Providers

Medical Policy Upcoming Updates

Notification Date: September 16, 2020

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
High Frequency Chest Wall Compression (HFCWC) Devices (III-DEV.20)	Re-Reviewed	11/16/2020	Medically necessary for a select population of patients	Transitioned to MCG guideline: High Frequency Chest Compression Device (A-0356). Medical Necessity Criteria: Has an appropriate clinical condition: Bronchiectasis not due to cystic fibrosis, and daily sputum production Cystic fibrosis Has a contraindication to, failure of, or intolerance of chest percussion and postural drainage. High frequency chest wall compression remains investigative and therefore not covered for all other indications, including but not limited to, neuromuscular disorders.
Genetic Testing for Susceptibility to Hereditary Breast and Ovarian Cancer (III-DIA.04)	Re-Reviewed	09/16/2020 Enhanced benefit	Medically necessary for a select population of patients	Change(s) to medical necessity criteria: Criteria added for an individual with a personal history of breast cancer An individual diagnosed at or before the age 50 with an unknown or limited family history.
Medicaid Home Health Aide (III.HOM.04)	Re-Reviewed	11/16/2020	Medically necessary for a select population of patients	Change(s) to medical necessity criteria: Criteria added that an assessment must be completed to determine the recipient's need for service. Criteria for HHA supervision specified that it be provided by a registered nurse or appropriate therapist (i.e., physical, occupational, speech-language pathology).
Proton Beam Radiation Therapy (III-MED.06)	Re-Reviewed	11/16/2020	Medically necessary for a select population of patients	Change(s) to medical necessity criteria: Criteria added in accordance with community standards: Proton beam radiation therapy may be indicated for a condition/diagnosis not listed in Medical Necessity Section I., including recurrences or metastases in selected individual cases. Requests for exceptions will be reviewed on a case-by-case basis by a Medical Director when designated criteria are met.
Spinal Cord and Dorsal Root Ganglion Stimulation for Treatment of Pain (III-DEV.23) (Formerly titled: Spinal Cord Stimulation of the Dorsal Column for Treatment of Pain)	Re-Reviewed	11/16/2020	Medically necessary for a select population of patients	The following determination was added to the policy: Dorsal root ganglion stimulation for the treatment of pain is investigative and therefore not covered.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Wireless Capsule Endoscopy (CE) and Capsule Technology to Verify Patency Prior to Capsule Endoscopy	Re-Reviewed	9/16/2020	Covered for some indications; investigative and therefore not covered for all other indications	New Determinations: The following two new indications are no longer investigative and are now covered: Small Bowel Neoplasm: evaluation of suspected, but undiagnosed, small bowel neoplasm, in members who are symptomatic for a neoplasm and when the diagnosis has not been confirmed by upper GI endoscopy, colonoscopy, and nuclear imaging or radiologic procedures. GI polyposis syndromes: surveillance of the small bowel in patients with hereditary small bowel polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome. The following two current indications remain covered (see policy for specifics): Occult gastrointestinal bleeding Crohn's disease The following remain Investigative: Wireless CE for all other indications. Capsule technology to verify patency prior to capsule endoscopy.

Policy Title

Status

Effective Date

Determination

Summary of Change

Wireless Capsule Endoscopy (CE) and Capsule Technology to Verify Patency Prior to Capsule Endoscopy

Re-Reviewed

9/16/2020

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

New Determinations:

The following two new indications are no longer investigative and are now covered:

Small Bowel Neoplasm: evaluation of suspected, but undiagnosed, small bowel neoplasm, in members who are symptomatic for a neoplasm and when the diagnosis has not been confirmed by upper GI endoscopy, colonoscopy, and nuclear imaging or radiologic procedures.
GI polyposis syndromes: surveillance of the small bowel in patients with hereditary small bowel polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome.

The following two current indications remain covered (see policy for specifics):

Occult gastrointestinal bleeding
Crohn's disease

The following remain Investigative:

Wireless CE for all other indications.
Capsule technology to verify patency prior to capsule endoscopy.

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.

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