Providers

Medical Policy Upcoming Updates

Notification Date: April 15, 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
MCG Care Guidelines^®	Re-Reviewed	On or after 06/15/2020	Medically necessary for a select population of patients	Medica may use tools developed by third parties, such as MCG Care Guidelines^®, to assist in administering health benefits. Medica will begin using the 24^th edition of MCG Care Guidelines on or after June 15, 2020.
Bone Growth Stimulators (III-DEV.07)	Re-Reviewed	06/15/2020	Medically necessary for a select population of patients	Change to medical necessity criteria: Ultrasound bone growth stimulation is medically necessary for non-union scaphoid fractures. New Investigative Indications, which are not covered: Electric bone growth stimulation for scaphoid fractures (all types: e.g. nonunion, acute/fresh, delayed union) Ultrasound bone growth stimulation for scaphoid fractures other than nonunions (e.g., acute/fresh, delayed union).
Implanted Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (III-SUR.43)	Re-Reviewed	06/15/2020	Medically necessary for a select population of patients	Change to medical necessity criteria: Apnea-Hypopnea Index (AHI) decreased from 20 to 15 for the lower parameter. Criteria: apnea-hypopnea index (AHI) greater than or equal to 15 (was 20) and less than or equal to 65. Added investigative indication: All other indications not specifically mentioned in the Medical Necessity Criteria section are investigative and therefore not covered.
Outpatient Enteral Nutritional Therapy (III-MED.03)	Re-Reviewed	06/15/2020	Medically necessary for a select population of patients	New investigative device: Digestive enzyme cartridges (e.g., Relizorb^® [HCPCS code: B4105]) used in conjunction with enteral nutrition therapy is investigative and therefore not covered.
Real-Time Mobile Cardiac Outpatient Telemetry (RT-MCOT) (III-DIA.008)	Re-Reviewed	06/15/2020	Medically necessary for a select population of patients	Change to medical necessity criteria: The practitioners who can order RT-MCOT were expanded beyond cardiologists to also include: an electrophysiologist, neurologist, or a nurse practitioner or physician assistant practicing within one of these specialties.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Actigraphy	Re-Reviewed	06/15/2020	Covered for some indications; investigative and therefore not covered for all other indications	Insufficient sleep syndrome added as a new covered indication for actigraphy.
Stem Cell and Cellular Bone Matrix Products for Orthopedic Applications (previous title: Stem Cell Therapy for Orthopedic Applications)	Re-Reviewed	06/15/2020	Investigative and therefore not covered	New title. New investigative therapy: cellular bone matrix products. Stem cell and cellular bone matrix products for orthopedic applications are investigative. This includes: Concentrated, engineered or expanded stem cells Allograft bone products containing stem cells Allograft or synthetic bone graft substitutes that must be combined with autologous blood or bone marrow Cellular Bone Matrix products Bone marrow aspirate.

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.