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Utilization Management Policies


In this section you will find current versions of Medica utilization management (UM) policies.  Documents are developed using an evidence-based approach analyzing scientific literature and input from practicing physicians, Care Management staff and Medica Medical Directors.  Documents are updated as necessary.

 

A utilization management (UM) policy is a document containing clinical criteria used by Medica staff members for prior authorization, appropriateness of care determination and coverage.  The criteria are specific to the clinical characteristics of the population that will benefit from the treatment or technology.  The needs of individual patients who may not meet these criteria must be considered and are addressed by the process in the section labeled “Coverage Issues” on the UM policy.


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Important information – please read the Medical Policy Usage Notice before using these policies:
Medical Policy Usage Notice



Devices/Equipment 
 
  Bone Growth Stimulators (III-DEV.07) 

  Real-Time Continuous Glucose Monitoring Systems (III-DEV.16)

Diagnostics 
 
  Computed Tomography (CT) for Coronary Artery Calcium Scoring (CACS) (III-DIA.02) 

  Computed Tomography (CT) Coronary Angiography for Detection or Assessment of Coronary Artery Disease (CAD) (III-DIA.03)

Drugs
  Recombinant Coagulation Factor VIIa (NovoSeven®) Therapy (III-DRU.05)

Home Care 
 
  Extended Hours Home Care (Skilled Nursing Services) for Patients with Medically Complex or Medically Fragile Conditions (III-HOM.01)

  Home Health Care (III-HOM.02) 

  Personal Care Assistant (III-HOM.03) 

Inpatient 
 
  Inpatient (Hospital) Level of Care (III-INP.01) 

  Skilled Nursing Facility (III-INP.03) 

Medical/Surgical Treatments 
 
  Outpatient Enteral Nutrition Therapy (III-MED.03) 

  Cancer Clinical Trial Participation, Coverage of Routine Supplies and Services (III-MED.04) 

Surgical Procedures 
 
  Nasal Reconstructive Surgery - Rhinoplasty Procedure With or Without Septoplasty (III-SUR.04) 

  Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive Sleep Apnea/Hypopnea Syndrome (III-SUR.08) 

  Breast Implant Removal, Revision, or Reimplantation (III-SUR.11) 

  Abdominoplasty/Panniculectomy (III-SUR.13) 

  Sclerotherapy for Varicose Veins of the Leg (III-SUR.19) 

  Adult Gender Reassignment Surgery (III-SUR.20) 

  Thoracic Sympathectomy for Hyperhidrosis (III-SUR.25) 

  Endovenous Radiofrequency or Laser Ablation for Varicose Veins and Chronic Venous Insufficiency (III-SUR.26)

  Female Breast Reduction Surgery - Reduction Mammoplasty (III-SUR.27)

  Upper Eyelid Reconstructive Blepharoplasty (III.SUR.29)

  Gastrointestinal Surgery for Morbid Obesity (III-SUR.30)

Transplants - Organ & Bone Marrow 
 
  Bone Marrow or Stem Cell (Peripheral or Umbilical Cord Blood) Transplantation (III-TRA.01) 

  Liver Transplantation (III-TRA.02) 

  Kidney Transplantation (III-TRA.03) 

  Pancreas Transplantation (Pancreas Alone) (III-TRA.04) 

  Pancreas-Kidney (SPK, PAK) Transplantation (III-TRA.05) 

  Heart/Lung Transplantation (III-TRA.08) 

  Lung Transplantation (Single or Double) (III-TRA.11) 

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