Providers

Medical Policy Upcoming Updates

Notification Date: April 17, 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
MCG Care Guidelines^®	Re-Reviewed	On or after 06/17/2019	Medically necessary for a select population of patients	Medica may use tools developed by third parties, such as MCG Care Guidelines^®, to assist in administering health benefits. Medica will begin using the 23^rd edition of MCG Care Guidelines on or after June 17, 2019
Bariatric Surgery (III-SUR.30)	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Bone Growth Stimulation (III-DEV.07)	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Comparative Genomic Hybridization (CGH) Microarray Genetic Testing (III-DIA.09)	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Genetic Testing for Susceptibility to Colorectal Cancer (CRC) Syndromes (III-DIA.06)	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	Additional required genetic counseling documentation now includes: Discussion of possible impacts of testing (e.g., psychological, social, limitations of nondiscrimination statutes) Discussion of possible test outcomes (i.e., positive, negative, variant of uncertain significance) Explanation of potential benefits, risks, and limitations of testing Explanation of purpose of evaluation (e.g., to confirm, diagnose, or exclude genetic condition) Obtaining informed consent for genetic test.
Implanted Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (III-SUR.43)	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	Background – Definitions Section Added definition for central sleep apnea and mixed apnea. Revised current definition for obstructive sleep apnea. Medical Necessity Criteria – Contraindication Section: Added a contraindication: central plus mixed apneas greater than 25% of the total apnea-hypopnea index (AHI).
Maternal Plasma Testing for Detection of Cell-Free Fetal DNA for Analysis of Chromosomal Aneuploidies (III-DIA.11)	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	Additional required genetic counseling documentation now includes: Discussion of possible impacts of testing (e.g., psychological, social, limitations of nondiscrimination statutes) Discussion of possible test outcomes (i.e., positive, negative, variant of uncertain significance) Explanation of potential benefits, risks, and limitations of testing Explanation of purpose of evaluation (e.g., to confirm, diagnose, or exclude genetic condition) Obtaining informed consent for genetic test.
Microprocessor Controlled Knee Prostheses, with or Without Polycentric, Three-Dimensional Endoskeletal Hip Joint System (III-DEV.17)	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Outpatient Enteral Nutrition Therapy (III-MED.03)	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Positron Emission Tomography (PET) Scan (III-DIA.12)	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Real-Time Mobile Cardiac Outpatient Telemetry (RT-MCOT) (III-DIA.08	Re-Reviewed	06/17/2019	Medically necessary for a select population of patients	No change to medical necessity criteria

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Automated, Non-Invasive Nerve Conduction Velocity (NCV) Testing	Re-Reviewed	06/17/2019	Investigative and therefore not covered	No change in determination
Bioimpedance Spectroscopy (BIS) Devices for Detection of Lymphedema	Re-Reviewed	06/17/2019	Investigative and therefore not covered	No change in determination
Cell Therapy for the Treatment of Cardiac Disease	Re-Reviewed	06/17/2019	Investigative and therefore not covered	No change in determination
Collagen Cross Links Tests as Markers of Bone Turnover	Re-Reviewed	06/17/2019	Investigative and therefore not covered	No change in determination
Intradiscal Electrothermal Therapy (IDET)	Re-Reviewed	06/17/2019	Investigative and therefore not covered	No change in determination
Stem Cell Therapy for Peripheral Artery Disease	Re-Reviewed	06/17/2019	Investigative and therefore not covered	No change in determination
Synthetic Cartilage Implants for First Metatarsophalangeal Joint	New	06/17/2019	Investigative and therefore not covered	Investigative e.g., Cartiva SCI (synthetic cartilage implant)

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.