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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 23rd 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.


Date: 7/31/2021 10:05:27 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02