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Medical Policy Upcoming Updates

Notification Date: August 15, 2018 

Below are the policies that are new or have been reviewed, along with the determination and summary of any changes.

Utilization Management Policies 

 
Policy Title
Status
Effective Date
Determination
Summary of Change
MCG Care Guidelines®
Re-reviewed
N/A
Medically necessary for a select population of patients
21st edition of MCG Care Guidelines have been reaffirmed and will continue to be used

Coverage Policies 

Policy Title
Status
Effective Date
Determination
Summary of Change
Antigen Leukocyte Cellular Antibody Test (ALCAT Test) for Food & Chemicals
Re-reviewed
10/15/2018
Investigative and therefore not covered
No change in determination
Cytotoxic Testing for Allergy Diagnosis
Re-reviewed
10/15/2018
Investigative and therefore not covered
No change in determination
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in Multiple Sclerosis
Re-reviewed
10/15/2018
Investigative and therefore not covered
No change in determination
Genetic Testing for Epilepsy and Seizure Disorders
New
10/15/2018
Investigative and therefore not covered
Investigative for all indications
Intracellular Micronutrient Analysis: MicroNutrient Testing; Intracellular Mineral Electrolyte Analysis
Re-reviewed
10/15/2018
Investigative and therefore not covered
No change in determination
Keratoprosthesis for Corneal Opacity
Re-Reviewed
10/15/2018
Covered for some indications; investigative and therefore not covered for all other indications
No change in determination
Laser Therapy for Nicotine Dependence
Re-Reviewed
10/15/2018
Investigative and therefore not covered
No change in determination
Noncontact Normothermic Wound Therapy
Re-Reviewed
10/15/2018
Investigative and therefore not covered
No change in determination
OncoSorb® Therapy (UltraPheresis) for Non-Hematologic Cancer
Re-Reviewed
10/15/2018
Investigative and therefore not covered
No change in determination
Outdoor Behavioral Healthcare
Re-Reviewed
10/15/2018
Investigative and therefore not covered
No change in determination
Percutaneous Tibial Nerve Stimulation
Re-Reviewed
10/15/2018
Covered for some indications; investigative and therefore not covered for all other indications
No change in determination
Repair of Pierced Body Parts
Re-Reviewed
10/15/2018
Covered for some indications; otherwise is excluded from coverage
No change in determination
Serial Dilution Endpoint Titration for Diagnosis and Treatment of Airborne Allergy
Re-Reviewed
10/15/2018
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.

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


Date: 7/31/2021 10:18:16 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02