Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.

All policies found in the Coordinated Care Clinical Policy Manual apply to Coordinated Care members. Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a “Centene” heading. Coordinated Care utilizes InterQual^® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Coordinated Care clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual^® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Coordinated Care. In addition, Coordinated Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual^®criteria is payable by Coordinated Care.

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Coordinated Care Payment Policy Manual apply with respect to Coordinated Care members. Policies in the Coordinated Care Payment Policy Manual may have either a Coordinated Care or a “Centene” heading. In addition, Coordinated Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Coordinated Care.

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Ambetter Payment Policies

3-Day Payment Window (PDF) (CC.PP.500)
30-Day Readmission (PDF) (CC.PP.501)
Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
Assistant Surgeon (PDF) (CC.PP.029)
Bilateral Procedures (PDF) (CC.PP.037)
Cerumen Removal (PDF) (CC.PP.008)
Clean Claims (PDF) (CC.PP.021)
Coding Overview (PDF) (CC.PP.011)
Cosmetic Procedures (PDF) (CC.PP.024)
Distinct Procedural Modifiers (PDF) (CC.PP.020)
Duplicate Primary Code Billing (PDF) (CC.PP.044)
E&M Medical Decision-Making (PDF) (CC.PP.051)
EM Bundling Edits (PDF) (CC.PP.010)
Global Maternity Billing (PDF) (CC.PP.016)
Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)

Inpatient Consultation (PDF) (CC.PP.038)
Inpatient Only Procedures (PDF) (CC.PP.018)
IV Hydration (PDF) (CC.PP.012)
Leveling of Emergency Room Services (PDF) (CC.PP.053)
Maximum Units (PDF) (CC.PP.007)
Moderate Conscious Sedation (PDF) (CC.PP.015)
Modifier -25 clinical validation (PDF) (CC.PP.013)
Modifier -59 clinical validation (PDF) (CC.PP.014)
Modifier DOS Validation (PDF) (CC.PP.034)
Modifier to Procedure Code Validation (PDF) (CC.PP.028)
Multiple CPT Code Replacement (PDF) (CC.PP.033)
Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
Payment Reduction (MDCR)NCCI Unbundling (PDF) (CC.PP.031)
Never Paid Events (PDF) (CC.PP.017)
New Patient (PDF) (CC.PP.036)
Outpatient Consultation (PDF) (CC.PP.039)
Pelvic and Transabdominal US (PDF) (CC.PP.061)
Physician's Consultation Services (PDF) (CC.PP.054)
Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
Place of Service Mismatch (PDF) (CC.PP.063)
Post-Operative Visits (PDF) (CC.PP.042)
Pre-Operative Visits (PDF) (CC.PP.041)
Professional Component (PDF) (CC.PP.027)
Pulse Oximetry (PDF) (CC.PP.025)

Renal Hemodialysis (PDF) (CC.PP.067)
Robotic Surgery (PDF) (CC.PP.050)
Same Day Visits (PDF) (CC.PP.040)
Skilled Nursing Facility Leveling (PDF) (CC.PP.206)
Sleep Studies Place of Services (PDF) (CC.PP.035)
Status "B" Bundled Services (PDF) (CC.PP.046)
Status P Bundled Services (PDF) (CC.PP.049)
Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
Transgender Related Services (PDF) (CC.PP.047)
Unbundled Surgical Procedures (PDF) (CC.PP.045)
Unbundled Professional Services (PDF) (CC.PP.043)
Unlisted Procedure Codes (PDF) (CC.PP.009)
Wheelchair Accessories (PDF) (CC.PP.502)

Medicaid Payment Policies

1-Day Payment Window (PDF) (WA.PP.500)
Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
Assistant Surgeon (PDF) (CC.PP.029)
Bilateral Procedures (PDF) (CC.PP.037)
Cerumen Removal (PDF) (CC.PP.008)
Clean Claims (PDF) (CC.PP.021)
Coding Overview (PDF) (CC.PP.011)
Cosmetic Procedures (PDF) (CC.PP.024)
Distinct Procedural Modifiers (PDF) (CC.PP.020)
Duplicate Primary Code Billing (PDF) (CC.PP.044)
E&M Medical Decision-Making (PDF) (CC.PP.051)
EM Bundling Edits (PDF) (CC.PP.010)
Global Maternity Billing (PDF) (CC.PP.016)
Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)

