Providers

Medical Policy Upcoming Updates

Notification Date: February 17, 2021

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
Bone Marrow Or Stem Cell (Peripheral Or Umbilical Cord Blood) Transplantation (III-TRA.01)	Re-Reviewed	04/19/2021	Medically necessary for a select population of patients	Change to medical necessity criteria: The following criteria have been removed from Medica's policy and the transplant institution's suitability criteria will be used: Individual performance scores (Karnofsky and Lansky) Individual response and appropriateness to conventional chemotherapy agents treatment.
Facet Injections And Percutaneous Denervation Procedures (Radiofrequency And Laser Ablation) For Facet-Mediated Joint Pain (III-SUR.44)	New	04/19/2021	Medically necessary for a select population of patients	Prior authorization is required for initial diagnostic intra-articular facet joint injections, medial branch nerve blocks, therapeutic facet denervation procedures, and for any subsequent facet injections/denervation combination. Medical necessity criteria for initial or repeat diagnostic facet joint injections: Diagnostic blocks (medial branch nerve block, intra-articular injection) needed to confirm or validate facet joint pain Patient is candidate for facet neurotomy Failure of 3 months of conservative therapy Radiologic imaging studies have been done. Investigative and not covered for all other indications, including, but not limited to, all therapeutic injections. Medical necessity criteria for percutaneous denervation procedures for facet-mediated joint pain: Initial non-pulsed radiofrequency ablation (RFA) denervation/ neurotomy Repeat RFA denervation/neurotomy at the same facet joint level. Investigative indications that are not covered: Laser, pulsed, cooled percutaneous RFA ablation/denervation of the facet joint Ablation/denervation of sacroiliac (SI) joint by any method.
Intestinal Transplantation (III-TRA.13)	Re-Reviewed	04/19/2021	Medically necessary for a select population of patients	Change to medical necessity criteria: A new indication for intestine/liver transplant was added: The individual has a diagnosis of acute diffuse intestinal infarction with hepatic failure.
Kidney Transplantation (III.TRA.03)	Re-Reviewed	04/19/2021	Medically necessary for a select population of patients	Change to medical necessity criteria: Clarified that one of the criteria for end-stage renal disease is "advanced chronic renal failure" on dialysis vs "chronic kidney disease" on dialysis.
Pancreas Transplantation (Pancreas Alone) (III.TRA.04)	Re-Reviewed	04/19/2021	Medically necessary for a select population of patients	Change to medical necessity criteria: The following criteria have been removed from Medica's policy and the transplant institution's suitability criteria will be used: A history of frequent, acute and severe life-threatening complications requiring medical attention Inability to tolerate and failure of exogenous insulin-based management to prevent acute complications.
Pancreas-Kidney (SPK, PAK) Transplantation (III.TRA.05)	Re-Reviewed	04/19/2021	Medically necessary for a select population of patients	Change to medical necessity criteria: Clarified that one of the criteria for end-stage renal disease is "advanced chronic renal failure" on dialysis vs "chronic kidney disease" on dialysis. The following criteria have been removed from Medica's policy and the transplant institution's suitability criteria will be used: For simultaneous pancreas kidney transplant (SPK) all of the following criteria must be met: Labile Insulin-dependent diabetes Imminent or established end-stage kidney disease. For sequential pancreas after kidney transplant (PAK), all of the following criteria must be met: Labile Insulin-dependent diabetes Previously successful kidney transplant with stable function.
Uvulopalatopharyngoplasty (UPPP or U3P) For Obstructive Sleep Apnea/Hypopnea Syndrome	Re-Reviewed	04/19/2021	Medically necessary for a select population of patients	New medical necessity criterion: Member must have a documented history of failed, or reasons for exclusion, of other alternatives treatments (e.g., mandibular advancement device, hypoglossal neurostimulator therapy) is required.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Mechanical Circulatory Support Devices	New	02/15/2021	Covered for some indications; investigative and therefore not covered for all other indications	Reminder: Utilization Management policy converted into a new Coverage Policy. Prior Authorization is no longer required. However, Notification within 48 hours of device placement is requested. Notification will allow for referral of the member into Medica's case management services. A notification form is available on medica.com: Notification Form (admissions section) Notification can also 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]
Vitamin D Testing for Screening	New	04/19/2021	Not medically necessary and therefore not covered	Vitamin D testing (blood test) for general population screening is not medically necessary.

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.