Providers

Medical Policy Upcoming Updates

Notification Date: September 15, 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	09/20/2021 Enhanced Benefit	Medically necessary for a select population of patients	Additional indications added to the autologous transplant section: Autologous Bone Marrow or Stem cell Transplant is now medically necessary for: Autoimmune Diseases: Multiple Sclerosis Systemic Sclerosis (Scleroderma)
Facet Injections and Percutaneous Denervation Procedures (Radiofrequency and Laser Ablation) for Facet-Mediated Joint Pain (III-SUR.45)	Re-Reviewed	11/15/2021	Medically necessary for a select population of patients	Additional criterion added to Medical Necessity criteria for *repeat* non-pulsed percutaneous radiofrequency ablation denervation / neurotomy of the facet joint: Repeat RFA treatment procedure is limited to three levels per side of each spinal region (cervical, thoracic or lumbar) in a six-month period. All other criteria remain unchanged.
Positron Emission Tomography (PET) Scan (III-DIA.12)	Re-Reviewed	09/20/2021 Enhanced Benefit	Medically necessary for a select population of patients	Additional indications added to the cardiology section: PET is now medically necessary to evaluate: Suspected prosthetic valve endocarditis when transthoracic or transesophageal echocardiography is inconclusive or unable to be completed. Suspected left ventricular assist device (LVAD) related infection when other imaging is inconclusive or unable to be completed. Please note that PET assessment of all other infections and inflammation continues to be investigative. All other criteria remain unchanged.

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

09/20/2021

Enhanced Benefit

Medically necessary for a select population of patients

Additional indications added to the autologous transplant section:

Autologous Bone Marrow or Stem cell Transplant is now medically necessary for:

Autoimmune Diseases:
- Multiple Sclerosis
- Systemic Sclerosis (Scleroderma)

Facet Injections and Percutaneous Denervation Procedures (Radiofrequency and Laser Ablation) for Facet-Mediated Joint Pain (III-SUR.45)

Re-Reviewed

11/15/2021

Medically necessary for a select population of patients

Additional criterion added to Medical Necessity criteria for repeat non-pulsed percutaneous radiofrequency ablation denervation / neurotomy of the facet joint:

Repeat RFA treatment procedure is limited to three levels per side of each spinal region (cervical, thoracic or lumbar) in a six-month period.

All other criteria remain unchanged.

Positron Emission Tomography (PET) Scan (III-DIA.12)

Re-Reviewed

09/20/2021

Enhanced Benefit

Medically necessary for a select population of patients

Additional indications added to the cardiology section:

PET is now medically necessary to evaluate:

Suspected prosthetic valve endocarditis when transthoracic or transesophageal echocardiography is inconclusive or unable to be completed.
Suspected left ventricular assist device (LVAD) related infection when other imaging is inconclusive or unable to be completed.

Please note that PET assessment of all other infections and inflammation continues to be investigative.
All other criteria remain unchanged.

Clinical Guidelines

Policy Title	Status	Effective Date	Determination	Summary of Change
Estimated Glomerular Filtration Rate (eGFR)	New	09/20/2021	N/A	New Guideline Medica's goal is to achieve equity and eliminate disparities in kidney care. The purpose of this guideline is to provide evidence-based information for alternative approaches to GFR equations that calculate kidney function without the inclusion of the race coefficient, meet the standards of transparency and shared decision-making, and ensure equity and personalized care for patients with kidney disease. Medica supports eliminating race correction in the GFR calculation.

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.