Inpatient Consultation (PDF) (CC.PP.038)
Inpatient Only Procedures (PDF) (CC.PP.018)
IV Hydration (PDF) (CC.PP.012)
Leveling of Emergency Room Services (PDF) (CC.PP.053)
Maximum Units (PDF) (CC.PP.007)
Moderate Conscious Sedation (PDF) (CC.PP.015)
Modifier -25 clinical validation (PDF) (CC.PP.013)
Modifier -59 clinical validation (PDF) (CC.PP.014)
Modifier DOS Validation (PDF) (CC.PP.034)
Modifier to Procedure Code Validation (PDF) (CC.PP.028)
Multiple CPT Code Replacement (PDF) (CC.PP.033)
Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
NCCI Unbundling (PDF) (CC.PP.031)
Never Paid Events (PDF) (CC.PP.017)
New Patient (PDF) (CC.PP.036)
Outpatient Consultation (PDF) (CC.PP.039)
Pelvic and Transabdominal US (PDF) (CC.PP.061)
Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
Place of Service Mismatch (PDF) (CC.PP.063)
Post-Operative Visits (PDF) (CC.PP.042)
Pre-Operative Visits (PDF) (CC.PP.041)
Professional Component (PDF) (CC.PP.027)
Provider Preventable Readmissions (PDF) (WA.PP.501)
Pulse Oximetry (PDF) (CC.PP.025)

Renal Hemodialysis (PDF) (CC.PP.067)
Same Day Visits (PDF) (CC.PP.040)
Sepsis Diagnosis (PDF) (CP.PP.073)
Skilled Nursing Facility Leveling (PDF) (CC.PP.206)
Sleep Studies Place of Services (PDF) (CC.PP.035)
Status "B" Bundled Services (PDF) (CC.PP.046)
Status P Bundled Services (PDF) (CC.PP.049)
Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
Transgender Related Services (PDF) (CC.PP.047)
Unbundled Surgical Procedures (PDF) (CC.PP.045)
Unbundled Professional Services (PDF) (CC.PP.043)
Unlisted Procedure Codes (PDF) (CC.PP.009)
Wheelchair Accessories (PDF) (CC.PP.502)

Policy Revision Summary (Clinical)

Policy Number	Policy Title	Revision Notes
CP.MP.186	Burn Surgery	Annual review. Added criteria II.C. that burn must be deep partial-thickness or full-thickness. Added used according to FDA indications to II.D.3. References reviewed and updated. Reviewed by internal specialist

No revisions this month.

