Providers

Medical Policy Upcoming Updates

Notification Date: February 16, 2022

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
Gender Reassignment (Gender Affirmation) Procedures (III-SUR.20)	Re-Reviewed	02/16/2022 Enhanced Benefit	Medically necessary for a select population of patients	Change to medical necessity criteria: Medica considers all non-genital secondary sex characteristic procedures/surgeries medically necessary for an individual to conform to his/her gender identity or expression when specified criteria are met. Note: A list of examples of these procedures/surgeries is included in an Appendix located in the policy.
Liver Transplantation (III-TRA.02)	Re-Reviewed	04/18/2022	Medically necessary for a select population of patients	Change to medical necessity criteria: Removed the specific criteria used to define end-stage liver disease (e.g., life expectancy, quality of life). Portopulmonary hypertension added to the list of end-stage liver disease conditions.

Policy Title

Status

Effective Date

Determination

Summary of Change

Gender Reassignment (Gender Affirmation) Procedures (III-SUR.20)

Re-Reviewed

02/16/2022

Enhanced Benefit

Medically necessary for a select population of patients

Change to medical necessity criteria:

Medica considers all non-genital secondary sex characteristic procedures/surgeries medically necessary for an individual to conform to his/her gender identity or expression when specified criteria are met.
Note: A list of examples of these procedures/surgeries is included in an Appendix located in the policy.

Liver Transplantation (III-TRA.02)

Re-Reviewed

04/18/2022

Medically necessary for a select population of patients

Change to medical necessity criteria:

Removed the specific criteria used to define end-stage liver disease (e.g., life expectancy, quality of life).
Portopulmonary hypertension added to the list of end-stage liver disease conditions.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Liposuction for Lymphedema or Lipedema	New	04/18/2022	Covered for some indications; investigative and therefore not covered for all other indications	Liposuction for the treatment of moderate to severe lipedema or moderate to severe lymphedema when condition has not responded to standard conservative treatment (e.g., compression therapy program managed by physician and/or physical/occupational therapist) and the condition is causing significant functional impairment that interferes with activities of daily living is covered. Liposuction is investigative and not covered for all other lipedema and lymphedema indications.
Skin and Soft Tissue-Engineered Substitutes for Wound and Surgical Care	Re-Reviewed	02/16/2022 Enhanced Benefit	Covered for some indications; investigative and therefore not covered for all other indications	Change in determination: The following products are no longer investigative for the specific indication listed: Post-mastectomy breast reconstructive surgery: Strattice® Treatment of (1) non-infected wounds, or (2) non-infected chronic ulcers (diabetic or venous insufficiency) of the lower-extremity, either of which have not adequately responded to conventional therapy: AmnioBand® DermACELL AWM® EpiCord™ Grafix® Core Grafix® Prime Primatrix® TheraSkin® Dystrophic epidermolysis bullosa: OrCel™ All other uses of the tissue-engineered skin substitutes listed in the policy are investigative. All other tissue-engineered skin substitutes not listed in the policy are investigative for all indications.
Three Dimensional (3-D) Printed Anatomic Modeling for Surgical Planning	New	04/18/2022	Investigative and therefore not covered
Wound Imaging and Measuring Systems for Managing Chronic Wounds (e.g., Fluorescent Wound Imaging; Camera Wound Imaging)	New	04/18/2022	Investigative and therefore not covered

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.