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Medical Policy Upcoming Updates

Notification Date: December 16, 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
Mechanical Circulatory Support Devices (III-SUR.38) Policy Inactivated 02/15/2021 Medically necessary for a select population of patients
  • Prior Authorization will no longer be required as of 2/15/2021 and the UM policy will be inactivated and converted into a Coverage Policy (please see below).
  • However, notification within 48 hours of device placement is requested. Notification will allow for referral of the member into Medica's case management services. Please see coverage policy below for the notification process.

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Endoscopic Balloon Sinuplasty Ostial Dilation and Steroid-Eluting Sinus Stents for Treatment of Chronic Sinusitis Re-Reviewed 02/15/2021 Covered for some indications; investigative and therefore not covered for all other indications No change in determinations.

Determinations will be addressed in two separate policies effective 02/15/2021:
  1. Endoscopic Balloon Sinuplasty Ostial Dilation for Treatment of Chronic Sinusitis
    • Covered for some indications; investigative and therefore not covered for all other indications
  2. Drug-Eluting Sinus Stents for Maintenance of Patency Following Sinus Surgery
    • Investigative and therefore not covered
Juvenile Cartilage Allograft Tissue Implantation for Articular Cartilage Repair

New Title:
Minced Cartilage (Allograft) Repair for Articular Cartilage Defects
Re-Reviewed 02/15/2021 Investigative and therefore not covered
  • New product: BioCartilage reviewed and determined to be investigative and therefore not covered.
  • Scope of coverage policy expanded to allogeneic minced cartilage versus only juvenile cartilage.
  • Allogeneic minced cartilage (e.g., DeNovo® NT Natural Tissue Graft, BioCartilage®) for repair of articular cartilage defects is investigative and therefore not covered.
Mechanical Circulatory Support Devices New 02/15/2021 Covered for some indications; investigative and therefore not covered for all other indications Utilization Management policy converted into a new Coverage Policy. No change in determinations.
  • Ventricular Assist Devices (VADs) and Total Artificial Hearts (TAHs) are covered when FDA approved devices are used for medically appropriate indications.
  • VADs are investigative and not covered when non-FDA approved devices are used.
  • TAHs are investigative and not covered when non-FDA approved devices are used and/or for destination therapy.
Notification within 48 hours of device placement is requested. Notification will allow for referral of the member into Medica's case management services.

Notification can be completed by fax or email: In addition, a notification form will be available on medica.com on 02/15/2021.
Tissue-Engineered Skin Substitutes for Wound and Surgical Care Current Policy 03/20/2019 Covered for some indications; investigative and therefore not covered for all other indications Title changed from:
Tissue-Engineered Skin Substitutes for Wound and Surgical Care
to
Skin and Soft Tissue-Engineered Substitutes for Wound and Surgical Care
Percutaneous Radiofrequency and Laser Ablation/Denervation Procedures for Facet and Sacroiliac Joints

New Title:
Facet Injections and Percutaneous Denervation Procedures (Radiofrequency and Laser ablation) for Facet-Mediated Joint Pain
Re-Reviewed 02/15/2021 Covered for some indications; investigative and therefore not covered for all other indications The following determination was added to the policy:
  • Intra-articular facet joint injection/medial branch nerve block with image guidance, is not investigative for diagnosis/validation of facet joint pain in individuals with severe chronic neck, thoracic, or back pain when all of the following criteria are met:
    • Diagnostic block is needed to confirm facet joint as source of spinal pain
    • Patient is candidate for radiofrequency ablation/denervation of the facet joint
    • Failure of conservative management
    • Other causes of spinal pain have been ruled out.
  • Facet joint injection/medial branch nerve is investigative for ALL other diagnostic/validation indications and for ALL treatment modalities.
  • No change in current determinations for Percutaneous Radiofrequency and Laser Ablation/Denervation Procedures for Facet and Sacroiliac Joints.



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 9:52:06 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02