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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



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.


Date: 7/31/2021 9:50:19 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01