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Medical Policy Upcoming Updates

Notification Date: November 20, 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
Autologous Chondrocyte Implantation in the Knee (III-SUR.35)

New Title: was Autologous Cultured Chondrocyte Transplantation for the Knee
Re-Reviewed 11/20/2019

Enhanced Benefit
Medically necessary for a select population of patients Changes/additions to medical necessity criteria:
  • The lesion can now be a single or multiple full thickness defect of the femoral condyle and/or patella.
  • No longer requires a failed arthroscopic or other surgical repair prior to this surgery.
  • Individual must try and fail non-surgical management for at least 6 weeks prior to surgery.
  • No knee surgery, on the affected knee, within 6 months directly before evaluation for this surgery.
Cervical Spine Surgeries (III-SUR.37) Re-Reviewed 01/20/2020 Medically necessary for a select population of patients
  • Added facetectomy to the definitions and to the lists of procedures that require prior authorization.
  • Added synthetic ceramic-based and bioactive glass bone substitutes/fillers to the examples of procedures considered investigative and therefore not covered.
  • Updated Appendix 4, Demineralized Bone (DBM) Matrix Products.
Lumbar Spine Surgeries (III-SUR.34) Re-Reviewed 01/20/2020 Medically necessary for a select population of patients
  • Added facetectomy to the definitions and to the lists of procedures that require prior authorization.
  • Added synthetic ceramic-based and bioactive glass bone substitutes/fillers to the examples of procedures considered investigative and therefore not covered.
  • Updated Appendix 4, Demineralized Bone (DBM) Matrix Products.
Positron Emission Tomography (PET) Scan (III-DIA.12) Re-Reviewed 11/20/2019

Enhanced Benefit
Medically necessary for a select population of patients Changes to medical necessity criteria:
  • New section for sarcoidosis. PET is medically indicated for the diagnosis or monitoring of cardiac sarcoidosis and/or extracardiac sarcoidosis.
  • PET is now medically indicated to differentiate diagnosis of fronto-temporal dementia (FTD) from Alzheimer disease (AD) when ordered by a neurologist and when the results will impact the treatment plan.
  • Note: PET to diagnosis Alzheimer’s disease or dementia continues to be investigative and not covered.
Spinal Cord Stimulation of the Dorsal Column for Treatment of Pain (III-DEV.23) Re-Reviewed 01/20/2020 Medically necessary for a select population of patients Changes to medical necessity criteria:
  • Added Protégé™ System (St. Jude Medical) to the examples of FDA approved devices.
  • Removed the following contraindication: Administration of anticoagulant or antiplatelet therapy.
Varicose Vein and Venous Insufficiency Treatments (III-SUR.26) Re-Reviewed 11/20/2019

Enhanced Benefit
Medically necessary for a select population of patients

Change to Definitions:
Endovenous radiofrequency (RF) ablation and endovenous laser: added a statement that if more than one vein on the same leg needs to be ablated, they may be treated during the same visit.

Changes to Benefit Considerations:

  • Sclerotherapy limitation was increased from one visit to two visits per leg within a 6 month period.
  • Radiofrequency/laser ablation is limited to one visit per leg within a 6 month period.
  • Additional visits for both sclerotherapy and ablation will require review by the medical director to determine medical necessity.

Changes to medical necessity criteria:

  • Will no longer require a trial of compression stockings for any of the vein procedures listed.
  • For treatment of significant small varicose veins, reflux duration is no longer required. However, a venous duplex scan will continue to be required to check for saphenous reflux/incompetence.

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Percutaneous Ultrasonic Ablation of Soft Tissue New 01/20/2020 Investigative and therefore not covered Also known as focused aspiration of soft tissue (FAST), percutaneous ultrasonic fasciotomy, and percutaneous ultrasonic tenotomy. This technology uses ultrasonic energy to visualize, cut and remove diseased or damaged tissue in individuals with tendinopathies.
Radioembolization for Hepatic Tumors Re-Reviewed 11/20/2019 Covered for some indications; investigative and therefore not covered for all other indications Change in determination:
Radioembolization for the treatment of unresectable primary intrahepatic cholangiocarcinoma is no longer investigative and therefore covered.
Scrambler Pain Therapy New 01/20/2020 Investigative and therefore not covered Also known as Calmare® therapy or transcutaneous electrical modulation pain reprocessing, the device produces non-pain signals to 'scramble' an individual's perception of pain.
Measurement of Serum Drug and Antibody Levels to Infliximab, Adalimumab, Ustekinumab, and Vedolizumab

New Title: was Serum Drug Levels and Antibody Levels to Monitor Tumor Necrosis Factors (TNF) Inhibitors
Re-Reviewed 01/20/2020 Investigative and therefore not covered No change in investigative determination, however decision was updated to include additional drugs: serum drug and antibody levels to monitor biologics for inflammatory bowel disease (e.g., Infliximab, Adalimumab, Ustekinumab, Vedolizumab, and biosimilars) is investigative.
Sleep Studies for Initial Diagnosis of Obstructive Sleep Apnea Re-Reviewed 12/18/2019

Enhanced Benefit
Covered for some indications; investigative and therefore not covered for all other indications

Change in determination:
The following three indications are now considered not investigative for polysomnography for children and adolescents:

  • Parasomnia
  • Periodic limb movement disorder
  • Narcolepsy

All other indications remain the same. Refer to the coverage policy for complete details.

XEN® Glaucoma Treatment System New 01/20/2020 Investigative and therefore not covered Investigative



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 9:27:00 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01