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May 2018 Medical Policy Updates
- Physical and occupational therapy – rehabilitative
- Cranial remolding helmet/band and protective helmet
- Cranial remolding helmet/band and protective helmet – Minnesota Health Care Programs
- DME Benefits Grid
- Medical necessity
- Speech therapy – rehabilitative
- Spinal cord stimulator
- Flutter device
- Investigational Services – list of noncovered services
- Chronic Pain – Multidisciplinary Intensive Day Treatment Programs
- Genetic testing
- Dietitian consultation
- Genetic Testing for Connective Tissue, Skeletal, and Integumentary Disorders
- Hospital Bed – Minnesota Health Care Programs
- Genetic Testing: Molecular Profiling Assays for Cancer Management
- Genetic Testing for Gastrointestinal Disorders
- Genetic Testing: Pharmacogenetics
- Genetic Testing: Coagulation Disorders and Cardiovascular Risk Assessments
- Bezlotoxumab (Zinplava)
- Ambulance Transportation Services-Minnesota Health Care Programs
- Court-ordered care – mental health
- Sympathectomy (Thoracic) for the Treatment of Primary Hyperhidrosis
- Genetic Testing: Neurological, Developmental, and Sensory Disorders and Congenital Anomalies (Effective May 1, 2018)
- Nutritional Support
- Nutrition (medical) therapy – Minnesota Health Care Programs
- Rhinoplasty & septorhinoplasty
- Reconstructive surgery
- Circumcision – Minnesota Health Care Programs
- Proton beam radiation therapy
- Health Education
- Speech therapy – habilitative
- Prosthesis-Lower Limb
- Pressure reducing support surfaces
- Anesthesia services for routine gastrointestinal endoscopic procedures
- Physical & occupational therapy – habilitative
- Chimeric antigen receptor/genetically engineered T-cell receptor (CAR-T) therapy – Effective 5/1/2018
- Neuromuscular electrical stimulator (NMES)
May 2018 Pharmacy Policy Updates
Changes for Commercial and State Programs include several updates for opioid medications, starting July 2, 2018:
- The first opioid prescription for members will be limited to a 7-day supply. Members starting therapy with opioid medications are also limited to a 14-day supply per episode. This limit is intended to allow one refill. Prior authorization is required for longer therapy.
- The cumulative daily dose of opioids will be limited. This expands our current dose limit to include all opioid prescriptions. Current limits are for individual drugs and allow multiple prescriptions. This expansion “rolls up” the dose limit to include all opioid medications. Prior authorization is required when the cumulative opioid dose is equal or greater than 90 morphine-equivalents per day.
- Long-acting opioids will require prior authorization for members with new prescriptions.
- Codeine and tramadol is non-formulary for younger children <= age 11.
- Codeine cough syrups are non-formulary for younger children <= age 17.
Policy Alerts monitors Commercial and Medicare medical policies for changes. While medical Insurance carriers typically update medical policies annually, there are many reasons why they might review or update a policy. When reviews occur out of cycle they often go unnoticed. Policy Alerts keeps you updated when Payers make coverage changes to medical policies affecting your business.
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Health economic and reimbursement information provided by Policy Alerts is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. All product and company names are trademarks™ or registered® trademarks of their respective holders. Use of them does not imply any affiliation with or endorsement by them. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice.