Providers

Medical Policy Upcoming Updates

Notification Date: December 19, 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	Status	Effective Date	Determination	Summary of Change
Cytochrome P450 (CYP450) Variant Genotyping (e.g., CYP2D6, CYP2C9, CYP2C19, CYP1A2, CYP3A4)	Re-Reviewed	02/18/2019	Investigative and therefore not covered	No change in determination
Exhaled Breath Tests for Asthma and Other Inflammatory Pulmonary Conditions: Exhaled Nitric Oxide Breath Test and Exhaled Breath Condensate pH Measurement	Re-Reviewed	02/18/2019	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Lipoprotein-associated Phospholipase A2 (Lp-PLA2) Immunoassay for Prediction of Risk for Coronary Heart Disease or Ischemic Stroke (PLAC® Test)	Re-Reviewed	02/18/2019	Investigative and therefore not covered	No change in determination
Lipoprotein Subclass Testing for Screening, Evaluation, and Monitoring of Cardiovascular Disease	Re-Reviewed	02/18/2019	Investigative and therefore not covered	No change in determination
Multichannel Intraluminal Esophageal Impedance with pH Monitoring	Re-Reviewed	12/19/2018 Enhanced benefit	Covered for some indications; investigative and therefore not covered for all other indications	Change in determination: Not investigative for the evaluation of gastroesophageal reflux disease (GERD) in individuals non-responsive to treatment or with atypical symptoms. Investigative for all other indications.
Quantitative Electroencephalogram (qEEG) and Referenced Electroencephalogram (rEEG)	Re-Reviewed	02/18/2019	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Transcatheter Heart Valve Replacement and Repair Procedures	Re-Reviewed	02/18/2019	Covered for some indications; investigative and therefore not covered for all other indications	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.