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Medical Policy Upcoming Updates

Notification Date: November 15, 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
Cervical Spine Surgeries
(III-SUR.37)
Re-Reviewed  01/15/2018 Medically necessary for a select population of patients

No change to medical necessity criteria

Electric Tumor Treatment Fields (III-DEV.27)  Re-Reviewed 01/15/2018 Medically necessary for a select population of patients 

No change to medical necessity criteria 

Lumbar Spine Surgeries (III-SUR.34) Re-Reviewed 01/15/2018 Medically necessary for a select population of patients

No substantive changes to medical necessity criteria 

Spinal Cord Stimulation of
the Dorsal Column for the Treatment of Pain
(III-DEV.23)
Re-Reviewed 01/15/2018 Medically necessary for a select population of patients

No change to medical necessity criteria

Varicose Vein &
Venous Insufficiency
Treatments
(III-SUR.26)
Re-Reviewed 01/15/2018 Medically necessary for a select population of patients

No change to medical necessity criteria

Whole Exome Sequences (III-DIA.13) Re-Reviewed 01/15/2018 Medically necessary for a select population of patients

No change to medical necessity criteria


Clinical Guidelines

Policy Title
Status
Effective Date
Summary of Change
Preventive Services for
Children and Adolescents
Enrolled in Minnesota Health Care Programs (VI-PRV.01)
Re-
Reviewed
01/15/2018

Revisions based on changes to the Minnesota Child and Teen (C&TC) Schedule.

Routine Prenatal Care (VI-GYN.02)
New
01/15/2018

Professionally recognized appropriateness of care outlined for the following:
1. First prenatal visit
2. First and second trimester care
3. 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 9:49:26 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02