The Medical Affairs Medical Policy Committee recently approved medical policies that will become effective April 1, 2018, unless specified below. Here are the significant policy change highlights. Additional updates and information will also be in the Spring Newsletter.
Medical Policy Highlights
Intraoperative Neurophysiologic Monitoring (IONM):
Prior authorization is no longer required effective 1/1/18.
MRA, MRS, PET Scan Reminder:
Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Check the prior authorization list on our website or customer services as listed on the member card for authorization process specific plan, benefit, and network status information
Magnetic Resonance Angiography (MRA): Verify health plan requirements for review of high tech imaging.
- Indications for MRA of neck includes ultrasound: For evaluation of carotid stenosis or occlusion, after an abnormal doppler ultrasound showing:
- Stenosis (≥ 60%) of the ICA or CCA or
- Reversal of flow in the carotid or vertebral artery or
- An inconclusive or technically inadequate study
- Indications for abdominal/pelvic MRA include ultrasound:
- To further evaluate hepatic vascular abnormalities (e.g. aneurysm, venous thrombosis, stenosis, or obstruction in the portal or hepatic veins (portal venous thrombosis or Budd-Chiari syndrome) or systemic veins, such as inferior vena cava, renal veins, or iliac veins after indeterminate or equivocal ultrasound.
- To evaluate hepatic vasculature prior to transjugular intrahepatic portosystemic shunt (TIPS) procedure after indeterminate or equivocal ultrasound.
Magnetic Resonance Spectroscopy (MRS):
- An indication was added for assessing progress after surgery.
- Added that MRS is considered unproven for evaluation of liver disease, Multiple Sclerosis or prostate cancer.
PET Scan:
- Reminder: Providers should specify the tracer being used. For some indications, the medical necessity of the PET/CT study is dependent upon the choice of radiopharmaceutical that will be used. Tracers such as Choline C-11, and Gallium Ga-68 dotatate (NETSPOT) require PA along with the PET request.
- PET scan with fluoclovine (Axumin) for recurrent prostate cancer is considered experimental, investigational, and unproven to affect health outcomes.
- An omission (serum thyroglobin level) in the criteria for thyroid cancer was corrected
- Thyroid cancer provided all the following are met:
a) Cell type is papillary, follicular, or Hurthle cell origin
b) Patient had thyroidectomy AND radioiodine ablation initially
c) Current whole body I-131 scan is negative
d) Current serum thyroglobulin > 10ng/mL
Reduction Mammoplasty for Symptomatic Macromastia: Many health plans exclude coverage for reduction mammoplasty except after mastectomy. We strongly recommend that you verify the Health Plan coverage before submitting prior authorization. Prior authorization is required, provided there is a benefit.
A requirement was added for mammogram: negative for cancer within the two years prior to the date of the planned reduction mammoplasty if member is ≥ 40 years of age.
Sleep Disorder Testing:
- Opioid use was added as a comorbidity and as a contra-indication to home study.
- Snoring alone is not considered an indication for sleep study.
- In-Lab studies require a Sleep Medicine Specialist order. For purpose of this policy, a sleep medicine specialist is one of the following:
- A Diplomate of the American Board of Sleep Medicine or
- A practitioner with certification in sleep medicine and one of the following Board-Certified Specialties: Pulmonologist, Otolaryngologist, Neurologist, Pediatrician, Internist, Family Medicine Physician, or Psychiatrist; or Nurse Practitioner or Physician Assistant working in collaboration with one of the listed specialists.
- Added an indication for in-lab study when a home sleep study is inconclusive, or is negative, provided that a sleep medicine specialist assesses and recommends the in-lab study.
Sleep Disorder Treatment Reminder:
A three-month trial of Positive Airway Pressure (e.g. CPAP) device is required to ensure compliance prior to purchase. The Health Plan does not allow for rental costs beyond the purchase price. Submit repair/replacement estimates for determination of device replacement versus repair of PAP devices.
- The indication for cognitive dysfunction attributed to sleep requires diagnosis using a clinically recognized cognitive assessment tool or current use of medication for dementia.
- California Verbal Learning Test
- Digit Span (from the Wechsler Adult Intelligence Scale-Revised)Informant Questionnaire on Cognitive Decline in the Elderly
- Mini-Mental State Examination (MMSE)
- Montreal Cognitive Assessment (MoCA) test
- Trails A or B
Varicose Vein Treatments: Varithena continues to be considered unproven and therefore not covered for sclerotherapy.
Reminder: When medical necessity criteria are met, one Treatment Day of Service for each leg is approved. A Treatment Day of Service can consist of treatment (e.g. ablations, stab phlebectomies) of as many veins as have been approved, done during that one date of service.
Clarified: Multiple dates of service in the office setting will be considered not medically necessary unless there is documentation of the medical need for repeated visits andrequires Medical Director review.
Non-Covered Services and Procedures (NCS) Highlights
We don't advise providers to submit prior authorization requests for items included in our Non-Covered Services and Procedures Medical Policy as they are not covered.
Note: Genetic tests and some other procedures require prior authorization. See the
Prior Authorization List on our website.
Removed from non-covered:
- Cartilage procedures for the knee do not require prior authorization effective 1/1/18 (e.g. Autologous chondrocyte Implantation; Meniscal allograft Transplant; Mosaicplasty; Microfracture; Osteochondral autograft transplant system (OATS) procedure; osteochondral allograft).
Note: Collagen meniscus implant (CMI, Menaflex), DeNovo NT Natural Tissue Graft, juvenile cartilage allograft implantation, and BioCartilage (Arthrex) continue to be considered unproven.
- IPEX genetic testing continues to require prior authorization with progress notes from the ordering provider.
- SAVI brachytherapy device requires prior authorization
Added to NCS:
- Eustachian Tube Balloon Dilation devices
- Color Hereditary Cancer Direct To Consumer test (Color Genomics)
- ThyraGenX and ThyraMir molecular diagnostic tests for Indeterminate FNA of Thyroid nodules.
Note: Prior authorization coverage indications are available for the Afirma Thyroid FNA Analysis
Items reconfirmed on the NCS:
- Confocal Endomicroscopy and Endocytoscopy
- Multi-condition gene panels
- Thread Carpel Tunnel Procedure
Disclaimer: Medical Policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in a policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact Customer Service as listed on the member card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. Medical Policies and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.
The complete library of our medical policies and the quarterly Medical Policy Update reports can be found on our website at
Aspirus Arise Medical Policies.
To obtain a referenced MCG guideline specific to your patient's review, contact Medical Affairs at 920-490-6901 or toll-free at 888-711-1444. For general medical policy, MCG requests, questions, or comments, contact us at
medical.policies@wpsic.com
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