Providers

Medical Policy Upcoming Updates

Notification Date: October 17, 2018

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

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Allogeneic Pancreatic Islet Cell Transplantation	Re-Reviewed	12/17/2018	Investigative and therefore not covered	No change in determination
Genetic and Pharmacogenetic Testing	Re-Reviewed	12/17/2018	Covered for some indications	No change in determination
Laboratory Tests	Re-Reviewed	12/17/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Minimally Invasive Spine Surgeries	Re-Reviewed	12/17/2018	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Prostate Health Index (PHI) Lab Test	New	12/17/2018	Covered for some indications; investigative and therefore not covered for all other indications	Not Investigative Determination: Screening and detection of prostate cancer, in men age 50 years and older, with prostate-specific antigen (PSA) results in the range of 4 to 10 ng/mL, and who have a negative digital rectal examination (FDA approved indications). Investigative Determination: Screening and detection of prostate cancer for all other indications.
Stem Cell Therapy for Orthopedic Applications	Re-Reviewed	12/17/2018	Investigative and therefore not covered	No change in determination Further defined that this investigative indication includes: Concentrated, engineered or expanded stem cells Allograft bone products containing stem cells.
Transmyocardial Revascularization	Re-Reviewed	12/17/2018	Covered for some indications; investigative and therefore not covered for all other indications	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.