Medical Policy Upcoming Updates

MCG Care Guidelines®

Medica may use tools developed by third parties, such as MCG Care Guidelines®, to assist in administering health benefits. Medica will begin using the 28th edition of MCG Care Guidelines on or after May 1, 2024.

Medica may use tools developed by third parties, such as Carelon, to assist in administering health benefits. Medica will begin using selected Carelon Guidelines on or after May 1, 2024 More detailed clinical policy information to be presented in an upcoming Connections newsletter.

For further information, please call the Medica Provider Literature Request Line toll­free at 1 (800) 458­5512, option 1, then option 8, ext. 2­2355.

Heart Transplantation (Adult and Pediatric) III-TRA.12

New indications for Heart Transplant Evaluation were added under medical necessity criteria 1.A.6.

• Cardiac amyloidosis, light chain (AL) or transthyretin (ATTR) type.

Glaucoma Surgical Treatments
Former title: Minimally Invasive Glaucoma Surgery (MIGS): Microstent Implantation

The following procedures have been added to the policy:

• Aqueous Shunt/Aqueous Drainage Devices (Ab externo approach):
  Insertion of aqueous shunts is not investigative when used according to U.S. Food and Drug Administration (FDA)-approved labeled indications and when ALL of the following criteria are met:

1. Treatment to reduce intraocular pressure (IOP) in adults with mild to moderate open-angle glaucoma.
2. Medical therapies have failed or are inappropriate to adequately control IOP.
3. At least one of the conventional surgical techniques has failed or are inappropriate (e.g., trabeculectomy, argon laser therapy or selective traculoplasty).

• Aqueous shunt devices are investigative for all other indications not listed above, including but not limited to:

1. Patients with glaucoma when IOP is adequately controlled by medications.
2. Ab externo shunts devices not approved by the FDA.
   • Reliable evidence does not permit conclusions concerning its effectiveness.

• Canaloplasty and Viscocanalostomy (Schlemm Canal Dilation):
  Canaloplasty (ab externo) is not investigative when ALL of the following criteria are met:

1. Treatment to reduce IOP in adults with chronic open-angle glaucoma.
2. Medical therapies have failed or are inappropriate to adequately control IOP.
3. The patient is not a candidate for any other IOP-lowering procedure (e.g., trabeculectomy or glaucoma drainage implant).

Canaloplasty (ab externo) is investigative for all other indications not listed above. Reliable evidence does not permit conclusions concerning its effectiveness.

Ab interno canaloplasty is investigative for all indications. Reliable evidence does not permit conclusions concerning its effectiveness.

Viscocanalostomy is investigative for all indications. Reliable evidence does not permit conclusions concerning its effectiveness.

Home Use of Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) for Sleep Apnea