Providers

Medical Policy Upcoming Updates

Notification Date: June 21, 2017

Below are the policies that are new or have been reviewed, along with the determination and summary of any changes.

Utilization Management

Policy Title	Status	Effective Date	Determination	Summary of Change
Comparative Genomic Hybridization (CGH) Microarray Testing	Re-reviewed	06/21/2017 Enhanced benefit	Medically necessary for a select population of patients	Addition to the medical necessity criteria CHG microarray testing for individuals diagnosed with hematologic malignancy is medically necessary when criteria are met.
Positron Emission Tomography (PET) Scans	Re-reviewed	06/21/2017 Enhanced benefit	Medically necessary for a select population of patients	Changes in medical necessity criteria Cardiology section: single photon emission computed tomography (SPECT) removed as a requirement for myocardial perfusion assessment. Cardiology section: added cardiac sarcoidosis as a new indication. PET is considered medically necessary for diagnosis or monitoring of cardiac sarcoidosis when MRI is inconclusive or contraindicated (e.g., implanted devices). Definitions Added definition of cardiac sarcoidosis.
Abdominoplasty/ Panniculectomy	Re-reviewed	08/21/2017	Medically necessary for a select population of patients	No change to medical necessity criteria
Bariatric Surgery	Re-reviewed	08/21/2017	Medically necessary for a select population of patients	Change in medical necessity criteria Added ‘Removal of adjustable gastric band and/or port’ to the list of procedures appropriate for surgical revision.
Blepharoplasty, Blepharoptosis Repair, and Brow Lift	Re-reviewed	08/21/2017	Medically necessary for a select population of patients	No change to medical necessity criteria
Breast Implant Removal, Revision, or Reimplantation	Re-reviewed	08/21/2017	Medically necessary for a select population of patients	Change in medical necessity criteria Breast implant-associated anaplastic large cell lymphoma added as an indication for removal.
Female Breast Reduction Surgery	Re-reviewed	08/21/2017	Medically necessary for a select population of patients	No change to medical necessity criteria
Implanted Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea	New	08/21/2017	Medically necessary for a select population of patients	Prior Authorization is now required. Medically necessary when the following criteria are met: The device is FDA-approved The member is age 22 or older Obstructive sleep apnea is present with an apnea-hypopnea index greater than or equal to 20 and less than or equal to 65 There is documented history of failed CPAP after a trial of at least 8 weeks or the member cannot tolerate CPAP Other non-surgical options have been considered and excluded
Male Gynecomastia Surgery	Re-reviewed	08/21/2017	Medically necessary for a select population of patients	No change to medical necessity criteria
Otoplasty	Re-reviewed	08/21/2017	Medically necessary for a select population of patients	Change in medical necessity criteria Clarification made that audiogram and documentation is only need when hearing is impaired.
Rhinoplasty Procedure with or without Septoplasty	Re-reviewed	08/21/2017	Medically necessary for a select population of patients	No change to medical necessity criteria
Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive Sleep Apnea/ Hypopnea Syndrome	Re-reviewed	08/21/2017	Medically necessary for a select population of patients	No change to medical necessity criteria

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Surgical and Minimally Invasive Treatments for Benign Hypertrophy/Hyperplasia (BPH)	Re-reviewed	06/21/2017 – Enhanced benefit 08/21/2017 – Additions to investigative list	Investigative for some indications; not investigative for other indications	Enhanced criteria: Treatments no longer considered investigative: UroLift^® System Prostatic stents Additional Investigative treatments: Water Vapor Thermal Therapy System (e.g., Rezūm) Waterjet Tissue Ablation (e.g. AquaBeam System)
Methylenetetrahydrofolate Reductase (MTHFR) Gene Mutation Testing	Re-reviewed	08/21/2017	Investigative	No change in determination
Proton Beam Radiation Therapy	Re-reviewed	08/21/2017	Investigative for some indications; not investigative for other indications	No change in determination
Tongue Base Suspension Procedures for Obstructive Sleep Apnea	Re-reviewed	08/21/2017	Investigative and therefore not covered	No change in determination
Urethral Bulking Agents for Urinary Incontinence	Re-reviewed	08/21/2017	Not investigative	No change in determination

The updated clinical policies and guidelines above are available as of July 17, 2017. 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 5, then ext. 2-2355.

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