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Medical Policy Upcoming Updates

Notification Date: July 18, 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
Effective Date
Summary of Change
Digital Breast Tomosynthesis
Coverage for screening and diagnosis of breast cancer
Coverage Policy inactivated
Durable Medical Equipment
Covered according to the terms of the member's plan document
New non-covered indication:
DME purchases from online retailers are not covered
Endoscopic Balloon Sinuplasty Ostial Dilation and Steroid-Eluting Sinus Stents for Treatment of Chronic Sinusitis 

Former Title: Endoscopic Balloon Sinuplasty for Treatment of Chronic Sinusitis 

New and Re-reviewed
Balloon Sinuplasty: Covered for some indications; investigative and therefore not covered for all other indications.
Steroid-Eluting Sinus Stents: Investigative and therefore not covered
Ballon Sinuplasty: No change in determination 

Steroid-Eluting Sinus Stents: New determination 

KRAS Mutation Analysis for Predicting Response to Drug Therapy
Covered for some indications; investigative and therefore not covered for all other indications
New indication:
KRAS mutation analysis for predicting response to anti-epidermal growth factor receptor (EGFR) monoclonal antibodies is not investigative for patients with non-small cell lung cancer (NSCLC)
Scar Revision
Covered for some indications. Cosmetic procedures are excluded from coverage.
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.

Where information conflicts with applicable state and/or federal law, Medica follows such applicable federal and/or state law.

Date: 7/31/2021 10:19:46 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01