Nasal reduction, closed/open Neck lift/Platysmaplasty Neuroma excision Nevus excision Open carpal tunnel release ORIF of bones of hand and forearm Otoplasty Palatal repair, minor Palmar fasciotomy Phalangectomy Panniculectomy Reconstruction post mastectomy Repair/reconstruction or decompression of, nerves, ligaments and tendons of hand and forearm Reconstruction of Auricle Rhinoplasty Scar revision Skin contracture treatment Skin flaps –Local and Distal Skin graft Septoplasty Suture removal Tattoo excision Tendon repair – Extensor and Flexor of hand Tenotomy Thigh Lift Wedge resection Z-plasty Zygoma reduction, closed J. PODIATRIC LIST OF APPROVED PROCEDURES: Administration/Injection of nerve blocks Achiles Tendon repair Amputation Ankle Arthrotomy Ankle Arthrodesis Ankle Arthroplasty Ankle Arthroscopy Ankle Stablization Arthrodesis Arthroplasty Arthroplasty of lesser toes Bunionectomy without osteotomy or implantation Bunionectomy with osteotomy Club foot correction Condylectomy/tailor’s bunion/solitary Cryosurgery Endoscopy Excise osseous tumor, rear foot Excision, cutaneous lesion Excision, foreign body (digits) Excision, foreign body (forefoot) Excision tendon lesion (rear foot) Excision soft tissue lesion Excision intermetatarsal neuroma Excision, nail matrix Excision os trigonum Excision osseous tumor digit and forefoot Excision plantar calcaneal exostosis Excision retrocalcaneal spur Excision soft tissue lesion rear foot (ganglion) Excision tarsal coalition Excision tendon lesion (ganglion) Exostectomy of phalanx Incision and Drainage Laser excision of skin lesion foot Laser vaporization of skin lesion of foot Matrixectomy Metatarsectomy Metatarsal head resection Metatarsal osteotomy (with/without fixation) ORIF of forefoot fracture resection Osteotomy Ostectomy Pan-metatarsal head Partial ostectomy, lesser tarsus Peripheral nerve release Phalangeal osteotomy (with/without fixation) Phalangectomy Plantar fascia release (ganglion) Prosthesis (silastic metatarsophalangeal joint) Reduction of fracture and dislocation with/without internal fixation ankle Removal lesser metatarsal plantar Removal of hardware or prosthesis Repair lacerations Rotational dermal flaps Sesamoidectomy Syndactyly repair (toes) Tarsal osteotomy Tarsal tunnel release Tendon transfer of mid-tarsus (rear foot) Tenotomy, capsulotomy (digits) Transfer and neurolysis in the foot and ankle including tarsal tunnel release K. ANESTHESIA LIST OF APPROVED PROCEDURES: Brachial plexus block Epidural (lumbar/caudal) Major Blocks: Spinal C-arm guided epidural injections Cervical Plexus Block Intercostal Nerve Block Stellate ganglion block Permanent nerve block (alcohol) Paravertebral block (lumbar sympathetic) Peripheral block of extremities Ultrasound guided peripheral nerve block Ultrasound guided venous access placement L. NEUROSURGICAL LIST OF APPROVED PROCEDURES: Anterior Cervical Fusion and Discectomy Creation of subcutaneous pocket Diagnostic procedures including discography ultrasound and fluoroscopy I&D of Abscess Implantation and management of neurostimulators and CNS (central nervous system) infusion devices Intraspinous process decompression Microlaminectomy and Discectomy – lumbar or cervical Minor anesthesia including injection or administration of local Peripheral nerve decompression including endoscopic carpal tunnel release Peripheral nerve neurolysis Peripheral nerve repair Peripheral nerve transposition M. DERMATOLOGY LIST OF APPROVED PROCEDURES: Cryosurgery fulguration Dermabrasion Excise malignant lesion Excise simple or complex lesions Eyelid biopsy I&D abscess Lip shave Lip wedge resection Minor anesthesia Repair of complex lacerations Repair of simple or complex skin lesions Skin flaps Skin graft N. PAIN MANAGEMENT/PHYSICAL MEDICINE & REHAB LIST OF APPROVED PROCEDURES: C-arm guided epidural injections Cervical Plexus block Discography and fluoroscopic guided epidural injections Extremity and sympathetic nerve blocks Implantation of chronic pain control devices Intercostal Nerve block Neurolytic procedures including celiac plexus blocks Permanent Nerve block (alcohol) Spinal cord stimulator implant Stellate ganglion block O. PULMONARY LIST OF APPROVED PROCEDURES: Bronchoscopy Pleural biopsy Transtracheal aspiration Endotracheal intubation P. RADIOLOGY ONCOLOGY LIST OF APPROVED PROCEDURES: Brachytherapy Reference:

Effective Date: July 1, 2010

Revision Date: June 14, 2018