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Re-Reviewed
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On or after 06/17/2019 |
Medically necessary for a select population of patients
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Medica may use tools developed by third parties, such as MCG Care Guidelines® , to assist in administering health benefits. Medica will begin using the 23rd edition of MCG Care Guidelines on or after June 17, 2019
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Bariatric Surgery (III-SUR.30)
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Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria
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Bone Growth Stimulation (III-DEV.07) |
Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
Comparative Genomic Hybridization (CGH) Microarray Genetic Testing (III-DIA.09) |
Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
Genetic Testing for Susceptibility to
Colorectal Cancer (CRC) Syndromes (III-DIA.06) |
Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
Additional required genetic counseling documentation now includes:
- Discussion of possible impacts of testing (e.g., psychological, social, limitations of nondiscrimination statutes)
- Discussion of possible test outcomes (i.e., positive, negative, variant of uncertain significance)
- Explanation of potential benefits, risks, and limitations of testing
- Explanation of purpose of evaluation (e.g., to confirm, diagnose, or exclude genetic condition)
- Obtaining informed consent for genetic test.
|
Implanted Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (III-SUR.43) |
Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
Background – Definitions Section
- Added definition for central sleep apnea and mixed apnea.
- Revised current definition for obstructive sleep apnea.
Medical Necessity Criteria – Contraindication Section:
- Added a contraindication: central plus mixed apneas greater than 25% of the total apnea-hypopnea index (AHI).
|
Maternal Plasma Testing for Detection
of Cell-Free Fetal DNA for Analysis of Chromosomal Aneuploidies (III-DIA.11) |
Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
Additional required genetic counseling documentation now includes:
- Discussion of possible impacts of testing (e.g., psychological, social, limitations of nondiscrimination statutes)
- Discussion of possible test outcomes (i.e., positive, negative, variant of uncertain significance)
- Explanation of potential benefits, risks, and limitations of testing
- Explanation of purpose of evaluation (e.g., to confirm, diagnose, or exclude genetic condition)
- Obtaining informed consent for genetic test.
|
Microprocessor Controlled Knee
Prostheses, with or Without Polycentric, Three-Dimensional Endoskeletal Hip Joint System (III-DEV.17) |
Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
Outpatient Enteral Nutrition Therapy (III-MED.03) |
Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
Positron Emission Tomography (PET) Scan (III-DIA.12) |
Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |
Real-Time Mobile Cardiac Outpatient Telemetry (RT-MCOT) (III-DIA.08 |
Re-Reviewed |
06/17/2019 |
Medically necessary for a select population of patients |
No change to medical necessity criteria |