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Medical Policy Upcoming Updates

Notification Date: October 19, 2022

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 Changes
Hip Arthroplasty (III-SUR.46) Applies to: • IFB members with plans in Iowa and Nebraska, with exception of members in the Medica With CHI product • Commercial members with plans in Nebraska	New	01/01/2023	Medically necessary for a select population of patients	Medica will initiate the use of the following MCG™ Ambulatory Care Guidelines (ACGs) to administer these services: • ORG: S-560 (ISC), Hip Arthroplasty • ORG: S-565 (ISC), Hip Resurfacing
Intraoperative Neurophysiologic Monitoring (IONM) (III-DIA.15)	New	Q1 2023	Medically necessary for a select population of patients	Prior authorization is required for Intraoperative neurophysiologic monitoring (IONM). The use of IONM is considered medically necessary when the following criteria are met: 1. One or more of the following IONM are used: • Somatosensory evoked potentials (SSEPs) motor evoked potentials (MEPs) • Brainstem auditory, BAEPs) • Electromyography (EMG) • Electroencephalogram (EEG) • Electrocorticography (ECoG). 2. IONM is performed by either a licensed physician trained in clinical neurophysiology or a trained technologist who is practicing within the scope of his/her state license/certification, working under the direct supervision of a physician trained in neurophysiology, and who is not the operating surgeon or anesthesiologist. 3. There is significant risk of damage to a cranial nerve, spinal cord, or to an essential central nervous system structure compromising neurologic function during the surgical procedure. Note: See IONM utilization management policy for a list of complete indications. The use of IONM is investigative and therefore not covered for all other indications not specifically mentioned in the Medical Necessity Criteria section, including but not limited to: 1. Individuals undergoing routine surgical procedures: • Routine cervical/lumbar/thoracic fusion • Nerve decompression or discectomy for disc herniation • Laminectomy for spinal stenosis • Routine thyroid and parathyroid gland lobectomy or dissection. 2. Cardiac surgery 3. Esophageal surgeries. IONM performed by the attending surgeon or anesthesiologist is considered integral to the primary procedure and not separately reimbursable.
Knee Arthroplasty, Total (III-SUR.47) Applies to: • IFB members with plans in Iowa and Nebraska, with exception of members in the Medica With CHI product • Commercial members with plans in Nebraska	New	01/01/2023	Medically necessary for a select population of patients	Medica will initiate the use of the following MCG™ Ambulatory Care Guidelines (ACGs) to administer these services: • ORG: S-700 (ISC), Knee Arthroplasty, Total

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Changes
Genetic Testing: Algorithmic Testing This policy addressed gene expression profiling	New*	12/30/2022	Covered for some indications; investigative and not covered for other indications.	*Replaces multiple Medica coverage policies addressing gene expression profiling. Addresses many additional gene expression profiling tests.
Genetic Testing: Cancer Screening This policy addresses genetic marker testing for colorectal and lung cancer screening tests	New	12/30/2022	Covered for some indications; investigative and not covered for other indications.	N/A
Genetic Testing: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)	New*	12/30/2022	Covered for some indications; investigative and not covered for other indications.	Replaces former Medica coverage policy, Liquid Biopsy: Testing of Circulating Tumor Cells or Cell-Free Tumor DNA*
Genetic Testing: Cytogenetic Testing This policy addresses FISH and PCR technologies for classification of solid cell tumors and hematologic malignancies	New*	12/30/2022	Covered for some indications; investigative and not covered for other indications.	* Replaces former Medica coverage policy, Bladder Cancer Screening, Diagnosis and Monitoring using Ancillary Urinary Tests Addresses many additional cytogenetic tests.
Genetic Testing: Hereditary Cancer Susceptibility This policy addresses genetic testing for germline mutations, including single gene and panel testing	New*	12/30/2022	Covered for some indications; investigative and not covered for other indications.	Replaces former Medica coverage policy, TP53 (p53) Testing for Li-Fraumeni Syndrome* Addresses many additional hereditary cancer susceptibility tests.
Genetic Testing: Molecular Analysis of Solid Tumors and Hematologic Malignances This policy addresses genetic testing for somatic mutations, including single gene and panel testing	New	12/30/2022	Covered for some indications; investigative and not covered for other indications.	N/A
Genetic Testing: Pharmacogenetics This policy addresses genetic testing for prediction of response to drug treatment	New*	12/30/2022	Covered for some indications; investigative and not covered for other indications.	*Replaces multiple Medica coverage policies addressing pharmacogenetic testing. Addresses many additional pharamcogenetic tests.
Genetic Testing: Non-Invasive Prenatal Screening (NIPS)	New*	12/30/2022	Medically necessary for some indications; investigational for all other indications.	Replaces former Medica coverage policy, Maternal Plasma Tests for Detection of Cell-free Fetal DNA for Analysis of Chromosomal Aneuploidies.* Criteria for maternal serum screening (e.g., free or total beta-HCG and PAPP-A) has been added.
Genetic Testing: Preimplantation Genetic Testing	New	12/30/2022	Medically necessary for some indications; investigational for all other indications.	N/A
Genetic Testing: Prenatal And Preconception Carrier Screening	New	12/30/2022	Medically necessary for some indications; investigational for all other indications.	N/A
Genetic Testing: Prenatal Diagnosis (Via Amniocentesis, Cvs, Or Pubs) And Pregnancy Loss	New	12/30/2022	Medically necessary for some indications; investigational for all other indications.	N/A