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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:

  1. Covered for functional (i.e., secondary) mitral regurgitation when using an FDA approved device (e.g., MitraClip®) and criteria are met.
  2. 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.


Date: 7/31/2021 9:57:33 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02