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Medical Policy Upcoming Updates

Notification Date: August 21, 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
Computerized Dynamic Posturography Re-Reviewed 10/21/2019 Investigative and therefore not covered No change in determination
Inhaled Nitric Oxide (iNO) Therapy Re-Reviewed 10/21/2019 Covered for some indications; investigative and therefore not covered for all other indications No change in determination
Laser Surgery for Corneal Pathology Re-Reviewed 10/21/2019 Covered when associated with disease or injury.

Coverage Policy inactivated 10/21/2019.

Please note that refractive eye surgery is generally excluded from coverage. Please refer to the specific member plan document.

Pelvic Vein Embolization Re-Reviewed 10/21/2019 Investigative and therefore not covered No change in determination
Single Nucleotide Polymorphism (SNP) Genetic Testing for Assessment of Cancer Risk Re-Reviewed 10/21/2019 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 9:55:45 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02