Abdominoplasty/Panniculectomy (III-SUR.13)
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Re-reviewed
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08/20/2018 |
Medically necessary for a select population of patients
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No change to medical necessity criteria
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Blepharoplasty, Blepharoptosis Repair and Brow Lift (III-SUR.29)
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Re-reviewed
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08/20/2018
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Medically necessary for a select population of patients
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No change to medical necessity criteria
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Breast Implant Removal, Revision, or Reimplantation (III-SUR.11)
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Re-reviewed
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08/20/2018
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Medically necessary for a select population of patients
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No change to medical necessity criteria
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Female Breast Reduction Surgery (III-SUR.27)
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Re-reviewed
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08/20/2018
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Medically necessary for a select population of patients
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Change(s) to medical necessity criteria
- Reinstated Medica's previous criteria for the amount of breast tissue to be removed in addition to the current Schur scale to allow for more body types.
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Male Gynecomastia Surgery (III-SUR.31)
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Re-reviewed
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08/20/2018
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Medically necessary for a select population of patients
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Change(s) to medical necessity criteria
- Other medical causes must be ruled out, as indicated by normal laboratory results (e.g., liver and kidney function studies/enzymes)
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Otoplasty (III-SUR.33)
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Re-reviewed
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08/20/2018
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Medically necessary for a select population of patients
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No change to medical necessity criteria
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Proton Beam Radiation Therapy (III-MED.06)
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Re-reviewed
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07/16/2018
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Medically necessary for a select population of patients
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Reinstatement of Medica's former utilization management policy
- Sunset MCG™ Care Guideline Criteria (21st edition, 2017: ACG: A-0389 (AC), Proton Beam Therapy).
Appropriate indications for PBRT:
- Chordomas or chondrosarcomas arising at the base of the skull or along the axial skeleton without distant metastasis [No change]
- Pediatric central nervous system tumors adjacent to vital structures (e.g. optic nerve, spinal cord) [Add back – no change]
- Melanoma of the uveal tract (iris, choroid, ciliary body) without extrascleral extension and with no evidence of metastasis [No change]
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Rhinoplasty Procedure with or without Septoplasty (III-SUR.04)
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Re-reviewed
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08/20/2018
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Medically necessary for a select population of patients
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Change(s) to medical necessity criteria
- New Indication: Residual large cutaneous defect following resection of a malignancy
- A fixed, medically significant obstruction that can only be corrected by rhinoplasty is now a stand-alone criterion.
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Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive Sleep Apnea/Hypopnea Syndrome (III-SUR.08)
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Re-reviewed
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08/20/2018
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Medically necessary for a select population of patients
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No change in determination
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