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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.


Date: 7/31/2021 10:23:28 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02