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 24th 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).
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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.
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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.
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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.
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