Providers

Medical Policy Upcoming Updates

Notification Date: July 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
Cervical Spine Surgeries (III-SUR.37) <AND> Lumbar Spine Surgeries (III-SUR.34)	Re-Reviewed	09/20/2021	Investigative and therefore not covered	New investigative indication: i-Factor™ Bone Graft Investigative and therefore not covered. Determination added to the Benefit Consideration section of the policy Please Note: spinal surgery otherwise meeting medical necessity criteria as outlined in the policy is not covered when performed in combination with any procedure Medica considers investigative.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Bioimpedance Spectroscopy (BIS) and Bioelectrical Impedance Analysis (BIA) Previous Title: Bioimpedance Spectroscopy (BIS) Devices for Detection of Lymphedema	New	09/20/2021	Investigative and therefore not covered	Coverage Policy expanded to include bioelectrical impedance analysis (BIA). Current coverage policy only addressed bioimpedance spectroscopy for lymphedema. Bioelectrical impedance analysis for body composition is investigative. Determination did not change for bioimpedance spectroscopy for lymphedema, which remains investigative.
Elastography Previous Title: Elastography for Evaluation of Hepatic Fibrosis	Re-Reviewed	09/20/2021	Investigative and therefore not covered (for non-liver diseases)	Coverage Policy expanded to include non-liver diseases (current policy only addressed liver disease). Ultrasound transient and magnetic resonance elastography is investigative for ALL non-liver diseases (i.e., breast, thyroid, prostate). Determinations did not change for liver disease.
Proton Beam Radiation Therapy (PBRT)	Re-Reviewed	09/20/2021	Covered for some indications; investigative and therefore not covered for all other indications	Coverage Policy expanded to indicate that PBRT is medically necessary when: Documentation in the medical record indicates that sparing of surrounding healthy tissue cannot be achieved using standard radiation therapy modalities (e.g., intensity-modulated radiation therapy (IMRT); stereotactic body radiation therapy (SBRT)), and Evaluation includes documentation of: (1) A comparison of treatment plans for PBRT, IMRT and SBRT, and (2) PBRT's ability to reduce the dose to adjacent critical structures in a clinically meaningful manner. All other not investigative and investigative/not medically necessary indications remain as previously determined.

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.