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Medical Policy Upcoming Updates

Notification Date: June 21, 2017 

Below are the policies that are new or have been reviewed, along with the determination and summary of any changes.

Utilization Management

Policy Title
Status
Effective Date
Determination
Summary of Change
Comparative Genomic Hybridization (CGH) Microarray Testing
Re-reviewed
06/21/2017 Enhanced benefit
Medically necessary for a select population of patients
Addition to the medical necessity criteria
  • CHG microarray testing for individuals diagnosed with hematologic malignancy is medically necessary when criteria are met.
Positron Emission Tomography (PET) Scans
Re-reviewed
06/21/2017 Enhanced benefit
Medically necessary for a select population of patients
Changes in medical necessity criteria
  • Cardiology section:  single photon emission computed tomography (SPECT) removed as a requirement for myocardial perfusion assessment. 
  • Cardiology section: added cardiac sarcoidosis as a new indication. PET is considered medically necessary for diagnosis or monitoring of cardiac sarcoidosis when MRI is inconclusive or contraindicated (e.g., implanted devices).

Definitions
  • Added definition of cardiac sarcoidosis.
Abdominoplasty/ Panniculectomy
Re-reviewed
08/21/2017
Medically necessary for a select population of patients
No change to medical necessity criteria
Bariatric Surgery
Re-reviewed
08/21/2017
Medically necessary for a select population of patients
Change in medical necessity criteria
  • Added ‘Removal of adjustable gastric band and/or port’ to the list of procedures appropriate for surgical revision.
Blepharoplasty, Blepharoptosis Repair, and Brow Lift
Re-reviewed
08/21/2017
Medically necessary for a select population of patients
No change to medical necessity criteria
Breast Implant Removal, Revision, or Reimplantation
Re-reviewed
08/21/2017
Medically necessary for a select population of patients
Change in medical necessity criteria
  • Breast implant-associated anaplastic large cell lymphoma added as an indication for removal.
Female Breast Reduction Surgery
Re-reviewed
08/21/2017
Medically necessary for a select population of patients
No change to medical necessity criteria
Implanted Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
New
08/21/2017
Medically necessary for a select population of patients
Prior Authorization is now required. 

Medically necessary when the following criteria are met:
  • The device is FDA-approved
  • The member is age 22 or older
  • Obstructive sleep apnea is present with an apnea-hypopnea index greater than or equal to 20 and less than or equal to 65
  • There is documented history of failed CPAP after a trial of at least 8 weeks or the member cannot tolerate CPAP
  • Other non-surgical options have been considered and excluded
Male Gynecomastia Surgery
Re-reviewed
08/21/2017
Medically necessary for a select population of patients
No change to medical necessity criteria
Otoplasty
Re-reviewed
08/21/2017
Medically necessary for a select population of patients
Change in medical necessity criteria
  • Clarification made that audiogram and documentation is only need when hearing is impaired. 
Rhinoplasty Procedure with or without Septoplasty
Re-reviewed
08/21/2017
Medically necessary for a select population of patients
No change to medical necessity criteria
Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive Sleep Apnea/ Hypopnea Syndrome
Re-reviewed
08/21/2017
Medically necessary for a select population of patients
No change to medical necessity criteria

 

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Surgical and Minimally Invasive Treatments for Benign Hypertrophy/Hyperplasia (BPH)
Re-reviewed
06/21/2017 – Enhanced benefit

08/21/2017 – Additions to investigative list
Investigative for some indications; not investigative for other indications
Enhanced criteria: Treatments no longer considered investigative:
  • UroLift® System
  • Prostatic stents

Additional Investigative treatments: 
  • Water Vapor Thermal Therapy System (e.g., Rezūm)
  • Waterjet Tissue Ablation (e.g. AquaBeam System)
Methylenetetrahydrofolate Reductase (MTHFR) Gene Mutation Testing
Re-reviewed
08/21/2017
Investigative
No change in determination
Proton Beam Radiation Therapy
Re-reviewed
08/21/2017
Investigative for some indications; not investigative for other indications
No change in determination
Tongue Base Suspension Procedures for Obstructive Sleep Apnea
Re-reviewed
08/21/2017
Investigative and therefore not covered
No change in determination
 
Urethral Bulking Agents for Urinary Incontinence
Re-reviewed
08/21/2017
Not investigative
No change in determination

 




The updated clinical policies and guidelines above are available as of July 17, 2017. View policies and guidelines.

To request paper copies of a policy, please leave a message at the Medica Provider Literature Request Line: 1-800-458-5512, option 1, then option 5, then ext. 2-2355.

Where information conflicts with applicable state and/or federal law, Medica follows such applicable federal and/or state law.


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