Providers

Medical Policy Upcoming Updates

Notification Date: July 17, 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
Amino Acid-Based Elemental Formula	Re-Reviewed	08/19/2019	Covered for some indications	No change in determination
Epidural Lysis of Adhesions	Re-Reviewed	09/16/2019	Investigative and therefore not covered	No change in determination
Prolotherapy	Re-Reviewed	09/16/2019	Investigative and therefore not covered	No change in determination
Sphenopalatine Ganglion Block for the Treatment of Migraines	Re-Reviewed	09/16/2019	Investigative and therefore not covered	No change in determination
Transcatheter Heart Valve Replacement and Repair – Transcatheter Mitral Valve Leaflet Repair	Re-Reviewed Enhanced Benefit	07/17/2019	Covered for some indications; investigative and therefore not covered for all other indications	New covered indication for mitral valve leaflet repair: Covered for functional (i.e., secondary) mitral regurgitation when using an FDA approved device (e.g., MitraClip®) and criteria are met. Note: Has been and continues to be covered for degenerative (i.e., primary) mitral valve regurgitation when using an FDA approved device and criteria are met.

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.