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Medical Policy Upcoming Updates

Notification Date: February 21, 2018 

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
Bone Marrow or Stem Cell (Peripheral or Umbilical Cord Blood) Transplantation) (III-TRA.01)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
No change to medical necessity criteria
Heart Transplantation (Adult and Pediatric) (III-TRA.12)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
No change to medical necessity criteria

Appendix 1: Updated Heart Failure Classification

Heart/Lung Transplantation (III-TRA.08)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
No change to medical necessity criteria

Appendix 1: Updated Heart Failure Classification

Intestinal Transplantation (III-TRA.13)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
No change to medical necessity criteria
Kidney Transplantation (III-TRA.03)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
No change to medical necessity criteria
Liver Transplantation (III-TRA.02)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
Changes to medical necessity criteria
  • Transplant Evaluation: Qualifying criteria for alcoholic liver disease removed. Abstinence or enrollment in a chemical dependency program is no longer required for the transplant evaluation.
  • Please Note: For the actual transplantation, there must be no active substance use disorder or for individuals with a recent (24 months) history of substance use disorder, there must be a successful completion of a chemical dependency program and 6 months of documented ongoing abstinence.
Lung Transplantation (III-TRA.11)
(formerly titled: Lung Transplantation (Single or Double)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
Changes to medical necessity criteria
  • Removed specific criteria for double lung transplant. Single and bilateral sequential lung transplant criteria were combined and both require a diagnosis of end-stage pulmonary disease.
Mechanical Circulatory Support Devices (III-SUR.38)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
Background:
  • Ventricular Assist Devices: added new FDA approved VAD device, HeartMate 3™.

Appendix 1: Updated Heart Failure Classification

Medicaid Home Care Nursing (HCN) Services (III-HOM.05)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
Changes in medical necessity criteria:
  • Added documentation requirement that home health agency must retain documentation of face-to-face encounter.
Definitions:
  • Added definition of face-to-face encounter.
Medicaid Home Health Aide (III-HOM.04)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
Changes in medical necessity criteria:
  • Added documentation requirement that home health agency must retain documentation of face-to-face encounter.
Definitions:
  • Added definition of face-to-face encounter.
Pancreas Transplantation (Pancreas Alone) (III-TRA.04)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
Changes in medical necessity criteria:
  • Irreversible multisystem organ failure added as a contraindication.
Pancreas-Kidney (SPK, PAK) Transplantation (III-TRA.05)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
No change to medical necessity criteria
Personal Care Assistance (III-HOM.03)
Re-reviewed
04/23/2018
Medically necessary for a select population of patients
Changes in medical necessity criteria:
  • Added documentation requirement that home health agency must retain documentation of face-to-face encounter.
Definitions:
  • Added definition of face-to-face encounter.

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
High Intensity Focused Ultrasound (HIFU) and Magnetic Resonance Guided Focused Ultrasound (MRgFUS)
(formerly titled: High Intensity Focused Ultrasound (HIFU) Ablation Therapy)
Re-reviewed
04/23/2018
Covered for some indications; investigative and therefore not covered for all other indications
No change in determination
Long Term Ambulatory Cardiac Rhythm Monitors
Re-reviewed
04/23/2018
Covered
No change in determination
Pharmacogenetic Testing of the VKORC1 Gene for Warfarin Response
Re-reviewed
04/23/2018
Investigative and therefore not covered
No change in determination
Pharmacogenetic Testing to Predict Toxicity to 5-Fluorouracil (F-FU)/Capecitabine- Based Chemotherapy
Re-reviewed
04/23/2018
Investigative and therefore not covered
No change in determination
Transcutanous Electrical Joint Stimulation
Re-reviewed
04/23/2018
Investigative and therefore not covered
No change in determination

 




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 10:24:13 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01