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Medical Policy Upcoming Updates

Notification Date: March 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

Genetic Testing for Cardiac Channelopathies, III-DIA.05

Re-Reviewed
03/20/2019
See Coverage Policies below
  • No longer requires prior authorization
  • UM policy inactivated and replaced by a Coverage Policy

Genetic Testing for Cardiomyopathies, III-DIA.01

Re-Reviewed 03/20/2019 See Coverage Policies below
  • No longer requires prior authorization
  • UM policy inactivated and replaced by a Coverage Policy

Coverage Policies

Policy Title Status Effective Date Determination Summary of Change

Autologous Blood-Derived Products (Platelet-Rich Plasma, Autologous Conditioned Serum, Autologous Whole Blood)

Re-Reviewed 05/20/2019 Investigative and therefore not covered No change in determination
Continuous Glucose Monitoring (CGM) for Managing Diabetes New and Re-Reviewed 03/20/2019
  • Type 2 diabetes mellitus
05/20/2019
  • Implantable glucose sensor CGM
Covered for some indications; investigative and therefore not covered for all other indications Change in determination:
  • Real-time CGM (non-implantable): Covered for insulin-dependent Type 2 diabetes mellitus using an FDA-approved device. (Previously investigative and therefore not covered.)
New determination:
  • CGM using an implantable glucose sensor (e.g., Eversense): Investigative and therefore not covered.
Genetic Testing for Cardiac Channelopathies New 03/20/2019 Covered for some indications; investigative and therefore not covered for all other indications

No change in determination.

Covered for:

  1. Brugada syndrome
  2. Catecholaminergic polymorphic ventricular tachycardia
  3. Long QT syndrome
  4. Short QT syndrome
Investigative and therefore not covered for all other indications.
Genetic Testing for Cardiomyopathies New 03/20/2019
Enhanced Benefit
Covered for some indications; investigative and therefore not covered for all other indications Two indications added to the three previous covered indications:
  1. Left ventricular noncompaction
  2. Restrictive cardiomyopathy
Investigative and therefore not covered for all other indications.
Genetic Testing of Thyroid Nodules for Thyroid Cancer Re-Reviewed 03/20/2019
Enhanced Benefit
Covered for some indications; investigative and therefore not covered for all other indications

Change in determination:

The following genetic tests are no longer investigative for testing cytological indeterminate thyroid nodules:

  1. Afirma® BRAF and MTC reflex testing
  2. ThyroSeq® Genomic Classifier
  3. ThyroSeq® v.3
  4. ThyraMIRTM
  5. ThyGenX® with or without ThyraMIRTM

Afirma® Gene Expression Classifier remains not investigative.

All other genetic molecular profiling of thyroid nodules in fine-needle aspirates of the thyroid for thyroid cancer is investigative

Meniett™ Portable Pulse Generator for Treatment of Meniere’s Disease Re-Reviewed 05/20/2019 Investigative and therefore not covered No change in determination
Palatal Implants for Obstructive Sleep Apnea Syndrome Re-Reviewed 05/20/2019 Investigative and therefore not covered No change in determination
Percutaneous Radiofrequency and Laser Ablation Denervation Procedures for Facet and Sacroiliac Joints Re-Reviewed 05/20/2019

Covered for some indications; investigative and therefore not covered for all other indications

No change in determination
Quantitative Sensory Tests Re-Reviewed 05/20/2019 Investigative and therefore not covered No change in determination
Salivary Estriol Test for Preterm Labor Re-Reviewed 05/20/2019 Investigative and therefore not covered No change in determination
Single Photon Emission Computed Tomography (SPECT) for Attention Deficit Hyperactivity Disorder (ADHD) Re-Reviewed 05/20/2019 Investigative and therefore not covered No change in determination
Tissue-Engineered Skin Substitutes for Wound and Surgical Care Re-Reviewed 03/20/2019
Enhanced Benefit
Covered for some indications; investigative and therefore not covered for all other indications

Change in determination:

The following products are no longer investigative for the specific indication listed:

Breast reconstructive surgery:

  • AlloDerm®
  • AlloMax
  • AlloMend®
  • Cortiva®
  • DermACELL®
  • DermaMatrix
  • FlexHD®
  • Graftjacket® Regenerative Tissue Matrix (RTM)
  • hMatrix®
  • Neoform Dermis

Treatment of (1) non-infected wounds, or (2) non-infected chronic ulcers (diabetic or venous insufficiency) of the lower-extremity, either of which have not adequately responded to conventional therapy:

  • Apligraf®
  • Dermagraft®
  • EpiFix®
  • Integra® Omnigraft, Dermal Regeneration Template, and Bilayer Matrix Wound Dressing (excludes flowable wound matrix)
  • Graftjacket® Regenerative Tissue Matrix
  • Oasis® Wound Matrix

Deep dermal or full thickness burns (2nd or 3rd degree burns):

  • Epicel®
  • Integra® Dermal Regeneration Template™
  • OrCel™ (HDE)
  • TranCyte®
  • Biobrane®

Stevens-Johnson syndrome and toxic epidermal necrolysis:

  • Biobrane®

Dystrophic epidermolysis bullosa:

  • OrCel™

All other uses of the tissue-engineered skin substitutes not listed above are investigative.

All other tissue-engineered skin substitutes not listed above are investigative for all indications.




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 10:07:15 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01