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Medical Policy Upcoming Updates

Notification Date: October 16, 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
Electric Tumor Treatment Fields (III-DEV.27) Re-Reviewed 10/16/2019
Enhanced benefit
N/A
  • No longer requires prior authorization.
  • UM policy inactivated.
  • Converted to a coverage policy (see below)

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Breast-Specific Gamma Imaging, Scintimammography, and Molecular Breast Imaging Re-Reviewed 12/16/2019 Investigative and therefore not covered No change in determination
Electric Tumor Treatment Fields (Optune®) New 10/16/2019 Covered for some indications; investigative and therefore not covered for all other indications

This was a previous utilization management policy, which has now been converted to a coverage policy.

Covered for:

  • Individuals 22 years of age or older for the treatment of newly diagnosed, histologically-confirmed supratentorial glioblastoma following debulking surgery and completion of radiation therapy, in conjunction with chemotherapy.
  • Individuals 22 years of age or older for the treatment of histologically- or radiologically-confirmed recurrent supratentorial glioblastoma as monotherapy, after surgical, chemotherapy, and radiological treatment have been exhausted.

Investigative for all other indications.

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications and Soft Tissue Injuries Re-Reviewed 12/16/2019 Investigative and therefore not covered No change in determination
LTX 3000™ (Spinal Unloading Device for Treatment of Low Back Pain) Re-Reviewed 12/16/2019 Investigative and therefore not covered Coverage Policy inactivated 12/16/2019.
Mechanized Spinal Decompression Traction Tables for Low Back Pain Re-Reviewed 12/16/2019 Investigative and therefore not covered No change in determination
Orthotrac™ Pneumatic Vest (Spinal Unloading Device for the Treatment of Low Back Pain) Re-Reviewed 12/16/2019 Investigative and therefore not covered No change in determination
Synthetic Ceramic-Based and Bioactive Glass Bone Substitutes/ Fillers New 12/16/2019 Investigative and therefore not covered

Ceramic-based bone grafts are made up of collagen, calcium phosphate, calcium sulfate and one or more of the following products:

  1. Synthetic hydroxyapatite, a component in bone and teeth
  2. Beta-tricalcium phosphates
  3. Biphasic calcium phosphate, which consists of both 1. and 2., above
  4. Bioactive glass.

These have been suggested for use as stand-alone products or in combination with other bone substitutes and/or enhancement products.

Note: This policy does not apply to dental applications.




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 9:28:02 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01