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Medical Policy Upcoming Updates

Notification Date: November 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 Changes
Cervical Spine Surgeries (III-SUR.37)	Re-review	12/19/2022 Enhanced Benefit	Medically necessary for a select population of patients	The following criterion was removed from Section II: Initial and repeat/revision cervical decompression, stabilization, or fusion Surgery is not to exceed two contiguous levels from C2 to C7. An example of three cervical levels would be C2-C3 & C3-C4 & C4-C5. NOTE: If either cervical fusion or decompression is being requested at more than two levels, send for medical director review for medical necessity. (Section II.E.)
Lumbar Spine Surgeries (III-SUR.34)	Re-review	12/19/2022 Enhanced Benefit	Medically necessary for a select population of patients	Updates to Recombinant human bone morphogenic protein-2 criteria: Other cages in addition to the LT-CAGE™ are referenced. The following criterion as been removed: Individual has been diagnosed with degenerative disc disease and has a specific risk factor for nonunion All other criteria remain unchanged.
Gender Affirmation Procedures (III-SUG.20) Formerly titled: Gender Reassignment (Gender Affirmation) Procedures	Re-review	01/16/2023	Medically necessary for a select population of patients	Updates made based on the September 2022 release of the updated World Professional Association for Transgender Health Inc.’s Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Updates include: Gender surgery: 12 month of transgender real life experience in the new/evolving gender role no longer required Added criteria added for post-pubescent adolescents (post-puberty to age 18) Secondary sex characteristic procedures/surgeries other than mastectomy or breast augmentation: Letters of recommendation changed from two letters to one letter Criteria added for: Voice surgery or therapy Non-genital hair removal or transplantation Surgeries related to facial reconstruction Appendices updated
Comparative Genomic Hybridization (CGH) Microarray Testing (III-DIA.09)	Inactivated	12/30/2022	Medically necessary for a select population of patients	UM Policy is being inactivated and replaced by the following new coverage policies: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss Molecular Analysis of Solid Tumors and Hematologic Malignancies Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay
Genetic Testing for Prostate Cancer (III-DIA.14)	Inactivated	12/30/2022	Medically necessary for a select population of patients	UM Policy is being inactivated and replaced by the following new coverage policy: Algorithmic Testing
Genetic Testing for Susceptibility to Colorectal Cancer (CRC) Syndromes (III-DIA.06)	Inactivated	12/30/2022	Medically necessary for a select population of patients	UM Policy is being inactivated and replaced by the following new coverage policies: Hereditary Cancer Susceptibility
Genetic Testing For Susceptibility to Hereditary Breast and/or Ovarian Cancer (III-DIA.04)	Inactivated	12/30/2022	Medically necessary for a select population of patients	UM Policy is being inactivated and replaced by the following new coverage policy: Hereditary Cancer Susceptibility
Whole Exome Sequencing (III-DIA.13)	Inactivated	12/30/2022	Medically necessary for a select population of patients	UM Policy is being inactivated and replaced by the following new coverage policies: Molecular Analysis of Solid Tumors and Hematologic Malignancies Exome and Genome Sequencing for The Diagnosis of Genetic Disorders

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Changes
Genetic Testing: Aortopathies and Connective Tissue Disorders	New	01/16/2023	Covered for some indications; investigative and therefore not covered for all other indications	N/A
Genetic Testing: Cardiac Disorders	New*	01/16/2023	Covered for some indications; investigative and therefore not covered for all other indications	*Replaces former Medica coverage policy, Gene Expression Profiling for Detection of Heart Transplantation Rejection. Addresses many additional genetic tests for cardiac disorder.
Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders	New*	01/16/2023	Covered for some indications; investigative and therefore not covered for all other indications	*Replaces former Medica coverage policy, Genetic Testing for Alzheimer Disease. Addresses many additional genetic tests for cardiac disorder.
Genetic Testing: Exome and Genome Sequencing for The Diagnosis of Genetic Disorders	New*	01/16/2023	Covered for some indications; investigative and therefore not covered for all other indications	*Replaces former Medica coverage policy, Whole Genome Sequencing and former Medica utilization management policy, Whole Exome Sequencing.
Genetic Testing: Gastroenterologic Disorders (Non-Cancerous)	New	01/16/2023	Covered for some indications; investigative and therefore not covered for all other indications	N/A
Genetic Testing: Hearing Loss	New	01/16/2023	Covered for some indications; investigative and therefore not covered for all other indications	N/A
Genetic Testing: Hematologic Conditions (Non-Cancerous)	New	01/16/2023	Covered for some indications; investigative and therefore not covered for all other indications	N/A
Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay	New*	01/16/2023	Covered for some indications; investigative and therefore not covered for all other indications	*Replaces former Medica utilization management policy, Comparative Genomic Hybridization Microarray Testing Addresses many additional genetic tests for multisystem inherited disorders, intellectual disability, and developmental delay.
Minimally Invasive Glaucoma Surgery (MIGS): Microstent Implantation Formerly titled: XEN® Glaucoma Treatment System	Re-review	11/16/2022 Enhanced benefit	Covered for some indications; investigative and therefore not covered for all other indications	Change in determination: Microstent implantation of the Glaukos iStent® Trabecular Micro-Bypass Stent system, Glaukos iStent inject®, XEN® Glaucoma Treatment System, or Hydrus® Microstent is not investigative when used according to FDA labeled indications to reduce intraocular pressure (IOP) in adults with mild to moderate open-angle glaucoma, when medical therapies have failed to adequately control IOP. Each of the aqueous stent devices listed above is investigative for all other indications not listed in the covered policy, including implantation of more than two microstents per eye.
Radioembolization for Hepatic Tumors	Re-review	11/16/2022 Enhanced benefit	Covered for some indications; investigative and therefore not covered for all other indications	Change in determination: Radioembolization for the treatment of unresectable metastatic liver tumors from uveal melanoma is no longer investigative and therefore covered. All other indications remain the same. Refer to the coverage policy for complete details.
Transcranial Magnetic Stimulation for Medical Indications Formerly titled: Transcranial Magnetic Stimulation	Re-review	11/16/2022	Covered for some indications; investigative and therefore not covered for all other indications	Policy reformatted and title changed: Behavioral health indications removed from Medica’s coverage policy. Information provided for contacting Medica Behavioral Health for questions specific to behavioral health indications.