Providers

Medical Policy Upcoming Updates

Notification Date: May 16, 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
Vagus Nerve Stimulation	Re-reviewed	07/16/2018	Medically necessary for a select population of patients	Non-implantable transcutaneous vagus nerve stimulation (e.g., gammaCore®) is investigative for all indications.
Wheelchairs, Scooters and Accessories (III-DEV.25)	Re-reviewed	07/16/2018	Medically necessary for a select population of patients	Changes to the Benefit Considerations section: A wheelchair evaluation cannot be performed by anyone that that has a financial relationship with the supplier. A back up manual wheelchair for individuals with a powered device is generally considered a duplicate device and/or convenience item and is excluded from coverage.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Extracorporeal Photopheresis (Photochemotherapy)	Re-reviewed	07/16/2018	Covered for some indications; investigative and therefore not covered for all other indications	Both skin and non-skin, graft-versus-host disease is not investigative. Atopic (neuro-) dermatitis (atopic eczema), recalcitrant and Dermatomyositis/polymyositis are investigative.
Gene Expression Profiling Assays for Breast Cancer	Re-reviewed	05/16/2018 Enhanced member benefit	Covered for some indications; investigative and therefore not covered for all other indications	Oncotype DX Breast Breast Cancer Assay: now covered for early stage breast cancer that is hormone receptor (+), HER2-receptor (-) and either Node (-) or Node (+) in 1-3 ipsilateral lymph nodes. (Previously covered for only Node (-) tumors.) Following 4 tests now covered for hormone receptor (+), HER2-receptor (-) and Node (-) breast tumors: Breast Cancer Index (BCI) EndoPredict MammaPrint Prosigna (PAM 50) The use of more than one gene expression profile assay per each breast cancer tumor type (either repeat testing of a previously performed assay or using a different assay) is investigative.
Gene Expression Profiling Assays for Predicting Colon Cancer Recurrence Risk	Re-reviewed	07/16/2018	Investigative and therefore not covered	No change in determination
Genetic Testing for Prostate Cancer	Re-reviewed	07/16/2018	Investigative and therefore not covered	Added the following Investigative genetic tests: Decipher® Prostate Cancer Classifier ProMark Proteomic Prognostic Test ConfirmMDx® for Prostate Cancer SelectMDx for Prostate Cancer
Liquid Biopsy: Testing of Circulating Tumor Cells or Cell-Free Tumor DNA Former Title: Circulating Tumor Cell Laboratory Testing	Re-reviewed	07/16/2018	Investigative and therefore not covered	Cell-free Tumor DNA (cfDNA) added to this policy. Testing of both circulating tumor cells and cell-free DNA are investigative. .
Lower Limb Activity-Based Locomotor Training	New	07/16/2018 Note: Former policy, Lower-Limb Functional Electrical Stimulation, will be inactivated on 7/16/2018 and incorporated into this policy.	Covered for some indications; investigative and therefore not covered for all other indications	Not Investigative Determination: Functional electrical stimulation (FES) and neuromuscular electrical stimulation (NMES) using stationary equipment when used as one component of a comprehensive facility-based rehabilitation program. Investigative Determination: FES/NMES for all indications not listed above FES ergometic cycles used in the home setting Dynamic spinal unloading devices (e.g., GIGER MD coordinated dynamic therapy device) Robotic-assisted locomotor treadmill therapy (e.g., Lokomat®) Note: Exercise programs, and the equipment used, are usually excluded services in the member’s plan document.
Multivariate Biomarker Blood Testing for Predicting Malignancy in Women with Adnexal Mass	Re-reviewed	07/16/2018	Investigative and therefore not covered	No change in determination.
Nebulized Intranasal Antibiotics/Antifungals for Sinusitis	Re-reviewed	07/16/2018	Investigative and therefore not covered	No change in determination.
Therapeutic Apheresis (TA): Plasmapheresis, Plasma Exchange	Re-reviewed	07/16/2018	Covered for some indications; investigative and therefore not covered for all other indications	Adjustments made to the covered and non-covered indications to reflect the indications re-assessed in the 2016 American Society for Apheresis Guideline: Use of Therapeutic Apheresis in Clinical Practice, and documented in the published clinical assessment monographs.
Thoracic Electrical Bioimpedance	Re-reviewed	07/16/2018	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.

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