Providers

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.