| Air Ambulance, Non-emergent (III.MED.07) |
Re-Reviewed |
11/18/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
| Genetic Testing for Susceptibility to Hereditary Breast and Ovarian Cancer (III-DIA.04) |
Re-Reviewed |
10/21/2019
Enhanced benefit
|
Medically necessary for a select population of patients |
Change(s) to medical necessity criteria
- Obstetrician/gynecologist (Ob/Gyn), surgeon, oncology nurse, or other health professional with expertise and experience in cancer genetics were added to the list of who can document family history or pedigree, advise of benefits and harms of testing, and obtain written consent.
- Criteria broadened for who can order the test to include physician assistant or nurse practitioner if working in a practice specializing in Ob/Gyn, surgery, oncology, or other practice with expertise in cancer genetics.
- Amended the age for testing an individual with a personal history of breast cancer from "at or before age 45" to "at or before age 50" for compliance with NCCN.
- Criteria added regarding family history of cancer on the same side of the family with three or more defined diagnoses for compliance with NCCN.
- Removed the requirement for a documented Gleason score when a close family member has/had a diagnosis of prostate cancer.
|
| High Frequency Chest Wall Compression (HFCWC) Devices (III-DEV.20) |
Re-Reviewed |
11/18/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
| Home Health Aide (III-HOM.02) |
Re-Reviewed |
11/18/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
| Magnetic Esophageal Ring for the Treatment of GERD (III-SUR.42) |
Re-Reviewed |
11/18/2019 |
Medically necessary for a select population of patients |
Change(s) to medical necessity criteria
- New Indication:
There is objective evidence of GERD, defined by the presence of a grade A or B esophagitis (The Los Angeles (LA) classification of GERD), as evidenced by endoscopy.
- Esophageal dysplasia is no longer an indication as this is considered Barrett’s esophagus, which is considered investigative and not covered.
|
| Medicaid Home Care Nursing (HCN) Services (III-HOM.05) |
Re-Reviewed |
11/18/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
| Medicaid Home Health Aide (III-HOM.04) |
Re-Reviewed |
11/18/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
| Personal Care Assistance (III-HOM.03) |
Re-Reviewed |
11/18/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
| Proton Beam Radiation Therapy (III-MED.06) |
Re-Reviewed |
11/18/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
| Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive Sleep Apnea/Hypopnea Syndrome (III-SUR.08) |
Re-Reviewed |
11/18/2019 |
Medically necessary for a select population of patients |
Change(s) to medical necessity criteria
- Polysomnography has been substituted with the term "sleep studies" to indicate that either, in-lab sleep studies or home sleep studies are accepted documentation for obstructive sleep apnea syndrome.
|
| Wheelchairs, Scooters and Accessories (III-DEV.25) |
N/A |
09/16/2019 |
Medically necessary for a select population of patients |
Department of Human Services (DHS) criteria will be used for Minnesota Health Care Programs.
- Please note: in accordance with DHS criteria, all determinations are based on the least costly, most effective and medically necessary mobility device for the individual member.
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