Providers

Medical Policy Upcoming Updates

Notification Date: March 17, 2021

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
MCG Care Guidelines^®	Re-Reviewed	On or after 05/17/2021	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 25^th edition of MCG Care Guidelines on or after May 17, 2021.
Genetic Testing for Susceptibility to Hereditary Breast and / or Ovarian Cancer (III-DIA.04)	New	05/17/2021	Medically necessary for a select population of patients	Medica has initiated the use of the following MCG™ Ambulatory Care Guidelines (ACGs) to administer these services: ACG: A-0466 (AC), Breast or Ovarian Cancer, Hereditary - BRCA1 and BRCA2 Genes ACG: A-0767 (AC), Breast Cancer (Hereditary) - Gene Panel ACG:A-0989 (AC), Breast Cancer - PALB2 Gene ACG: A-0790 (AC), Multiple Cancers, Including Cancer Syndromes (Hereditary) - Gene Panel

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Intraosseous Ablation of Basivertebral Nerve for Treating Low-Back Pain (e.g., Intracept^®)	New	05/17/2021	Investigative and therefore not covered	The Intracept intraosseous ablation procedure is a minimally invasive procedure intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic vertebrogenic low back pain, in patients who have not responded to conservative therapy.
Left Atrial Appendage Closure Devices (LAACDs)	Re-Reviewed	03/17/2021 Enhanced benefit	Covered for some indications; investigative and therefore not covered for all other indications	New determination: LAACDs are now covered when using an FDA-approved device for the FDA approved indication of prevention of stroke and systemic embolism in individuals with nonvalular atrial fibrillation who are unable to take long-term oral anticoagulation therapy. Note: LAACDs remain investigative and therefore not covered for all other indications.
Myoelectric Upper Limb Prosthetics and Orthotics	New	05/17/2021	Covered for some indications; investigative and therefore not covered for all other indications	Myoelectric upper limb prosthetic components are covered when ALL of the following criteria are met: The patient has an amputation or missing limb at the wrist or above. Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of activities of daily living. The remaining musculature of the arm(s) has sufficient microvolt threshold to allow proper function of the myoelectric prosthetic device. The patient has sufficient musculoskeletal, neurological and cognitive function to operate the prosthesis safely and effectively. The patient is free of comorbidities that could interfere with function of the prosthesis (neuromuscular disease, etc.). Provider or qualified prosthetist with appropriate expertise in patient's condition has evaluated patient and indicates that the prosthesis is likely to meet the functional needs when performing ADL. Member is willing and able to complete necessary training required for successful and independent use of requested device. Investigative Indications: Prosthetic with individually powered (multiarticulating) fingers (digits) that uses full or partial myoelectric power for independent movement of individual joints. Prosthetic components with both sensor and myoelectric control. Myoelectric controlled upper limb orthoses (e.g., MyoPro^®).

Policy Title

Status

Effective Date

Determination

Summary of Change

Intraosseous Ablation of Basivertebral Nerve for Treating Low-Back Pain (e.g., Intracept^®)

New

05/17/2021

Investigative and therefore not covered

The Intracept intraosseous ablation procedure is a minimally invasive procedure intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic vertebrogenic low back pain, in patients who have not responded to conservative therapy.

Left Atrial Appendage Closure Devices (LAACDs)

Re-Reviewed

03/17/2021

Enhanced benefit

Covered for some indications; investigative and therefore not covered for all other indications

New determination:

LAACDs are now covered when using an FDA-approved device for the FDA approved indication of prevention of stroke and systemic embolism in individuals with nonvalular atrial fibrillation who are unable to take long-term oral anticoagulation therapy.

Note: LAACDs remain investigative and therefore not covered for all other indications.

Myoelectric Upper Limb Prosthetics and Orthotics

New

05/17/2021

Covered for some indications; investigative and therefore not covered for all other indications

Myoelectric upper limb prosthetic components are covered when ALL of the following criteria are met:

The patient has an amputation or missing limb at the wrist or above.
Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of activities of daily living.
The remaining musculature of the arm(s) has sufficient microvolt threshold to allow proper function of the myoelectric prosthetic device.
The patient has sufficient musculoskeletal, neurological and cognitive function to operate the prosthesis safely and effectively.
The patient is free of comorbidities that could interfere with function of the prosthesis (neuromuscular disease, etc.).
Provider or qualified prosthetist with appropriate expertise in patient's condition has evaluated patient and indicates that the prosthesis is likely to meet the functional needs when performing ADL.
Member is willing and able to complete necessary training required for successful and independent use of requested device.

Investigative Indications:

Prosthetic with individually powered (multiarticulating) fingers (digits) that uses full or partial myoelectric power for independent movement of individual joints.
Prosthetic components with both sensor and myoelectric control.
Myoelectric controlled upper limb orthoses (e.g., MyoPro^®).

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.