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Rare Disease: Access to Diagnosis, Monitoring, and Treatment
This policy applies to Minnesota members (only) who are covered under specified Commercial/Individual (IFB) and Government Products.
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Utilization
Management
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New |
01/01/2024 |
Medically necessary for a select population of patients
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A rare disease or condition is defined as any disease or condition that affects fewer than 200,000 persons in the United States and is a chronic, serious, life-altering, or life-threatening disease/condition.
Beginning with dates of service 01/01/2024, the State of Minnesota has created new requirements (“the law”) related to access, coverage, and reimbursement for diagnosis, monitoring, and treatment of a rare disease or condition.
Further details can be found within Minnesota law 62Q.451:
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Facility-Based Polysomnography, Adults (Sleep Study) |
Utilization
Management |
New |
01/01/2024 |
Medically necessary for a select population of patients |
Prior authorization is required for a facility-based polysomnography for an adult 18 years of age or older with:
- Obstructive sleep apnea when:
- A home sleep study is contraindicated or unavailable, and
- Signs or symptoms suggestive of moderate risk to high-risk obstructive sleep apnea are present.
- Central sleep apnea or sleep-related hypoventilation meeting specified criteria.
- Obesity hypoventilation syndrome meeting specified criteria.
NOTE: Prior authorization is not required for a home sleep study for individuals 18 years of age or older.
NOTE: For coverage of home sleep studies in adults 18 years if age or older, see Medica Coverage Policy, Sleep Studies for Initial Diagnosis of Obstructive Sleep Apnea.
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Implanted Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea
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Utilization
Management |
Re-Reviewed |
12/18/2023
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Medically necessary for a select population of patients
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Changes to medical necessity criteria:
- Added age 13 to 18 years of age with Down syndrome, per FDA expanded indication.
- Changed the upper limit body mass index equal to or less than 40 (increase from ≤32 to ≤40), per FDA expanded indication.
- Changed upper limit baseline apnea-hypopnea index less than or equal to 100 (increase from ≤65 to ≤100) for ages 18 and older, per FDA expanded indication.
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| Intraoperative Neurophysiologic Monitoring (IONM) |
Utilization
Management |
N/A |
01/01/2024 |
N/A |
Prior Authorization will no longer be required for Medicare members as of 01/01/2024. The Medicare Utilization Management policy will be inactivated. The Coverage Policy Intraoperative Neurophysiologic Monitoring (IONM), currently used for other products (e.g., commercial, IFB), will be updated to include all Medicare products (Medica Advantage, Medica DUAL, and Medica AccessAbility Solutions). |
| Genetic Testing – 27 total policies |
Coverage |
Re-Review |
01/01/2024 |
Covered for some indications; investigative and therefore not covered for all other indications |
Changes reflect updated and validated genetic testing clinical criteria by Concert Genetics, an industry-leader in genetic testing technology assessment and policy development.
- Changes to coverage determinations are policy dependent.
- Refer to specific coverage policies for further information.
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| Implantable Deep Brain and Responsive Cortical Stimulation |
Coverage |
Re-Review |
10/18/2023 |
Covered for some indications; investigative and therefore not covered for all other indications |
Deep brain stimulation: Refractory epilepsy is now considered a COVERED indication.
Responsive Cortical Stimulation: Remains unchanged.
NOTE: This coverage policy does not address behavioral health indications. Providers can contact Medica’s Provider Service Center for information on these indications.
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