Providers

Medical Policy Upcoming Updates

Notification Date: March 20, 2024

Utilization Management Policies	Policy Type	Status	Effective Date	Determination	Summary of Changes
Carelon Guidelines for Cardiology Procedures Services include: Cardiac Resynchronization Therapy Diagnostic Coronary Angiography Endovascular Revascularization Imaging of the Heart Implantable Cardioverter Defibrillators Percutaneous Implantable Pacemakers Vascular Imaging	Utilization Management	New*	On or after 05/01/2024	Medically necessary for a select population of patients	*Replaces former Medica coverage policies: Coronary Artery Calcium Scoring (CACS) Coronary Computed Tomography Angiography (CCTA) for Coronary Artery Evaluation
Carelon Guidelines for Musculoskeletal Procedures, Interventional Pain Management Services include: Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks Paravertebral Facet Injection/Medial Branch Nerve Block/Neurolysis Regional Sympathetic Nerve Block Sacroiliac Joint Injection Spinal Cord and Nerve Root Stimulators For further information, please call the Medica Provider Literature Request Line tollfree at 1 (800) 458-5512, option 1, then option 8, ext. 22355.	Utilization Management	New*	On or after 05/01/2024	Medically necessary for a select population of patients	*Replaces former Medica Utilization Management (UM) policies: Facet Injections and Percutaneous Denervation Procedures (Radiofrequency and Laser Ablation) for Facet-Mediated Joint Pain Spinal Cord and Dorsal Root Ganglion Stimulation for Treatment of Pain
Carelon Guidelines for Musculoskeletal Procedures, (Large) Joint Surgery Services include: Arthroplasty – Hip, Knee, & Shoulder Arthroscopy and Open Procedures – Hip, Knee, & Shoulder Autologous Chondrocyte Implantation of the Knee For further information, please call the Medica Provider Literature Request Line tollfree at 1 (800) 458-5512, option 1, then option 8, ext. 22355.	Utilization Management	*New	On or after 05/01/2024	Medically necessary for a select population of patients	*Replaces former Medica Utilization Management (UM) policies: Hip Arthroplasty – currently limited membership Knee Arthroplasty – currently limited membership Autologous Chondrocyte Implantation of the Knee
Carelon Guidelines for Musculoskeletal Procedures, Spine Services include: Cervical Spine Decompression With/Without Fusion Disc Arthroplasty Lumbar Spine Discectomy, Foraminotomy, & Laminotomy Laminectomy Fusion & Treatment of Spinal Deformity Disc Arthroplasty Posterolateral or Intertransverse Lumbar Fusion (autograft not feasible) Additional Service include: Sacroiliac Joint Fusion (Percutaneous/ Minimally Invasive Techniques) Electrical Bone Growth Stimulation, Noninvasive Vertebroplasty/ Kyphoplasty Bone Graft Substitutes and Bone Morphogenic Proteins Anterior Lumbar Interbody Fusion (ALIF) or Laterial Lumber Interbody Fusion (i.e., XLIF) For further information, please call the Medica Provider Literature Request Line tollfree at 1 (800) 458-5512, option 1, then option 8, ext. 22355.	Utilization Management	*New	On or after 05/01/2024	Medically necessary for a select population of patients	Replaces former Medica Utilization Management (UM) policy(ies): Electrical Bone Growth Stimulators for spinal applications. Cervical Spine Surgeries, including disc arthroplasty and bone graft substitutes Lumbar Spine Surgeries, including disc arthroplasty and bone graft substitutes Sacroiliac Joint Fusion, minimally invasive Replaces former Medica coverage policies: Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty Recombinant Human Bone Morphogenic Protein-2 (rhBMP-2)/InFUSE and Allogeneic Morphogenic Protein (e.g., OsteoAMP™) Access Techniques for Lumbar Interbody Fusion (e.g., ALIF, XLIF, posterolateral/ intertansverse lumbar fusion) Minced Cartilage (Allograft) Repair for Articular Cartilage Defects
Carelon Guidelines for Advanced Radiology Services Services included: Selected applications of the following: Ultrasound Computed tomography (CT) Low-dose CT Magnetic resonance imaging (MRI) Functional MRI Magnetic resonance spectroscopy Magnetic resonance cholangiopancreatography (MRCP) Positron emission tomography (PET) CT or MR arthrography Low-field MRI MR-guided Procedures Nuclear Medicine Imaging Oncologic Imaging SPECT Imaging Vascular Imaging For further information, please call the Medica Provider Literature Request Line tollfree at 1 (800) 458-5512, option 1, then option 8, ext. 22355.	Utilization Management	*New	On or after 05/01/2024	Medically necessary for a select population of patients	Replaces former Medica Utilization Management (UM) policy: Positron Emission Tomography (PET) Scan Replaces former Medica coverage policy(ies): Breast Magnetic Imaging CT Colonography, MR Colonography, and CT Upper GI Endoscopy MRI Elastography for Evaluation of Hepatic Fibrosis Functional Magnetic Resonance Imaging Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening Magnetic Resonance Spectroscopy (MRS)
Coverage Policies	Policy Type	Status	Effective Date	Determination	Summary of Changes
Noncontact Near Infrared Spectroscopy	Coverage	New	05/20/2024	Investigative and therefore not covered	Investigative. Reliable evidence does not permit conclusion concerning its effectiveness.