Providers

Medical Policy Upcoming Updates

Notification Date: June 19, 2019

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
Abdominoplasty/ Panniculectromy (III-SUR.13)	Re-Reviewed	08/19/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Blepharoplasty, Blepharoptosis Repair and Brow Lift (III-SUR.29)	Re-Reviewed	08/19/2019	Medically necessary for a select population of patients	Definition added for browpexy. Statement added that browpexy requires review by a medical director.
Breast Implant Removal, Revision, or Reimplantation (III-SUR.11)	Re-Reviewed	08/19/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Female Breast Reduction Surgery — Reduction Mammoplasty (III-SUR.27)	Re-Reviewed	08/19/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Gender Reassignment Surgery (III-SUR.20) (Previous title: Adult Gender Reassignment Surgery)	Re-Reviewed	08/19/2019	Medically necessary for a select population of patients	No change to medical necessity criteria
Implantable Deep Brain Stimulation (III-DEV.19)	Inactivated	07/17/2019 Enhanced benefit	N/A	No longer requires prior authorization. UM policy inactivated. Converted to a coverage policy (see below)
Male Gynecomastia Surgery (III-SUR.31)	Re-Reviewed	08/19/2019	Medically necessary for a select population of patients	Changes to medical necessity criteria. Male gynecomastia surgery in the post pubertal-onset gynecomastia classified as a Grade II, per the American Society of Plastic Surgeons classification, is now considered not medically necessary.
Otoplasty (III-SUR.33)	Re-Reviewed	08/19/2019	Medically necessary for a select population of patients	No change in determination
Rhinoplasty Procedure with or without Septoplasty (III-SUR.04)	Re-Reviewed	08/19/2019	Medically necessary for a select population of patients	No change in determination
Thoracic Sympathectomy for Primary Hyperhidrosis (III-SUR.25)	Inactivated	06/17/2019 Enhanced benefit	N/A	No longer requires prior authorization. UM policy inactivated.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Breast Ductal Lavage	Re-Reviewed	08/19/2019	Investigative and therefore not covered	No change in determination
Cervicography	Re-Reviewed	08/19/2019	Investigative and therefore not covered	No change in determination
Donor-Derived Cell-Free DNA Testing to Detect Rejection in Kidney Transplantation	New	08/19/2019	Investigative and therefore not covered	Investigative e.g., AlloSure®
Genetic Testing for Inherited Susceptibility to Melanoma Former Title: Genetic Testing for Inherited Susceptibility to Malignant Melanoma	Re-Reviewed	08/19/2019	Investigative and therefore not covered	No change in determination
Implantable Deep Brain Stimulation	New	07/17/2019	Covered for some indications; investigative and therefore not covered for all other indications	This was a previous utilization management policy, which was converted into a coverage policy. Covered for: Upper extremity tremor suppression in individuals diagnosed with refractory essential tremor or Parkinsonian tremor. Adjunctive therapy in reducing some of the symptoms of advanced, levodopa-responsive, refractory Parkinson’s diseases. Investigative for all other indications.
Laser Treatments for Neovascularization Associated with Macular Degeneration	Re-Reviewed	08/19/2019	Covered for some indications; investigative and therefore not covered for all other indications	No change in determination
Nasal Expiratory Positive Airway Pressure (Provent®) for Obstructive Sleep Apnea	Re-Reviewed	08/19/2019	Investigative and therefore not covered	No change in determination
Tidal Knee Lavage for Osteoarthritis	Re-Reviewed	08/19/2019	Investigative and therefore not covered	No change in determination
Wireless Pulmonary Artery Pressure Monitoring Systems for Monitoring Heart Failure (CardioMEMS™)	Re-Reviewed	08/19/2019	Investigative and therefore not covered	No change in determination
Whole Genome Sequencing	Re-Reviewed	08/19/2019	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.