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Medical Policy Upcoming Updates

Notification Date: April 21, 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
Bone Growth Stimulators (III-DEV.07) Re-Reviewed 04/28/2021

Enhanced Benefit
Medically necessary for a select population of patients

Electric bone growth stimulation is no longer investigative for cervical spinal fusion surgery.

Change(s) to medical necessity criteria

  • Electric bone growth stimulation now applies to all regions of the spine (cervical, thoracic and lumbar).
  • When used adjunctively with fusion surgery:
    • On an individual with a previously failed fusion, the six (6) month limitation between surgeries has been removed.
    • High risk of pseduoarthorsis criterion has been removed. This is defined as a failed fusion which is already listed as a criterion.
Proton Beam Radiation Therapy N/A 04/21/2021 N/A
  • Prior Authorization will no longer be required as of 4/21/2021. The UM policy will be inactivated and converted into a Coverage Policy (please see coverage policy section).

Coverage Policies

Policy Title
Status
Effective Date
Determination
Summary of Change
Electromagnetic Navigation Bronchoscopy Re-Reviewed 04/21/2021 Not Investigative and is therefore covered New determination. Technology is no longer investigative and is therefore COVERED.
Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening Re-Reviewed 04/19/2021 Covered for some indications; investigative and therefore not covered for all other indications

The United States Preventive Services Task Force (USPSTF) recently released an update to their recommendation on annual screening for lung cancer. Medica's coverage policy has been updated to reflect these changes:

Annual screening for lung cancer with low-dose computed tomography is COVERED when all of the following criteria are met:

  • The individual is asymptomatic and between 50 (was 55) and 80 years of age
  • The individual is a current or former smoker with a 20 (was 30) pack-year smoking history
  • If the individual is a former smoker, he or she must have quit within the past 15 years
  • The individual has no health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

Low-dose computed tomography for lung cancer screening remains investigative for all other indications.

Proton Beam Radiation Therapy (PBRT) New 04/21/2021 Covered for some indications; investigative and therefore not covered for all other indications

Utilization Management policy converted into a new Coverage Policy.

PBRT is COVERED for:

  1. Advanced/unresectable head and neck cancer
  2. Chordomas or chondrosarcomas arising at the base of the skull or along the axial skeleton
  3. Malignant and benign central nervous system tumors
  4. Hepatocellular/hepatobiliary cancer
  5. Ocular tumors, including uveal melanoma not amenable to surgical excision or other conventional forms of treatment
  6. Paranasal sinus or other accessory sinus tumors
  7. Soft tissue sarcomas

PBRT is investigative and NOT COVERED for all other indications.

Sacral Nerve Stimulation (SNS) Re-Reviewed 06/21/2021 Covered for some indications; investigative and therefore not covered for all other indications

A new sacral nerve stimulation device was added to the policy.

  • The Axonics Rechargeable Sacral Neuromodulation (r-SNM) is investigative for all indications and is therefore not covered.



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 10:25:39 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01