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Medical Policy Upcoming Updates

Notification Date: February 15, 2023

Utilization Management Policies

Policy Title	Status	Effective Date	Determination	Summary of Changes
MCG Care Guidelines®	Re-Review	On or after May 1, 2023	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 27th edition of MCG Care Guidelines on or after May 1, 2023.
Bone Marrow Or Stem Cell (Peripheral Or Umbilical Cord Blood) Transplantation (III-TRA.01)	Re-Review	02/15/2023	Medically necessary for a select population of patients	Change to medical necessity criteria: New indications for allogeneic transplant were added: Blastic Plasmacytoid Dendritic Cell Neoplasm Fucosidosis Mixed Myelodysplastic/Myeloproliferative Neoplasms: Primary/secondary myelofibrosis and related conditions.
Heart Transplantation (Adult and Pediatric) (III-TRA.12)	Re-Review	02/15/2023	Medically necessary for a select population of patients	Change to medical necessity criteria: New indications for Heart Transplant Evaluation were added: American Heart Association Stage D: Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest. Inserted language for clarity: Congenital heart defects, “that have failed previous surgical correction” or that are not amenable to other medical or surgical intervention.
Lung Transplantation (III-TRA.11)	Re-Review	02/15/2023	Medically necessary for a select population of patients	Change to medical necessity criteria: New indication for Lung Transplant Evaluation was added: Acute respiratory distress syndrome (ARDS), including COVID-19-associated ARDS).

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Changes
Chronic Rhinitis: Cryoablation, Radiofrequency Ablation, and Laser Ablation, Office-Based	New	04/17/2023	Investigative and therefore not covered	Outpatient, off-based ablation therapy (e.g., RhinAer®, Neuromark®, and Clarifix®) for chronic rhinitis is investigative. Reliable evidence does not does not permit conclusions concerning its effectiveness.
Measurement of Serum Drug & Antibody Levels to Infliximab, Adalimumab, Ustekinumab & Vedolizumab	Re-Review	01/18/2023	Tests found not investigative.	Inactivated.
Genetic Testing: Dermatologic Conditions	New	02/20/2023	Covered for some indications; investigative and therefore not covered for all other indications	N/A
Genetic Testing: Kidney Disorders	New*	02/20/2023	Covered for some indications; investigative and therefore not covered for all other indications	Replaces former Medica coverage policy, Donor-Derived Cell-Free Testing to Detect Rejection in Kidney Transplantation* (e.g., Allosurel). Addresses many additional genetic tests for cardiac disorder.
Genetic Testing: Lung Disorders	New	02/20/2023	Covered for some indications; investigative and therefore not covered for all other indications	N/A
Genetic Testing: Eye Disorders	New	02/20/2023	Covered for some indications; investigative and therefore not covered for all other indications	N/A
Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders	New	02/20/2023	Covered for some indications; investigative and therefore not covered for all other indications	N/A
Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders	New	02/20/2023	Covered for some indications; investigative and therefore not covered for all other indications	N/A
Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders	New*	02/20/2023	Covered for some indications; investigative and therefore not covered for all other indications	Replaces former Medica coverage policy, Methylenetetrahydrofolate Reductase (MTHFR) Gene Mutation Testing*. Addresses many additional genetic tests for cardiac disorder.
Genetic Testing: General Approach to Genetic Testing	New*	02/20/2023	Covered for some indications; investigative and therefore not covered for all other indications	Replaces former Medica coverage policy, Genetic and Pharmacogenetic Testing*