Skip to Main Content
Providers

« Return to Updates to Medical Policies

Medical Policy Upcoming Updates

Notification Date: September 18, 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
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.

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Access Techniques for Lumbar Interbody Fusion Re-Reviewed 11/18/2019 Covered for some indications; investigative and therefore not covered for all other indications No change in determination
Confocal Laser Endomicroscopy for Barrett’s Esophagus Re-Reviewed 11/18/2019 Investigative and therefore not covered No change in determination
Eye Movement Desensitization and Reprocessing Re-Reviewed 11/18/2019 Covered for some indications; investigative and therefore not covered for all other indications No change in determination
Food Allergy/Intolerance Testing (in vitro) Re-Reviewed 11/18/2019 Covered for some indications; investigative and therefore not covered for all other indications No change in determination
Gene Expression Profiling for Assessing Cancers of Unknown Origin Re-Reviewed 11/18/2019 Investigative and therefore not covered No change in determination
Juvenile Cartilage Allograft Tissue Implantation for Articular Cartilage Repair Re-Reviewed 11/18/2019 Investigative and therefore not covered No change in determination
Magnetoencephalography and Magnetic Source Imaging Re-Reviewed 11/18/2019 Covered for some indications; investigative and therefore not covered for all other indications 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 9:54:49 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02