Providers

Medical Policy Upcoming Updates

Notification Date: April 18, 2018

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
MCG Care Guidelines^®	Re-reviewed	On or after 06/18/2018	Medically necessary for a select population of patients	Medica may use tools developed by third parties, such as MCG Care Guidelines^®, to assist in administering health benefits. Medica will begin using the 22nd edition of MCG Care Guidelines on or after June 18, 2018.
Adult Gender Reassignment Surgery (III-SUR.20)	Re-reviewed	06/18/2018	Medically necessary for a select population of patients	No change to medical necessity criteria.
Behavioral Health Services – Individual and Family business (IFB) (III-BEH.01)	Re-reviewed	06/18/2018	Medically necessary for a select population of patients	Prior authorization will be required for transcranial magnetic stimulation. The MCG Guideline, Transcranial Magnetic Stimulation (B-801-T), will be used for criteria for individuals with a diagnosis of major depressive disorder.
Bone Growth Stimulators (III-DEV.07)	Re-reviewed	06/18/2018	Medically necessary for a select population of patients	No change to medical necessity criteria.
Comparative Genomic Hybridization (CGH) Microarray Testing (III-DIA.09)	Re-reviewed	06/18/2018	Medically necessary for a select population of patients	No change to medical necessity criteria.
Implanted Hypoglossal Nerve Stimulation (III-SUR.43)	Re-reviewed	06/18/2018	Medically necessary for a select population of patients	No changes to medical necessity criteria.
Microprocessor Controlled Knee Prostheses, with or without Polycentric, Three-Dimensional Endoskeletal Hip Joint System (III-DEV.17)	Re-reviewed	06/18/2018	Medically necessary for a select population of patients	No changes to medical necessity criteria.
Outpatient Enteral Nutrition (III-MED.03)	Re-reviewed	06/18/2018	Medically necessary for a select population of patients	No change to medical necessity criteria.
Positron Emission Tomography (PET) Scan (III-DIA.12)	Re-reviewed	06/18/2018	Medically necessary for a select population of patients	Changes in medical necessity criteria: Written documentation for oncology services clarified. Requires either previous diagnostic imaging report(s) and/or pathology report(s).
Real-Time Mobile Cardiac Outpatient Telemetry (RT-MCOT) (III-DIA.08)	Re-reviewed	04/23/2018	Medically necessary for a select population of patients	Changes in medical necessity criteria: Eliminated the criteria requiring non-real-time cardiac monitoring prior to a cardiologist request for RT-MCOT.
Vagus Nerve Stimulation (III-DEV.24)	Re-reviewed	04/18/2018	Medically necessary for a select population of patients	Implantable vagus nerve stimulation (VNS) is now covered for all types of refractory epilepsy.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Coronary Computed Tomography Angiography (CCTA) For Coronary Artery Evaluation	Re-reviewed	06/18/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination.
In Vitro Chemosensitivity and Chemoresistance Assays	Re-reviewed	06/18/2018	Investigative and therefore not covered.	No change in determination.
Home Use of Bilevel Positive Airway Pressure (BiPAP) for Conditions Other Than Obstructive Sleep Apnea (OSA) Former Title: Home Use of Bilevel Positive Airway Pressure (BiPAP)	Re-reviewed	06/18/2018	Covered for some indications; investigative and therefore not covered for all other indications	Criteria for BiPAP used for OSA were removed from this policy and incorporated into the revised policy, Home Use of Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) for Obstructive Sleep Apnea (OSA).
Home Use of Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) for Obstructive Sleep Apnea (OSA) Former Title: Home Use of Continuous Positive Airway Pressure (CPAP)	Re-reviewed	06/18/2018	Outlines initial, maximum rental period, followed by purchase or device return to vendor.	BiPAP devices added to the policy and will be subject to the same rental and purchase/return requirement as CPAP.
Laser Spine Surgeries	Re-reviewed	06/18/2018	Investigative and therefore not covered	No change in determination.
Light Treatment and Laser Therapies for Benign Dermatologic Conditions	Re-reviewed	06/18/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination.
Motion Preserving Posterior Interspinous/Interlaminar Decompression/Stabilization Devices	Re-reviewed	06/18/2018	Investigative and therefore not covered	No change in determination.
Noncontact, Low-Frequency Ultrasound Therapy for Healing of Chronic Wounds	Re-reviewed	06/18/2018	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 8, then ext. 2-2355.

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