| Endoscopic Balloon Sinuplasty Ostial Dilation and Steroid-Eluting Sinus Stents for Treatment of Chronic Sinusitis |
Re-Reviewed |
02/15/2021 |
Covered for some indications; investigative and therefore not covered for all other indications |
No change in determinations.
Determinations will be addressed in two separate policies effective 02/15/2021:
- Endoscopic Balloon Sinuplasty Ostial Dilation for Treatment of Chronic Sinusitis
- Covered for some indications; investigative and therefore not covered for all other indications
- Drug-Eluting Sinus Stents for Maintenance of Patency Following Sinus Surgery
- Investigative and therefore not covered
|
Juvenile Cartilage Allograft Tissue Implantation for Articular Cartilage Repair
New Title:
Minced Cartilage (Allograft) Repair for Articular Cartilage Defects
|
Re-Reviewed |
02/15/2021 |
Investigative and therefore not covered |
- New product: BioCartilage reviewed and determined to be investigative and therefore not covered.
- Scope of coverage policy expanded to allogeneic minced cartilage versus only juvenile cartilage.
- Allogeneic minced cartilage (e.g., DeNovo® NT Natural Tissue Graft, BioCartilage®) for repair of articular cartilage defects is investigative and therefore not covered.
|
| Mechanical Circulatory Support Devices |
New |
02/15/2021 |
Covered for some indications; investigative and therefore not covered for all other indications |
Utilization Management policy converted into a new Coverage Policy. No change in determinations.
- Ventricular Assist Devices (VADs) and Total Artificial Hearts (TAHs) are covered when FDA approved devices are used for medically appropriate indications.
- VADs are investigative and not covered when non-FDA approved devices are used.
- TAHs are investigative and not covered when non-FDA approved devices are used and/or for destination therapy.
Notification within 48 hours of device placement is requested. Notification will allow for referral of the member into Medica's case management services.
Notification can be completed by fax or email:
- For group numbers that begin with IFB or B: Fax to 952-992-2836 or E-Mail to
[email protected]
- For group numbers that begin with A: Fax to 952-992-2396 or E-Mail to
[email protected]
- For all other group numbers: Fax to 952-992-3556 or E-Mail to
[email protected]
In addition, a notification form will be available on medica.com on 02/15/2021.
|
| Tissue-Engineered Skin Substitutes for Wound and Surgical Care |
Current Policy |
03/20/2019 |
Covered for some indications; investigative and therefore not covered for all other indications |
Title changed from:
Tissue-Engineered Skin Substitutes for Wound and Surgical Care
to
Skin and Soft Tissue-Engineered Substitutes for Wound and Surgical Care
|
Percutaneous Radiofrequency and Laser Ablation/Denervation Procedures for Facet and Sacroiliac Joints
New Title:
Facet Injections and Percutaneous Denervation Procedures (Radiofrequency and Laser ablation) for Facet-Mediated Joint Pain
|
Re-Reviewed |
02/15/2021 |
Covered for some indications; investigative and therefore not covered for all other indications |
The following determination was added to the policy:
- Intra-articular facet joint injection/medial branch nerve block with image guidance, is not investigative for diagnosis/validation of facet joint pain in individuals with severe chronic neck, thoracic, or back pain when all of the following criteria are met:
- Diagnostic block is needed to confirm facet joint as source of spinal pain
- Patient is candidate for radiofrequency ablation/denervation of the facet joint
- Failure of conservative management
- Other causes of spinal pain have been ruled out.
- Facet joint injection/medial branch nerve is investigative for ALL other diagnostic/validation indications and for ALL treatment modalities.
- No change in current determinations for Percutaneous Radiofrequency and Laser Ablation/Denervation Procedures for Facet and Sacroiliac Joints.
|