Providers

Medical Policy Upcoming Updates

Notification Date: July 19, 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
Wheelchairs, Scooters and Accessories	Re-reviewed	07/19/2017 – Enhanced benefit	Medically necessary for a select population of patients	Prior authorization requirement for accessories,repairs and modifications will be required when the billed charge is $1,000 or more per item. Previously, prior authorization had been required for a billed charge of $500 or more per item.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Subcutaneous Implantable Cardioverter-Defibrillator (S-ICD)	Re-reviewed	07/19/2017 – Enhanced benefit	Not investigative	S-ICD is no longer investigative
Breast-Specific Gamma Imaging, Scintimammography, and Molecular Breast Imaging	Re-reviewed	09/18/2017	Investigative and therefore not covered	No change in determination
Endoscopic Procedures for Treatment of Gastroesophageal Reflux Disease (GERD)	Re-reviewed	09/18/2017	Investigative and therefore not covered	No change in determination

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 5, then ext. 2-2355.

Where information conflicts with applicable state and/or federal law, Medica follows such applicable federal and/or state law.