MCG Care Guidelines®
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Re-reviewed
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On or after 06/18/2018
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Medically necessary for a select population of patients
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Medica may use tools developed by third parties, such as MCG Care Guidelines®, to assist in administering health benefits. Medica will begin using the 22nd edition of MCG Care Guidelines on or after June 18, 2018.
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Adult Gender Reassignment Surgery
(III-SUR.20)
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Re-reviewed
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06/18/2018
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Medically necessary for a select population of patients
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No change to medical necessity criteria.
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Behavioral Health Services – Individual and Family business (IFB) (III-BEH.01)
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Re-reviewed
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06/18/2018
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Medically necessary for a select population of patients
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Prior authorization will be required for transcranial magnetic stimulation.
The MCG Guideline, Transcranial Magnetic Stimulation (B-801-T), will be used for criteria for individuals with a diagnosis of major depressive disorder.
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Bone Growth Stimulators (III-DEV.07)
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Re-reviewed
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06/18/2018
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Medically necessary for a select population of patients
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No change to medical necessity criteria.
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Comparative Genomic Hybridization (CGH) Microarray Testing (III-DIA.09)
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Re-reviewed
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06/18/2018
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Medically necessary for a select population of patients
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No change to medical necessity criteria.
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Implanted Hypoglossal Nerve Stimulation
(III-SUR.43)
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Re-reviewed
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06/18/2018
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Medically necessary for a select population of patients
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No changes to medical necessity criteria.
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Microprocessor Controlled Knee Prostheses, with or without Polycentric, Three-Dimensional Endoskeletal Hip Joint System (III-DEV.17)
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Re-reviewed
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06/18/2018
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Medically necessary for a select population of patients
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No changes to medical necessity criteria.
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Outpatient Enteral Nutrition (III-MED.03)
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Re-reviewed
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06/18/2018
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Medically necessary for a select population of patients
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No change to medical necessity criteria.
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Positron Emission Tomography (PET) Scan (III-DIA.12)
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Re-reviewed
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06/18/2018
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Medically necessary for a select population of patients
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Changes in medical necessity criteria:
- Written documentation for oncology services clarified. Requires either previous diagnostic imaging report(s) and/or pathology report(s).
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Real-Time Mobile Cardiac Outpatient Telemetry (RT-MCOT) (III-DIA.08)
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Re-reviewed
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04/23/2018
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Medically necessary for a select population of patients
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Changes in medical necessity criteria:
- Eliminated the criteria requiring non-real-time cardiac monitoring prior to a cardiologist request for RT-MCOT.
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Vagus Nerve Stimulation (III-DEV.24)
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Re-reviewed
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04/18/2018
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Medically necessary for a select population of patients
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Implantable vagus nerve stimulation (VNS) is now covered for all types of refractory epilepsy.
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