Providers

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.