Providers

Medical Policy Upcoming Updates

Notification Date: September 19, 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
Air Ambulance, Non-emergent (III.MED.07)	New	01/01/2019	Medically necessary for a select population of patients	Prior Authorization is now required. Medically necessary when the following criteria are met: Ordered by an attending physician Provided by a licensed professional air ambulance service Transportation meets one of the following criteria: Hospital to nearest hospital, when care for members' condition isn't available at the hospital where member was first admitted. Hospital to nearest post-acute level of care or skilled nursing facility. If it is required by Medica The member is clinically stable The member requires skilled care or medical monitoring for air ambulance transport. Ambulance transportation cannot be provided by a ground ambulance because it poses a threat or seriously endangers the member's health. Written documentation in the medical record specifying the medical necessity for non-emergency air ambulance transportation is required.
Autologous Cultured Chondrocyte Transplantation for the Knee (III-SUR.35)	Re-Reviewed	11/19/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Genetic Testing for Cardiac Channelopathies (III-DIA.05)	Re-Reviewed	11/19/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Genetic Testing for Cardiomyopathies (III-DIA.07)	Re-Reviewed	11/19/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Genetic Testing for Susceptibility to Hereditary Breast and Ovarian Cancer (III-DIA.04)	Re-Reviewed	11/9/2018	Medically necessary for a select population of patients	Individuals diagnosed at any age: Changed requirement for *two* or more close blood relatives with breast cancer, pancreatic cancer, or prostate cancer at any age to one or more close blood relatives with breast cancer, pancreatic cancer, or prostate cancer at any age per the most recent NCCN Guideline, Genetic/Familial High-Risk Assessment: Breast and Ovarian. Version 2.2019 – July 30, 2018. Deleted the following requirement, as it is now incorporated into the change noted above: One or more close blood relatives with breast cancer diagnosed at or before age 50.
High Frequency Chest Wall Compression (HFCWC) Devices (III-DEV.20)	Re-Reviewed	11/19/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Home Health Aide (III-HOM.02)	Re-Reviewed	11/19/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Magnetic Esophageal Ring for the Treatment of GERD (III-SUR.42)	Re-Reviewed	11/19/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Medicaid Home Care Nurse (HCN) Services (III-HOM.05)	Re-Reviewed	11/19/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Medicaid Home Health Aide (III-HOM.04)	Re-Reviewed	11/19/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Personal Care Assistance (III-HOM.03)	Re-Reviewed	11/19/2018	Medically necessary for a select population of patients	No change to medical necessity criteria
Proton Beam Radiation Therapy (III-MED.06)	Re-Reviewed	09/17/2018	Medically necessary for a select population of patients	Proton beam radiation therapy is now considered medically necessary for the following indications: Malignant and benign CNS tumors, including primary or metastatic spine tumors (including pediatric CNS tumors) Ocular tumors, including melanoma of the uveal tract Hepatocellular/hepatobiliary cancer Advanced head and neck cancer Paranasal sinus or other accessory sinus tumors Soft tissue sarcomas (e.g., non-metastatic retroperitoneal sarcomas). NOTE: Chordomas or chondrosarcomas arising at the base of the skull or along the axial skeleton without distant metastasis remain medically necessary.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Clinical Trial Participation	Re-reviewed	11/19/2018	Covered for some indications; not covered for others.	No change in determination Policy in line with the Federal Mandate and MN State Mandate on coverage for clinical trial participation.
Sacroiliac Joint Fusion, Open and Minimally Invasive	New for open SI joint fusion	11/19/2018	Covered for some indications; investigative and therefore not covered for all other indications	Open SI Joint: Covered for: Sacral tumors when used adjunctively with sacrectomy or partial sacrectomy SI joint infections used adjunctively with medical treatments Traumatic injuries (e.g., pelvic ring fractures). Not covered for all other indications, including but not limited to: Degenerative sacroiliac joint Mechanical low back pain Radicular pain syndromes Sacroiliac joint syndrome. NOTE: Minimally invasive SI joint fusion remains investigative and therefore not covered for all indications.
Vestibular Evoked Myogenic Potentials (VEMP) Testing	Re-reviewed	11/19/2018	Investigative and therefore not covered	No change in determination

Policy Title

Status

Effective Date

Determination

Summary of Change

Clinical Trial Participation

Re-reviewed

11/19/2018

Covered for some indications; not covered for others.

No change in determination

Policy in line with the Federal Mandate and MN State Mandate on coverage for clinical trial participation.

Sacroiliac Joint Fusion, Open and Minimally Invasive

New for open SI joint fusion

11/19/2018

Covered for some indications; investigative and therefore not covered for all other indications

Open SI Joint:

Covered for:

Sacral tumors when used adjunctively with sacrectomy or partial sacrectomy
SI joint infections used adjunctively with medical treatments
Traumatic injuries (e.g., pelvic ring fractures).

Not covered for all other indications, including but not limited to:

Degenerative sacroiliac joint
Mechanical low back pain
Radicular pain syndromes
Sacroiliac joint syndrome.

NOTE: Minimally invasive SI joint fusion remains investigative and therefore not covered for all indications.

Vestibular Evoked Myogenic Potentials (VEMP) Testing

Re-reviewed

11/19/2018

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.