Providers

Medical Policy Upcoming Updates

Notification Date: October 18, 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
Blood Coagulation Home Testing Devices	Re-Reviewed	12/18/2017	Covered	No change in determination
Percutaneous Tibial Nerve Stimulation	New	10/17/2017	Covered for some indications; investigative and therefore not covered for all other indications	Not investigative for overactive bladder in individuals 18 years of age and older Investigative for all other indications
Sacral Nerve Stimulation (SNS)	New	10/17/2017	Covered for some indications; investigative and therefore not covered for all other indications	Not investigative for treatment of chronic urinary urge incontinence, non-obstructive urinary retention, and urge/frequency syndrome for individuals who have all the following: Failed conservative treatment Symptoms result in significant functional disability A positive response to a trial use of sacral nerve stimulation. Not investigative for treatment of fecal incontinence for adults who have all the following: Failed conservative treatments Failed surgical treatment or not a candidate for surgery Symptoms result in significant functional disability A positive response to a trial use of sacral nerve stimulation Investigative for treatment of fecal incontinence in children. Investigative for all other indications.

Utilization Management

Policy Title	Status	Effective Date	Determination	Summary of Change
Percutaneous Tibial Nerve Stimulation (III-MED.07)	Re-Reviewed	10/17/2017		No longer requires prior authorization Utilization Management policy archived Converted to Coverage Policy (see above)
Sacral Nerve Stimulation (SNS) (III-DEV.22)	Re-Reviewed	10/17/2017		No longer requires prior authorization Utilization Management policy archived Converted to Coverage Policy (see above)
Bariatric Surgery (III-SUR.30)	Re-Reviewed	01/01/2018	Medically necessary for a select population of patients	Change(s) to medical necessity criteria Criteria added for individuals less than 18 years of age. Growth criteria unique to this age group are: Greater than 95% of estimated adult height has been achieved. A minimum Tanner stage of IV.
Female Breast Reduction – Reduction Mammoplasty (III-SUR.27)	Re-Reviewed	01/01/2018	Medically necessary for a select population of patients	Change(s) to medical necessity criteria Using the Schnur Sliding Scale to determine medical necessity for breast tissue removal.
Orthognathic Surgery (III-SUR.32)	Re-Reviewed	01/01/2018	Medically necessary for a select population of patients	Change(s) to medical necessity criteria Criteria added for skeletal deformities with masticatory malocclusion and functional impairments. Will continue to use MCG™ Care Guidelines for orthognathic surgery associated with obstructive sleep apnea.

Clinical Guidelines

Policy Title	Status	Effective Date	Determination	Summary of Change
Routine Prenatal Care (VI-GYN.02)	New	01/01/2018	Provided evidence-based information for prenatal care in average risk pregnancies.	Nationally and locally recognized standards of practice are outlined for all of the following: First trimester care Second trimester care Third trimester care

Policy Title

Status

Effective Date

Determination

Summary of Change

Routine Prenatal Care (VI-GYN.02)

New

01/01/2018

Provided evidence-based information for prenatal care in average risk pregnancies.

Nationally and locally recognized standards of practice are outlined for all of the following:

First trimester care
Second trimester care
Third trimester care

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.