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Medical Policy Upcoming Updates

Notification Date: June 19, 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
Abdominoplasty/ Panniculectromy (III-SUR.13) Re-Reviewed 08/19/2019 Medically necessary for a select population of patients No change to medical necessity criteria
Blepharoplasty, Blepharoptosis Repair and Brow Lift (III-SUR.29) Re-Reviewed 08/19/2019 Medically necessary for a select population of patients
  • Definition added for browpexy.
  • Statement added that browpexy requires review by a medical director.
Breast Implant Removal, Revision, or Reimplantation (III-SUR.11) Re-Reviewed 08/19/2019 Medically necessary for a select population of patients No change to medical necessity criteria
Female Breast Reduction Surgery — Reduction Mammoplasty (III-SUR.27) Re-Reviewed 08/19/2019 Medically necessary for a select population of patients No change to medical necessity criteria
Gender Reassignment Surgery (III-SUR.20)

(Previous title: Adult Gender Reassignment Surgery)
Re-Reviewed 08/19/2019 Medically necessary for a select population of patients No change to medical necessity criteria
Implantable Deep Brain Stimulation (III-DEV.19) Inactivated 07/17/2019

Enhanced benefit
N/A
  • No longer requires prior authorization.
  • UM policy inactivated.
  • Converted to a coverage policy (see below)
Male Gynecomastia Surgery (III-SUR.31) Re-Reviewed 08/19/2019 Medically necessary for a select population of patients Changes to medical necessity criteria.
  • Male gynecomastia surgery in the post pubertal-onset gynecomastia classified as a Grade II, per the American Society of Plastic Surgeons classification, is now considered not medically necessary.
Otoplasty (III-SUR.33) Re-Reviewed 08/19/2019 Medically necessary for a select population of patients No change in determination
Rhinoplasty Procedure with or without Septoplasty (III-SUR.04) Re-Reviewed 08/19/2019 Medically necessary for a select population of patients No change in determination
Thoracic Sympathectomy for Primary Hyperhidrosis (III-SUR.25) Inactivated 06/17/2019

Enhanced benefit
N/A
  • No longer requires prior authorization.
  • UM policy inactivated.

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Breast Ductal Lavage Re-Reviewed 08/19/2019 Investigative and therefore not covered No change in determination
Cervicography Re-Reviewed 08/19/2019 Investigative and therefore not covered No change in determination
Donor-Derived Cell-Free DNA Testing to Detect Rejection in Kidney Transplantation New 08/19/2019 Investigative and therefore not covered Investigative
  • e.g., AlloSure®
Genetic Testing for Inherited Susceptibility to Melanoma

Former Title: Genetic Testing for Inherited Susceptibility to Malignant Melanoma
Re-Reviewed 08/19/2019 Investigative and therefore not covered No change in determination
Implantable Deep Brain Stimulation New 07/17/2019 Covered for some indications; investigative and therefore not covered for all other indications

This was a previous utilization management policy, which was converted into a coverage policy.

Covered for:

  1. Upper extremity tremor suppression in individuals diagnosed with refractory essential tremor or Parkinsonian tremor.
  2. Adjunctive therapy in reducing some of the symptoms of advanced, levodopa-responsive, refractory Parkinson’s diseases.

Investigative for all other indications.

Laser Treatments for Neovascularization Associated with Macular Degeneration Re-Reviewed 08/19/2019 Covered for some indications; investigative and therefore not covered for all other indications No change in determination
Nasal Expiratory Positive Airway Pressure (Provent®) for Obstructive Sleep Apnea Re-Reviewed 08/19/2019 Investigative and therefore not covered No change in determination
Tidal Knee Lavage for Osteoarthritis Re-Reviewed 08/19/2019 Investigative and therefore not covered No change in determination
Wireless Pulmonary Artery Pressure Monitoring Systems for Monitoring Heart Failure (CardioMEMS™) Re-Reviewed 08/19/2019 Investigative and therefore not covered No change in determination
Whole Genome Sequencing Re-Reviewed 08/19/2019 Investigative and therefore not covered 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 10:01:04 AM Version: 4.0.30319.42000 Machine Name: PWIM4-CDWEB01