Skip to Main Content
Providers

« Return to Updates to Medical Policies

Medical Policy Upcoming Updates

Notification Date: February 20, 2019

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

Hip Arthroplasty/ Replacement and Hip Resurfacing (III-SUR.40)

N/A
02/18/2019
N/A
  • No longer requires prior authorization
  • UM policy inactivated
Knee Arthroplasty/ Replacement (III-SUR.41) N/A 02/18/2019 N/A
  • No longer requires prior authorization
  • UM policy inactivated
Bone Marrow or Stem Cell (Peripheral or Umbilical Cord Blood) Transplantation) (III-TRA.01) Re-Reviewed 04/22/2019 Medically necessary for a select population of patients Background - Definitions
  • Stem cell boost definition has been expanded to include the terms donor leukocyte infusion (DLI), stem cell reinfusion, support and rescue
Heart Transplantation (Adult and Pediatric) (III-TRA.12) Re-Reviewed 04/22/2019 Medically necessary for a select population of patients No change to medical necessity criteria
Heart/Lung Transplantation (III-TRA.08) Re-Reviewed 04/22/2019              Medically necessary for a select population of patients No change to medical necessity criteria
Intestinal Transplantation (III-TRA.13) Re-Reviewed 04/22/2019 Medically necessary for a select population of patients No change to medical necessity criteria
Kidney Transplantation (III-TRA.03) Re-Reviewed 04/22/2019 Medically necessary for a select population of patients Changes to medical necessity criteria
  • A Glomerular Filtration Rate (GFR) of 20ml/min/m2 or less is required for end-stage renal disease (ESRD).
  • Creatinine clearance is no longer a required criteria for ESRD.
Liver Transplantation (III-TRA.02) Re-Reviewed 04/22/2019 Medically necessary for a select population of patients No change to medical necessity criteria
Lung Transplantation (Single or Double) (III-TRA.11) Re-Reviewed 04/22/2019 Medically necessary for a select population of patients No change to medical necessity criteria
Mechanical Circulatory Support Devices (III-SUR.38) Re-Reviewed 04/22/2019 Medically necessary for a select population of patients Change(s) to medical necessity criteria
  • AIDS-defining condition added as a contraindication for destination therapy for a ventricular assist device (VAD)
  • Appendix 2 added with a list of AIDS-defining conditions
Pancreas Transplantation (Pancreas Alone) (III-TRA.04) Re-Reviewed 04/22/2019 Medically necessary for a select population of patients No change to medical necessity criteria 
Pancreas-Kidney (SPK, PAK) Transplantation (III-TRA.05)  Re-Reviewed 04/22/2019 Medically necessary for a select population of patients Changes to medical necessity criteria
  • The insulin dependent diabetes (IDDM) criterion has been updated to “labile” IDDM throughout the medical necessity criteria for both evaluation and transplantation.

Coverage Policies

Policy Title Status Effective Date Determination Summary of Change

Upright Magnetic Resonance Imaging (MRI) (Standing/Seated/Weight Bearing/Vertical/Positional MRI)

Re-Reviewed 04/22/2019 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 10:09:50 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02