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Medical Policy Upcoming Updates

Notification Date: June 17, 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
Gender Reassignment Surgery (III-SUR.20) Re-Review 08/17/2020 Medically necessary for a select population of patients Change(s) to medical necessity criteria:
  • Added the following clarification under Readiness criteria (I.C.): The medical record documents that the individual has 12 consecutive months of living in a gender role that is congruent with his/her gender identity.
Varicose Vein and Venous Insufficiency Treatments (III-SUR.26) Re-Review 06/17/2020 Medically necessary for a select population of patients Change(s) to medical necessity criteria:
  • Cyanoacrylate adhesive (e.g., VenaSeal™) has been determined to be medically necessary treatment for specific veins (great saphenous vein, small saphenous vein, accessory saphenous veins and perforator veins, when medical necessity criteria is met.
  • Cyanoacrylate adhesive (e.g., VenaSeal™) will remain investigative for treatment of all other veins not specifically mentioned in the Medical Necessity Criteria section.

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Implanted Peripheral Nerve Stimulators for Treatment of Pain New 08/17/2020 Investigative and therefore not covered Two commercially available devices are addressed in the policy:
  • StimRouter Neuromodulation System
  • SPRINT PNS System
Repetitive Transcranial Magnetic Stimulation (rTMS) Therapy Re-Reviewed 08/17/2020 Covered for some indications; investigative and therefore not covered for all other indications New determinations:
  • Moderate to severe major depressive disorder (MDD) is covered
  • Mild MDD is investigative and therefore not covered.
All other indications previously addressed remain investigative and therefore not covered.
Surgical and Minimally Invasive Treatments for Benign Prostatic Hypertrophy/ Hyperplasia (BPH) Re-Reviewed 06/17/2020
08/17/2020
Covered for some indications; investigative and therefore not covered for all other indications New determinations:
  • Water Vapor Thermal Therapy (e.g. Rezūm® System) is not investigative for the treatment of benign prostatic hypertrophy/hyperplasia (BPH). Effective 06/17/2020.
  • Prostatic Arterial Embolization (PAE) for treatment of BPH is investigative. Reliable evidence does not permit conclusions concerning safety, effectiveness, or effect on health outcome. Effective 08/17/2020.



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 10:41:25 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02