Percutaneous Tibial Nerve Stimulation (III-MED.07) |
Re-Reviewed |
10/17/2017 |
|
No longer requires prior authorization
- Utilization Management policy archived
- Converted to Coverage Policy (see above)
|
Sacral Nerve Stimulation (SNS) (III-DEV.22) |
Re-Reviewed |
10/17/2017 |
|
No longer requires prior authorization
- Utilization Management policy archived
- Converted to Coverage Policy (see above)
|
Bariatric Surgery (III-SUR.30) |
Re-Reviewed |
01/01/2018 |
Medically necessary for a select population of patients |
Change(s) to medical necessity criteria
- Criteria added for individuals less than 18 years of age. Growth criteria unique to this age group are:
- Greater than 95% of estimated adult height has been achieved.
- A minimum Tanner stage of IV.
|
Female Breast Reduction – Reduction Mammoplasty (III-SUR.27) |
Re-Reviewed |
01/01/2018 |
Medically necessary for a select population of patients |
Change(s) to medical necessity criteria
- Using the Schnur Sliding Scale to determine medical necessity for breast tissue removal.
|
Orthognathic Surgery (III-SUR.32) |
Re-Reviewed |
01/01/2018 |
Medically necessary for a select population of patients |
Change(s) to medical necessity criteria
- Criteria added for skeletal deformities with masticatory malocclusion and functional impairments.
- Will continue to use MCG™ Care Guidelines for orthognathic surgery associated with obstructive sleep apnea.
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