Providers

Medical Policy Upcoming Updates

Notification Date: November 21, 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
Bariatric Surgery (III-SUR.30)	Re-Reviewed	1/21/2019	Medically necessary for a select population of patients. In addition, there are investigative services that are not covered.	No change to medical necessity criteria. Benefit Considerations: The following investigative bariatric surgery techniques were removed as outdated procedures: (1) Gastroplasty (gastric stapling without banding), and (2) jejuno ileal bypass. The following investigative bariatric surgery techniques were added based on clinical review in September 2018: (1) Single-anastomosis duodenal switch (aka, stomach intestinal pylorus-sparing surgery; SIPS), and (2) AspireAssist weight loss therapy implant.
Cervical Spine Surgeries (III-SUR.37)	Re-Reviewed	1/21/2019	Medically necessary for a select population of patients.	Changes to medical necessity criteria: Examples of FDA approved demineralized bone matrices (DBM) were removed from the criteria, Appendix 4, Demineralized Bone Matrix (DBM) Products, was added to the policy. This grid documents the following information for FDA-approved DBM products: Source Company DBM Product Name Available Forms FDA Uses
Electric Tumor Treatment Fields (III-DEV.27)	Re-Reviewed	1/21/2019	Medically necessary for a select population of patients	No change to medical necessity criteria.
Knee Arthroplasty (III-SUR. 41)	Re-Reviewed	1/21/2019	Medically necessary for a select population of patients.	No change to medical necessity criteria.
Lumbar Spine Surgeries (III-SUR.34)	Re-Reviewed	1/21/2019	Medically necessary for a select population of patients.	Benefit Considerations additions: Prior authorization is not required for tethered spinal cord syndrome in infants, children, and adults. Types of stem cell preparations were added to the existing statement: (i.e., concentrated, engineered or expanded stem cells, as well as allograft bone products containing stem cells). Changes to medical necessity criteria: Examples of FDA approved demineralized bone matrices (DBM) were removed from the criteria, Appendix 4, Demineralized Bone Matrix (DBM) Products, was added to the policy. This grid documents the following information for FDA-approved DBM products: Source Company DBM Product Name Available Forms FDA Uses
Orthognathic Surgery (III-SUR.32)	Re-Reviewed	1/21/2019	Medically necessary for a select population of patients.	No change to medical necessity criteria.
Rhinoplasty Procedure with or without Septoplasty (III-SUR.04)	Re-Reviewed	11/21/2018 1/21/2019	Medically necessary for a select population of patients. In addition, there are investigative services that are not covered.	Change to medical necessity criteria (effective 11/21/2018): A fixed, medically significant obstruction that can only be corrected by rhinoplasty is now a criterion of nasal deformity with airway obstruction. Benefit Considerations addition (effective 1/21/2019): Nasal implants, absorbable, for treatment of nasal valve collapse (e.g., Latera) is investigative and therefore not covered.
Spinal Cord Stimulation of the Dorsal Column for Treatment of Pain (III-DEV.23)	Re-Reviewed	1/21/2019	Medically necessary for a select population of patients.	No change to medical necessity criteria.
Varicose Vein and Venous Insufficiency Treatments (III-SUR.26)	Re-Reviewed	1/21/2019	Medically necessary for a select population of patients. In addition, there are investigative services that are not covered.	No change to medical necessity criteria. Benefit Considerations additions. The following services are investigative and therefore not covered: Medical adhesive, e.g. VenaSeal™ Closure System, for treatment of varicose veins. Sclerotherapy for great and/or small saphenous veins, including but not limited to Varithena® for treatment of great and/or small saphenous veins.
Whole Exome Sequencing (III-DIA.13)	Re-Reviewed	11/21/2018	Medically necessary for a select population of patients.	Change to medical necessity criteria. In addition to a board-certified medical geneticist the test can also be ordered by a neonatologist, neurologist, or developmental and behavioral pediatrician.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Annulus Fibrosis Repair Devices	Re-Reviewed	1/21/2019	Investigative and therefore not covered	No change in determination
Gene Expression Profiling Assay for Prediction of Coronary Artery Disease	New	1/21/2019	Investigative and therefore not covered	Investigative for all indications
Eustachian Tube Balloon Dilation	New	1/21/2019	Investigative and therefore not covered	Investigative for all indications e.g., Acclarent Aera ET balloon dilation system
Intense Pulsed Light Treatment for Dry Eye Disease	Re-Reviewed	1/21/2019	Investigative and therefore not covered	No change in determination
Meibomian Gland Evacuation Thera	Re-Reviewed	1/21/2019	Investigative and therefore not covered	No change in determination
Laser Therapy for the Treatment of Pain	Re-Reviewed	1/21/2019	Investigative and therefore not covered	No change in determination
Left Atrial Appendage Closure Devices Previous title: Percutaneous Left Atrial Appendage Closure Devices	Re-Reviewed	1/21/2019	Investigative and therefore not covered	No change in determination
Nasal Implant, Absorbable, for Treatment of Nasal Valve Collapse	New	1/21/2019	Investigative and therefore not covered	Investigative for all indications e.g., Latera nasal implant
Total Ankle Replacement Surgery	Re-Reviewed	1/21/2019	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.