Providers

Medical Policy Upcoming Updates

Notification Date: April 19, 2023

Utilization Management Policies

Utilization Management Policies	Policy Type	Status	Effective Date	Determination	Summary of Changes
Bone Growth Stimulators	Utilization Management	Re-Review	05/15/2023	Medically necessary for a select population of patients	Change to medical necessity criteria for electrical bone growth stimulators: Added Grade II or higher spondylolisthesis as a risk a factor under section B. 2b.
Gender Affirmation Procedures	Utilization Management	Revised	TBD	Medically necessary for a select population of patients	On or after May 1, 2023, Medica will use MCG Care Guideline (27th Edition, 2023), Gender-Affirming Surgery or Procedure for determining medical necessity for these services. Providers may call the Medica Provider Service Center at 1-800-458-5512 for additional information.
Implanted Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea	Utilization Management	Re-Review	05/15/2023	Medically necessary for a select population of patients	Change to medical necessity criteria: Age 18-21 yrs. was Included, per FDA expanded indication. Definitions for CPAP intolerance and PAP failure were also added.

Policy Type

Status

Effective Date

Determination

Summary of Changes

Bone Growth Stimulators

Utilization
Management

Re-Review

05/15/2023

Medically necessary for a select population of patients

Change to medical necessity criteria for electrical bone growth stimulators:

Added Grade II or higher spondylolisthesis as a risk a factor under section B. 2b.

Gender Affirmation Procedures

Utilization
Management

Revised

TBD

Medically necessary for a select population of patients

On or after May 1, 2023, Medica will use MCG Care Guideline (27th Edition, 2023), Gender-Affirming Surgery or Procedure for determining medical necessity for these services.

Providers may call the Medica Provider Service Center at 1-800-458-5512 for additional information.

Implanted Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea

Utilization
Management

Re-Review

05/15/2023

Medically necessary for a select population of patients

Change to medical necessity criteria:

Age 18-21 yrs. was Included, per FDA expanded indication.
Definitions for CPAP intolerance and PAP failure were also added.

Coverage Policies

Coverage Policies	Policy Type	Status	Effective Date	Determination	Summary of Changes
Biochemical Biomarker Panels for Assessing Hepatitis-Associated Liver Disease	Coverage	Re-review	06/19/2023	Covered for some indications; investigative and therefore not covered for all other indications	The following criteria remain unchanged. Covered: Hepatitis C Virus (HCV) FibroSure® and FibroTest/ActiTest panels in individuals with Hepatitis C virus. Not Covered: Hepatitis C Virus (HCV) FibroSure® and FibroTest/ActiTest panels in individuals with other forms of Hepatitis virus. All other biochemical biomarker panels (e.g., FibroSpect). All other applications of biochemical biomarker panels for assessing liver disease have been removed from this coverage policy. See related coverage policy, Genetic Testing: Gastroenterologic Disorders (Non-Cancerous), for biochemical biomarker panel use in management of non-hepatitis associated non-cancerous liver disease.
Cala Trio Therapy for Essential Tremor	Coverage	New	06/19/2023	Investigative and therefore not covered	Cala Trio therapy for essential tremor is investigative. Reliable evidence does not permit conclusion concerning its effectiveness.
Foot Care	Coverage	New	06/19/2023	Covered for some indications; investigative and therefore not covered for all other indications	Coverage for routine foot care is generally excluded from coverage in member plan documents. When not an excluded benefit: Covered if prescribed by a physician, performed by a healthcare professional, and the individual has one of the following:o Blindness Diabetes mellitus Peripheral neuropathy Peripheral vascular disease Significant neurologic condition, including but not limited to: Alzheimer's disease, amyotrophic lateral sclerosis (ALS), multiple sclerosis, Parkinson's disease. NOT COVERED in the absence of nail disease. NOT ELIGIBLE when pedicure services are performed in a retail salon.

Policy Type

Status

Effective Date

Determination

Summary of Changes

Biochemical Biomarker Panels for Assessing Hepatitis-Associated Liver Disease

Coverage

Re-review

06/19/2023

Covered for some indications; investigative and therefore not covered for all other indications

The following criteria remain unchanged.

Covered: Hepatitis C Virus (HCV) FibroSure® and FibroTest/ActiTest panels in individuals with Hepatitis C virus.
Not Covered:
- Hepatitis C Virus (HCV) FibroSure® and FibroTest/ActiTest panels in individuals with other forms of Hepatitis virus.
- All other biochemical biomarker panels (e.g., FibroSpect).
  All other applications of biochemical biomarker panels for assessing liver disease have been removed from this coverage policy.
See related coverage policy, Genetic Testing: Gastroenterologic Disorders (Non-Cancerous), for biochemical biomarker panel use in management of non-hepatitis associated non-cancerous liver disease.

Cala Trio Therapy for Essential Tremor

Coverage

New

06/19/2023

Investigative and therefore not covered

Cala Trio therapy for essential tremor is investigative. Reliable evidence does not permit conclusion concerning its effectiveness.

Foot Care

Coverage

New

06/19/2023

Covered for some indications; investigative and therefore not covered for all other indications

Coverage for routine foot care is generally excluded from coverage in member plan documents.
When not an excluded benefit:

Covered if prescribed by a physician, performed by a healthcare professional, and the individual has one of the following:o
- Blindness
- Diabetes mellitus
- Peripheral neuropathy
- Peripheral vascular disease
- Significant neurologic condition, including but not limited to: Alzheimer's disease, amyotrophic lateral sclerosis (ALS), multiple sclerosis, Parkinson's disease.
NOT COVERED in the absence of nail disease.
NOT ELIGIBLE when pedicure services are performed in a retail salon.