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Bariatric Surgery (III-SUR.30)
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Utilization
Management
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Re-Reviewed |
01/01/2024 |
Medically necessary for a select population of patients
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Beginning on January 1, 2024, the Medica Bariatric Centers of Excellence program will sunset.
- Effective January 1, 2024, the Medica Bariatric Centers of Excellence program will no longer apply for Individual and Family Business (IFB) members.
- Beginning on January 1, 2024, for Medica’s employer groups (commercial members), the removal of a center of excellence requirement will be effective upon the group’s renewal date.
NOTE: For information on the current bariatric centers of excellence program, refer to the Medica Administrative Manual located at: https://partner.medica.com/providers/medica-administrative-manual/health-management-and-quality-improvement/centers-of-excellence.
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Facet Injections and Percutaneous Denervation Procedures (Radiofrequency and Laser Ablation) For Facet-Mediated Joint Pain (III-SUR.45) |
Utilization
Management |
Re-Reviewed |
11/15/2023 |
Medically necessary for a select population of patients |
Added note to the policy under Benefit Consideration 1. and under Medical Necessity Criteria I.
- Prior authorization is valid for two diagnostic injections at the same facet joint level(s) within six months of each other if medically necessity criteria are met.
Replaced the term “non operative” with “conservative” under medical necessity criteria I.B.2. and II.A. 2.
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Positron Emission Tomography (PET) Scan (III-DIA.12) |
Utilization
Management |
Re-Reviewed |
11/15/2023
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Medically necessary for a select population of patients
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Added note to the policy under Medical Necessity Criteria I.
- PET of prostate-specific membrane antigen (PSMA-PET)-positive lesions with Gallium Ga 68 gozetotide (e.g., Illuccix, Locametz) is considered medically necessary and standard of care in men with prostate cancer with suspected metastasis who are candidates for initial definitive therapy; or with suspected recurrence based on elevated serum PSA level.
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| Spinal Cord and Dorsal Root Ganglion Stimulation for Treatment of Pain (III.DEV.23) |
Utilization
Management |
Re-Reviewed |
01/15/2024 |
Medically necessary for a select population of patients |
Clarification made to indicate that prior authorization is not required for removal only, without intended revision or reoperation. |
| Eustachian Tube Balloon Dilation |
Coverage |
Re-Review |
11/15/2023 |
Covered for some indications; investigative and therefore not covered for all other indications |
New determination:
Eustachian tube balloon dilation (ETBD) is not investigative for the treatment of chronic obstructive Eustachian tube dysfunction (ETD) in adults (18 years and older) that is refractory to medical management.
Note: Eustachian tube balloon dilation remains investigative and therefore not covered for all other indications.
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