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Medical Policy Upcoming Updates

Notification Date: October 21, 2020

Below are the policies that are new or have been reviewed, along with the determination and summary of any changes.

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Breast Magnetic Resonance Imaging (MRI) Re-Reviewed 10/21/2020

Enhanced benefit
Covered for some indications; not covered for screening women at average risk for breast cancer Additional covered indication:
A woman who has a lifetime risk of 20% or greater of developing breast cancer as defined by risk assessment models that are largely dependent on family history (e.g., Claus, BRCAPRO, BOADICEA, Tyrer-Cusick).
Implantable Deep Brain Stimulation Re-Reviewed 10/21/2020

Enhanced benefit
Covered for some indications; investigative and therefore not covered for all other indications Primary dystonia added to the covered indications.
Implantable Deep Brain and Responsive Cortical Stimulation

(Formerly titled Implantable Deep Brain Stimulation)
New determination for responsive cortical stimulation 12/21/2020 Covered for some indications; investigative and therefore not covered for all other indications Responsive cortical stimulation is covered for treatment of localized focal epilepsy when using an FDA-approved device for individuals 18 years or older with all of the following indications:
  1. A diagnosis of one or two well-identified localized seizure foci
  2. An average of at least three disabling seizures per month over the prior consecutive three months
  3. Refractory to two or more antiepileptic medications.
All other indications are investigative and therefore, not covered.
Irreversible Electroporation (NanoKnife® System) New 12/21/2020 Investigative and therefore not covered The NanoKnife System is an ablative device that uses irreversible electroporation (IRE) technology for surgical ablation of soft tissue or of solid organs, such as the liver, pancreas, and kidney.
VivAer Nasal Airway Remodeling for Airway Obstruction New 12/21/2020 Investigative and therefore not covered The VivAer Nasal Airway Remodeling is proposed for the treatment of nasal valve collapse, and is intended for reshaping nasal tissue to improve air flow.



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 9:53:55 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01