Providers

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: Brugada syndrome Catecholaminergic polymorphic ventricular tachycardia Long QT syndrome 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: Left ventricular noncompaction 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: Afirma^® BRAF and MTC reflex testing ThyroSeq^®Genomic Classifier ThyroSeq^® v.3 ThyraMIRTM 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.