Providers

Medical Policy Upcoming Updates

Notification Date: June 15, 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 Changes
MCG Care Guidelines®	Re-review	06/29/2022	Medically necessary for a select population of patients	Medica may use tools developed by third parties, such as MCG Care Guidelines®, to assist in administering health benefits. Medica will begin using the 26th edition of MCG Care Guidelines on June 29, 2022.
Varicose Vein and Venous Insufficiency Treatments of the Lower Extremities (III-SUR.26) [Formerly titled Varicose Vein and Venous Insufficiency Treatments]	Re-review	07/18/2022	Medically necessary for a select population of patients	Change(s) to medical necessity criteria Title changed to Varicose Vein and Venous Insufficiency Treatments of the Lower Extremities A patent deep venous system is no longer required in bilateral extremities, but rather now limited to the affected extremity.

Policy Title

Status

Effective Date

Determination

Summary of Changes

MCG Care Guidelines®

Re-review

06/29/2022

Medically necessary for a select population of patients

Medica may use tools developed by third parties, such as MCG Care Guidelines®, to assist in administering health benefits. Medica will begin using the 26th edition of MCG Care Guidelines on June 29, 2022.

Varicose Vein and Venous Insufficiency Treatments of the Lower Extremities (III-SUR.26)

[Formerly titled Varicose Vein and Venous Insufficiency Treatments]

Re-review

07/18/2022

Medically necessary for a select population of patients

Change(s) to medical necessity criteria

Title changed to Varicose Vein and Venous Insufficiency Treatments of the Lower Extremities
A patent deep venous system is no longer required in bilateral extremities, but rather now limited to the affected extremity.