Providers

Medical Policy Upcoming Updates

Notification Date: March 21, 2018

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
Coronary Artery Calcium Scoring	Re-Reviewed	05/21/2018	Investigative and therefore not covered	No change in determination
Electromagnetic Navigation Bronchoscopy	Re-Reviewed	05/21/2018	Investigative and therefore not covered	No change in determination
Expanded Carrier Testing for Genetic Diseases	Re-Reviewed	05/21/2018	Covered for some indications; investigative and therefore not covered for all other indications	Added 5 additional conditions/diseases to the not investigative indications for limited genetic panels for individuals of Ashkenazi Jewish ancestry: familial hyperinsulinism, glycogen storage disease type I, Joubert syndrome, maple syrup urine disease, Usher syndrome. Expanded carrier testing panels remain investigative for all indications.
Health Research Institute/Pfeiffer Treatment Center Protocols	Re-Reviewed	05/21/2018	Investigative and therefore not covered	No change in determination
Percutaneous Disc Decompression Procedures (Percutaneous Discectomies, Nucleoplasty)	Re-Reviewed	05/21/2018	Investigative and therefore not covered	No change in determination
PancraGEN™ Genotyping for Risk Assessment of Pancreatic Cancer	New	05/21/2018	Investigative and therefore not covered	PancraGEN™ is a new molecular anatomic pathology test for pancreas cancer. This policy replaces Topographic Genotyping (PathFinder TG^®) policy that has been retired.
Sacral Nerve Stimulation (SNS)	Re-Reviewed	05/21/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Topographic Genotyping (PathFinder TG^®) for Diagnosis of Cancer	Re-Reviewed	05/21/2018	Inactivated	Policy inactivated because the test has been retired from the market and is no longer commercially available.
Vision Therapy	Re-Reviewed	02/21/2018	Covered for some indications per the member plan document.	Policy inactivated 02/21/18. Vision Therapy benefits are cited in the member plan document.

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.