Providers

Medical Policy Upcoming Updates

Notification Date: February 19, 2020

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
All Solid Organ and Hematopoietic Stem Cell Transplantation Policies	Re-Reviewed	03/16/2020	Medically necessary for a select population of patients	The medical necessity criteria related to informed consent, guardian and social support, funding, substance use disorder/chemical dependency, and contraindications were removed from the policy. These areas are evaluated and managed by the transplant facility and are included in their transplant eligibility criteria. Medica will continue to require that the individual meets the institution’s eligibility criteria.
Cognitive Rehabilitation (III-MED.08)	Withdrawn			This utilization management policy was to be effective 02/17/2020. However, after further consideration, cognitive rehabilitation will not be prior authorized for members enrolled in Minnesota Health Care Programs, therefore, the utilization management policy has been withdrawn. Please see Medica's coverage policy, Cognitive Rehabilitation/ Remediation.
Liver Transplantation (III-TRA.02)	Re-Reviewed	03/16/2020	Medically necessary for a select population of patients	Background Section. The following definitions were updated: Liver transplantation revised to include liver malignancy and metabolic disorders as other conditions correctable by liver transplantation. Model for End Stage Liver Disease (MELD) updated to include sodium (Na) as a factor in the calculation of the MELD score. Medical Necessity Criteria: "Secondary" sclerosing cholangitis added as an appropriate condition.

Policy Title

Status

Effective Date

Determination

Summary of Change

All Solid Organ and Hematopoietic Stem Cell Transplantation Policies

Re-Reviewed

03/16/2020

Medically necessary for a select population of patients

The medical necessity criteria related to informed consent, guardian and social support, funding, substance use disorder/chemical dependency, and contraindications were removed from the policy.

These areas are evaluated and managed by the transplant facility and are included in their transplant eligibility criteria.

Medica will continue to require that the individual meets the institution’s eligibility criteria.

Cognitive Rehabilitation (III-MED.08)

Withdrawn

This utilization management policy was to be effective 02/17/2020. However, after further consideration, cognitive rehabilitation will not be prior authorized for members enrolled in Minnesota Health Care Programs, therefore, the utilization management policy has been withdrawn.

Please see Medica's coverage policy, Cognitive Rehabilitation/ Remediation.

Liver Transplantation (III-TRA.02)

Re-Reviewed

03/16/2020

Medically necessary for a select population of patients

Background Section. The following definitions were updated:

Liver transplantation revised to include liver malignancy and metabolic disorders as other conditions correctable by liver transplantation.
Model for End Stage Liver Disease (MELD) updated to include sodium (Na) as a factor in the calculation of the MELD score.

Medical Necessity Criteria:

"Secondary" sclerosing cholangitis added as an appropriate condition.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Corneal Cross-Linking	Re-Review	04/20/2020	Covered for some indications; investigative and therefore not covered for all other indications	New Determination: Conventional and accelerated corneal cross-linking when combined with intrastromal corneal ring segments (INTACS) is investigative. No change in current determinations: Not Investigative: Conventional and accelerated corneal cross-linking for the treatment of keratoconus and corneal ectasia. Investigative: Conventional and accelerated corneal cross-linking for all other indications. Transepithelial and partial epithelium-off corneal cross-linking.
Fecal Calprotectin Testing	Re-Review	02/19/2020 Enhanced benefit	Covered for some indications; investigative and therefore not covered for all other indications.	Not investigative for use in: Differentiating inflammatory bowel disease (e.g., Crohn’s disease, ulcerative colitis) from irritable bowel syndrome in individuals with symptoms that have lasted greater than four weeks. Monitoring/managing disease activity in inflammatory bowel disease. Investigative: All other indications.
Gene Expression Profiling for Detection of Heart Transplantation Rejection	Re-Review	04/20/2020	Covered for some indications; investigative and therefore not covered for all other indications.	New Determination: Molecular Microscope Diagnostic System-Heart (MMDx-Heart) gene expression profile is investigative. No change in current determinations for AlloMap profile: Not Investigative for monitoring rejection when more than six months post-transplant. Investigative for all other indications.

Policy Title

Status

Effective Date

Determination

Summary of Change

Corneal Cross-Linking

Re-Review

04/20/2020

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

New Determination:
Conventional and accelerated corneal cross-linking when combined with intrastromal corneal ring segments (INTACS) is investigative.

No change in current determinations:
Not Investigative:

Conventional and accelerated corneal cross-linking for the treatment of keratoconus and corneal ectasia.

Investigative:

Conventional and accelerated corneal cross-linking for all other indications.
Transepithelial and partial epithelium-off corneal cross-linking.

Fecal Calprotectin Testing

Re-Review

02/19/2020

Enhanced benefit

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

Not investigative for use in:

Differentiating inflammatory bowel disease (e.g., Crohn’s disease, ulcerative colitis) from irritable bowel syndrome in individuals with symptoms that have lasted greater than four weeks.
Monitoring/managing disease activity in inflammatory bowel disease.

Investigative: All other indications.

Gene Expression Profiling for Detection of Heart Transplantation Rejection

Re-Review

04/20/2020

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

New Determination:
Molecular Microscope Diagnostic System-Heart (MMDx-Heart) gene expression profile is investigative.

No change in current determinations for AlloMap profile:
Not Investigative for monitoring rejection when more than six months post-transplant.

Investigative for all other indications.

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.