Providers

Medical Policy Upcoming Updates

Notification Date: June 20, 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
Abdominoplasty/Panniculectomy (III-SUR.13)	Re-reviewed	08/20/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Blepharoplasty, Blepharoptosis Repair and Brow Lift (III-SUR.29)	Re-reviewed	08/20/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Breast Implant Removal, Revision, or Reimplantation (III-SUR.11)	Re-reviewed	08/20/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Female Breast Reduction Surgery (III-SUR.27)	Re-reviewed	08/20/2018	Medically necessary for a select population of patients	Change(s) to medical necessity criteria Reinstated Medica's previous criteria for the amount of breast tissue to be removed in addition to the current Schur scale to allow for more body types.
Male Gynecomastia Surgery (III-SUR.31)	Re-reviewed	08/20/2018	Medically necessary for a select population of patients	Change(s) to medical necessity criteria Other medical causes must be ruled out, as indicated by normal laboratory results (e.g., liver and kidney function studies/enzymes)
Otoplasty (III-SUR.33)	Re-reviewed	08/20/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Proton Beam Radiation Therapy (III-MED.06)	Re-reviewed	07/16/2018	Medically necessary for a select population of patients	Reinstatement of Medica's former utilization management policy Sunset MCG™ Care Guideline Criteria (21st edition, 2017: ACG: A-0389 (AC), Proton Beam Therapy). Appropriate indications for PBRT: Chordomas or chondrosarcomas arising at the base of the skull or along the axial skeleton without distant metastasis [No change] Pediatric central nervous system tumors adjacent to vital structures (e.g. optic nerve, spinal cord) [Add back – no change] Melanoma of the uveal tract (iris, choroid, ciliary body) without extrascleral extension and with no evidence of metastasis [No change]
Rhinoplasty Procedure with or without Septoplasty (III-SUR.04)	Re-reviewed	08/20/2018	Medically necessary for a select population of patients	Change(s) to medical necessity criteria New Indication: Residual large cutaneous defect following resection of a malignancy A fixed, medically significant obstruction that can only be corrected by rhinoplasty is now a stand-alone criterion.
Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive Sleep Apnea/Hypopnea Syndrome (III-SUR.08)	Re-reviewed	08/20/2018	Medically necessary for a select population of patients	No change in determination

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Bladder Cancer Screening, Diagnosis and Monitoring Using Ancillary Urinary Tests	Re-reviewed	08/20/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Cognitive rehabilitation/Remediation	Re-reviewed	08/20/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
GeneticTesting: ScoliScore™ Adolescent Idiopathic Scoliosis (AIS) Prognostic Test	Re-reviewed	08/20/2018	Investigative and therefore not covered	No change in determination
Genetic Testing: TP53 (p53) Testing for Li-Fraumeni Syndrome	Re-reviewed	06/20/2018 Enhanced member benefit	Covered for some indications; investigative and therefore not covered for all other indications	Genetic testing for TP53 (p53) mutation is not investigative for women with early-onset breast cancer (less than age 31).
Magnetic Resonance Spectroscopy (MRS)	Re-reviewed	06/20/2018 Enhanced member benefit	Covered for some indications; investigative and therefore not covered for all other indications	Magnetic resonance spectroscopy is not investigative for the following indications: Distinguishing low grade from high grade gliomas Distinguishing recurrent or residual brain tumor from post-therapy changes (e.g., radiation-necrosis).
Non-Powered or Single Use Negative Pressure Wound Therapy Systems	Re-reviewed	08/20/2018	Investigative and therefore not covered	No change in determination
Transcatheter Closure of Cardiac Defects	Re-reviewed	06/20/2018 Enhanced member benefit	Covered for some indications; investigative and therefore not covered for all other indications	Transcatherter closure of patent foramen ovale (PFO) is no longer investigative when: The device has received FDA approval, and The FDA-approved indications for the specific device are met.
Vaginal Tactile Imaging	New	08/20/2018	Investigative	Investigative

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.