Providers

Medical Policy Upcoming Updates

Notification Date: September 20, 2017

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

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Gastric Electrical Stimulation	Re-reviewed	11/20/2017	Covered for some indications; investigative and therefore not covered for all other indications.	No change in determination
Hyperbaric Oxygen Therapy (HBOT)	Re-reviewed	11/20/2017	Covered for some indications; investigative and therefore not covered for all other indications.	No change in determination
Minimally Invasive Sacroiliac Joint Fusion for Low Back Pain	Re-reviewed	11/20/2017	Investigative and therefore not covered.	Title change: Formerly titled Sacroiliac Joint Fusion No change in determination
Salivary Hormone Tests	Re-reviewed	11/20/2017	Investigative and therefore not covered.	No change in determination
Surgical Interruption of Pelvic Nerve Pathways for Treatment of Pelvic Pain (e.g., Presacral Neurectomy and Uterosacral Nerve)	Re-reviewed	11/20/2017	Investigative and therefore not covered.	No change in determination
Wireless Capsule Endoscopy (CE) and Capsule Technology to Verify Patency Prior to Capsule Endoscopy	Re-reviewed	11/20/2017	Covered for some indications; investigative and therefore not covered for all other indications.	No change in determination

Utilization Management

Policy Title	Status	Effective Date	Determination	Summary of Change
Genetic Testing for Cardiac Channelopathies (III-DIA.05)	Re-reviewed	09/20/2017 Enhanced benefit	Medically necessary for a select population of patients.	Changes in medical necessity criteria: Genetic testing considered medically necessary for Short QT Syndrome meeting specified criteria.
Magnetic Esophageal Ring for the Treatment of Gastroesophageal Reflux Disease (III-SUR.42)	New	11/20/2017	Medically necessary for a select population of patients.	Prior Authorization is now required. Medically necessary when all the following criteria are met: Objective evidence of GERD defined by one of the following: -An abnormal pH study -Dysplasia as evidenced by endoscopy. A diagnosis of refractory GERD, as evidenced by all of the following: -Failure of PPI medication -Failure of other nonsurgical treatments such as weight loss, smoking cessation, and avoidance of trigger foods. No documented contraindications: -No suspected or known allergies to titanium, stainless steel, nickel, or ferrous materials -No implanted devices such as defibrillators or pacemakers -No hiatal hernia greater than 3 cm in size. Written documentation in the medical record must include a description of all trials of conservative therapy including the length and results of treatment.
Autologous Cultured Chondrocyte Transplantation for the Knee (III-SUR.35)	Re-reviewed	11/20/2017	Medically necessary for a select population of patients.	Title change: Removed “Carticel” from the title. Formerly titled Autologous Cultured Chondrocyte (Carticel™) Transplantation for the Knee Changes in medical necessity criteria: FDA approved product was added as a requirement. Wording changed: corresponding chondromalacia (kissing) lesion requirement was replaced with corresponding lesion on opposing surface. Definitions: Expanded definition of autologous chondrocyte transplantation (ACT) to include first, second and third generation ACT. In addition, FDA approved products are listed.
Genetic Testing for Cardiomyopathies (III-DIA.07)	Re-reviewed	11/20/2017	Medically necessary for a select population of patients.	No change to medical necessity criteria
Genetic Testing for Susceptibility to Hereditary Breast and Ovarian Cancer (III-DIA.04)	Re-reviewed	11/20/2017	Medically necessary for a select population of patients.	No change to medical necessity criteria
High Frequency Chest Wall Compression (HFCWC) Devices (III-DEV.20)	Re-reviewed	11/20/2017	Medically necessary for a select population of patients.	Changes in medical necessity criteria: Removed sub criteria for bronchiectasis.
Home Health Aide (III-HOM.02)	Re-reviewed	11/20/2017	Medically necessary for a select population of patients.	No change to medical necessity criteria
Knee Arthroplasty /Replacement (III-SUR.41)	Re-reviewed	11/20/2017	Medically necessary for a select population of patients.	No change to medical necessity criteria
Medicaid Home Care Nurse (HCN) Services (III-HOM.05)	Re-reviewed	11/20/2017	Medically necessary for a select population of patients.	Changes in medical necessity criteria: Physician services have been expanded to include advanced practice registered nurse and physician assistant. Definitions: Updated to include advanced practice registered nurse and physician assistant.
Medicaid Home Health Aide (III-HOM.04)	Re-reviewed	11/20/2017	Medically necessary for a select population of patients.	Changes in medical necessity criteria: Residence service location has been expanded to include services in the community where normal life activities take the recipient. Definitions: Updated to include above expanded service location.
Personal Care Assistance (III-HOM.03)	Re-reviewed	11/20/2017	Medically necessary for a select population of patients.	No change to medical necessity criteria

Clinical Guidelines

Policy Title	Status	Effective Date	Determination	Summary of Change
Management of Benign Uterine Conditions (VI-GYN.01)	Re-reviewed	11/20/2017	Guideline addresses medically appropriate conservative treatments for selected indications.	No changes in guideline criteria.

The updated clinical policies and guidelines above will be available as of their effective date, as noted. 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 8, then ext. 2-2355.

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