Providers

Medical Policy Upcoming Updates

Notification Date: May 19, 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
Maternal Plasma Tests for Detection of Cell-Free Fetal DNA for Analysis of Chromosomal Aneuplodies	N/A	05/19/2021	N/A	Prior Authorization will no longer be required as of 05/19/2021. The UM policy will be inactivated and converted into a Coverage Policy (please see coverage policy section).

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Coronary Artery Calcium Scoring (CACS)	Re-Reviewed	05/19/2021 Enhanced Benefit	Covered for some indications; investigative and therefore not covered for all other indications	No longer investigative in asymptomatic individuals 40 to 75 years of age without diabetes mellitus with LDL level greater than or equal to 70 mg/dL – 189 mg/dL, at a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of greater than or equal to 7.5% to 19.9% for the purpose of making a treatment decision (e.g., stain therapy). Remains investigative for all other indications including both symptomatic and asymptomatic individuals, with or without risk factors.
Genetic Testing for Prostate Cancer	Re-Reviewed	05/19/2021 Enhanced Benefit	Covered for some indications; investigative and therefore not covered for all other indications	No longer investigative are Decipher^® Prostate Cancer Classifier Assay, OncotypeDx^® Genomic Prostate Score, Prolaris^®, and ProMark^® Proteomic Prognostic Test, when performed on prostate biopsy or radical prostatectomy specimens, and the individual’s risk stage as defined by the current National Comprehensive Cancer Network (NCCN) guidelines, is one of the following: Men with low- or favorable intermediate-risk disease with life expectancy equal or greater than 10, and the test results of the prostate biopsy will be used for making a decision about active surveillance. Men with unfavorable intermediate- or high-risk disease with life expectancy equal or greater than 10, and the test results will be used for making the decision about postoperative secondary therapy (e.g., radiation therapy, adjuvant or early salvage therapy) following radical prostatectomy. Remains investigative for all other prostate cancer indications and gene expression profiling and biomarkers tests not listed above.
Maternal Plasma Tests for Detection of Cell-Free Fetal DNA for Analysis of Chromosomal Aneuplodies	New	05/19/2021 Enhanced Benefit	Covered for some indications; investigative and therefore not covered for all other indications	No longer investigative in women less than 35 years of age at the time of delivery with a singleton pregnancy who are being screened for fetal aneuploidy (i.e., trisomy 13, 18 and/or 21). NOTE: This determination was largely based on the revised American College of Obstetricians and Gynecologists' (ACOG) Practice Bulletin No. 226 (October 2020), Screening for Fetal Chromosomal Abnormalities, which states that all women with a singleton pregnancy should be offered this testing. Remains investigative for all other indications including: Multiple gestation pregnancy Detection of any of the following: Aneuploidies other than trisomies 13, 18, or 21 Microdeletions Monogenic disorders (e.g., congenital adrenal hyperplasia, beta-thalassemia, hemophilia) Sex chromosome disorders (e.g., 45, X, 47, XXY).

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.