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Medical Policy Upcoming Updates

Notification Date: May 15, 2019

Below are the policies that are new or have been reviewed, along with the determination and summary of any changes.

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Chemoembolization for Hepatic Tumors Re-Reviewed 07/15/2019 Covered for some indications; investigative and therefore not covered for all other indications No change in determination
Endoscopic Radiofrequency Ablation for Barrett’s Esophagus Re-Reviewed 07/15/2019 Covered for some indications; investigative and therefore not covered for all other indications No change in determination
Genetic Testing for Alzheimer Disease Re-Reviewed 07/15/2019 Investigative No change in determination
Interferential Current Stimulation Re-Reviewed 07/15/2019 Investigative No change in determination
Intraoperative Neurophysiologic Monitoring (IONM) New 07/15/2019 Covered for some indications; investigative and therefore not covered for all other indications

The use of IONM is not investigative when the following criteria are met:

  • One or more of the following IONM are used:
    1. Somatosensory evoked potentials (SSEPs) motor evoked potentials (MEPs)
    2. Brainstem auditory, BAEPs)
    3. Electromyography (EMG)
    4. Electroencephalogram (EEG)
    5. Electrocorticography (ECoG).
  • IONM is provided by a physician (other than the surgical team) that is trained in clinical neurophysiology.
  • The individual has an abnormal anatomy that pose a potential risk of significant damage to a cranial nerve, spinal cord, or to an essential central nervous system structure compromising neurologic function.
    Note: See IONM coverage policy for a list of complete indications.

The use of IONM is investigative and therefore not covered for all other indications, including but not limited to:

  • Individuals with normal anatomy undergoing routine surgical procedures
    1. Routine spinal fusion, decompression, discectomy, or laminectomy
    2. Routine thyroid and parathyroid gland lobectomy or dissection.
  • Cardiac surgery
  • Esophageal surgeries.
Powered Robotic Exoskeleton Devices Re-Reviewed 07/15/2019 Investigative No change in determination
Sleep Studies for Initial Diagnosis of Obstructive Sleep Apnea Re-Reviewed 07/15/2019 Covered for some indications; investigative and therefore not covered for all other indications

No change in determination

New Device: Home (unattended/unsupervised) sleep studies with a portable device using peripheral arterial tonometry (PAT) (e.g., WatchPAT) was added to the policy: Covered for a subset of adults at least 18 years of age; investigative and not covered for children and adolescents.

Transvaginal and Transurethral Radiofrequency (RF) Treatments of Stress Urinary Incontinence in Women Re-Reviewed 07/15/2019 Investigative 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.


Date: 7/31/2021 10:02:49 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02