Providers

Medical Policy Upcoming Updates

Notification Date: November 18, 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
Cervical Spine Surgeries	Re-Reviewed	01/18/2021	Medically necessary for a select population of patients	Clarified criteria for cervical spine surgeries when/if osteoporosis in also present. Removed "moderate" from the contraindication of facet arthritis to state that (only) "severe" facet arthritis is not present.
Lumbar Spine Surgeries	Re-Reviewed	01/18/2021	Medically necessary for a select population of patients	Clarified criteria for lumbar spine surgeries when/if osteoporosis in also present.
Sacroiliac Joint Fusion, Open and Minimally Invasive	New	01/18/2021	Medically necessary for a select population of patients	Prior Authorization is now required for initial or repeat/revision SI joint fusion, open and minimally invasive. The following medical necessity criteria apply: Open sacroiliac joint fusion (SIJF) is medically necessary for one of the following indications: Sacral tumors SI joint infections Traumatic injuries Minimally invasive SIJF is medically necessary: For moderate-to-severe SI joint pain of at least six months duration, when: Pain is documented as SI joint in origin Radiologic imaging has been done within 12 months of surgery Pain is refractory to six months intensive conservative therapy, with documented limitations in activities of daily living Pain reduction of at least 75% within 2 hours of SI joint injection on two separate occasions. Absence of an SI joint condition not suited to minimally invasive SIJF. When the iFuse SI Joint System is used.

Policy Title

Status

Effective Date

Determination

Summary of Change

Cervical Spine Surgeries

Re-Reviewed

01/18/2021

Medically necessary for a select population of patients

Clarified criteria for cervical spine surgeries when/if osteoporosis in also present.
Removed "moderate" from the contraindication of facet arthritis to state that (only) "severe" facet arthritis is not present.

Lumbar Spine Surgeries

Re-Reviewed

01/18/2021

Medically necessary for a select population of patients

Clarified criteria for lumbar spine surgeries when/if osteoporosis in also present.

Sacroiliac Joint Fusion, Open and Minimally Invasive

New

01/18/2021

Medically necessary for a select population of patients

Prior Authorization is now required for initial or repeat/revision SI joint fusion, open and minimally invasive.

The following medical necessity criteria apply:
Open sacroiliac joint fusion (SIJF) is medically necessary for one of the following indications:

Sacral tumors
SI joint infections
Traumatic injuries

Minimally invasive SIJF is medically necessary:

For moderate-to-severe SI joint pain of at least six months duration, when:
- Pain is documented as SI joint in origin
- Radiologic imaging has been done within 12 months of surgery
- Pain is refractory to six months intensive conservative therapy, with documented limitations in activities of daily living
- Pain reduction of at least 75% within 2 hours of SI joint injection on two separate occasions.
- Absence of an SI joint condition not suited to minimally invasive SIJF.
When the iFuse SI Joint System is used.

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.

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