Providers

Medical Policy Upcoming Updates

Notification Date: August 15, 2018

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

Utilization Management Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
MCG Care Guidelines^®	Re-reviewed	N/A	Medically necessary for a select population of patients	21^stedition of MCG Care Guidelines have been reaffirmed and will continue to be used

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Antigen Leukocyte Cellular Antibody Test (ALCAT Test) for Food & Chemicals	Re-reviewed	10/15/2018	Investigative and therefore not covered	No change in determination
Cytotoxic Testing for Allergy Diagnosis	Re-reviewed	10/15/2018	Investigative and therefore not covered	No change in determination
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in Multiple Sclerosis	Re-reviewed	10/15/2018	Investigative and therefore not covered	No change in determination
Genetic Testing for Epilepsy and Seizure Disorders	New	10/15/2018	Investigative and therefore not covered	Investigative for all indications
Intracellular Micronutrient Analysis: MicroNutrient Testing; Intracellular Mineral Electrolyte Analysis	Re-reviewed	10/15/2018	Investigative and therefore not covered	No change in determination
Keratoprosthesis for Corneal Opacity	Re-Reviewed	10/15/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Laser Therapy for Nicotine Dependence	Re-Reviewed	10/15/2018	Investigative and therefore not covered	No change in determination
Noncontact Normothermic Wound Therapy	Re-Reviewed	10/15/2018	Investigative and therefore not covered	No change in determination
OncoSorb® Therapy (UltraPheresis) for Non-Hematologic Cancer	Re-Reviewed	10/15/2018	Investigative and therefore not covered	No change in determination
Outdoor Behavioral Healthcare	Re-Reviewed	10/15/2018	Investigative and therefore not covered	No change in determination
Percutaneous Tibial Nerve Stimulation	Re-Reviewed	10/15/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Repair of Pierced Body Parts	Re-Reviewed	10/15/2018	Covered for some indications; otherwise is excluded from coverage	No change in determination
Serial Dilution Endpoint Titration for Diagnosis and Treatment of Airborne Allergy	Re-Reviewed	10/15/2018	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.