Policy Number	Policy Title	Revision Notes
CP.MP.107	Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines	Annual review. Updated description with no impact on criteria. Changed Orthopedic Care Equipment to Prosthetics and Orthotics Equipment. Table of contents updated. Retired pneumatic compression device criteria (E0675) for IQ. Updated "Cabinet style..." note under Ultraviolet panel lights. Under “Other Equipment” added code E0240 to “Specialized supply or equipment” section and added section, criteria, and coding (E1399, A9900) for “ROMTech device”. Reformatted Foot orthotics, custom criteria in “Prosthetics and Orthotics Equipment” section. Added criteria for Prosthetics and additions: Upper Extremity and Myoelectric in “Prosthetics and Orthotics Equipment” section. Added section, criteria, and coding (L8701, L8702) for “MyoPro Orthosis” under “Prosthetics and Orthotics Equipment”. Removed code L8035 from "other surgical supplies" and added section and criteria for "Breast Prosthetics" (L8030, L8035). Removed pediatric wheelchair codes (E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1037) from manual wheelchair section. References reviewed, updated, and reformatted. Internal specialist review.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.525	Catheter Ablation for Supraventricular Tachyarrhythmia	Annual review. References updated. Use of InterQual guidelines removed and policy updated to align with current HCA billing guidelines. CPT 93654 removed per billing guidelines.
WA.CP.MP.500	Mandibular Advancement Devices	Annual review. Reference reviewed
CP.MP.38	Ultrasound in Pregnancy	Updated Table 4 (Diagnosis Codes that Support Medical Necessity for First Detailed Fetal Ultrasound) to include the following codes and code ranges: A92.5, D56.0 through D56.9, D57.00 through D57.819, M32.0 through M32.9, M33.00 through M33.99, M34.0 through M34.9, M35.00 through M35.09, M35.1, M35.5, M35.8 through M35.9, M36.0, M36.8, N18.9, O00.01, O00.111 through O00.119, O00.211 through O00.219, O00.81, O00.91, O09.892 through O09.93, O10.012 through O10.019, O10.112 through O10.119, O10.212 through O10.219, O10.312 through O10.319, O10.412 through O10.419, O10.912 through O10.919, O11.2 through O11.3, O12.00, O12.02 through O12.03, O12.10, O12.12 through O12.13, O12.20, O12.22 through O12.23, O13.2 through O13.3, O13.5 through O13.9, O14.00, O14.02 through O14.03, O14.10, O14.12 through O14.13, O14.20, O14.22 through O14.23, O14.90, O14.92 through O14.93, O15.00, O15.02 through O15.03, O15.9, O16.2 through O16.3, O16.9, O22.50, O22.52 through O22.53, O23.00, O23.02 through O23.03, O24.414 through O24.415, O26.20, O26.22 through O26.23, O26.30, O26.32 through O26.33, O26.40, O26.42 through O26.43, O26.612 through O26.619, O26.832 through O26.839, O26.843 through O26.849, O26.852 through O26.859, O26.872 through O26.879, O28.5, O28.8 through O28.9, O29.012 through O29.019, O29.022 through O29.029, O29.112 through O29.119, O29.122 through O29.129, O29.212 through O29.219, O29.292 through O29.299, O30.90, O30.92 through O30.93, O31.30X1 through O31.30X9, O31.32X0 through O31.32X9, O31.33X0 through O31.33X9, O31.8X20 through O31.8X29, O31.8X30 through O31.8X39, O31.8X90 through O31.8X99, O32.0XX3 through O32.0XX9, O32.1XX1, O32.2XX1, O32.3XX1, O32.6XX1, O32.8XX1, O32.9XX1, O34.02 through O34.03, O34.30, O34.32 through O34.33, O36.20X0 through O36.20X9, O36.22X0 through O36.22X9, O36.23X0 through O36.23X9, O36.4XX0 through O36.4XX9, O36.60X0 through O36.60X9, O36.62X0 through O36.62X9, O36.63X0 through O36.63X9, O36.70X0 through O36.70X9, O36.72X0 through O36.72X9, O36.73X0 through O36.73X9, O36.80X0 through O36.80X9, O36.8130 through O36.8139, O36.8190 through O36.8199, O36.8220 through O36.8229, O36.8230 through O36.8239, O36.8290 through O36.8299, O36.8320 through O36.8329, O36.8330 through O36.8339, O36.8390 through O36.8399, O41.8X20 through O41.8X29, O41.8X30 through O41.8X39, O42.00, O42.012 through O42.02, O42.10, O42.112 through O42.119, O42.912 through O42.919, O43.012 through O43.019, O43.022 through O43.029, O43.112 through O43.119, O43.122 through O43.129, O43.212 through O43.219, O43.222 through O43.229, O43.232 through O43.239, O43.812 through O43.819, O44.00, O44.02 through O44.03, O44.10, O44.12 through O44.13, O44.20, O44.22 through O44.23, O44.30, O44.32 through O44.33, O44.40, O44.42 through O44.43, O44.50, O44.52 through O44.53, O45.002 through O45.009, O45.012 through O45.019, O45.022 through O45.029, O45.092 through O45.099, O46.002 through O46.009, O46.012 through O46.019, O46.022 through O46.029, O46.092 through O46.099, O46.8X2 through O46.8X9, O46.90, O46.92 through O46.93, O48.0 through O48.1, O60.00, O60.02 through O60.03, O60.10X0 through O60.10X9, O60.12X0 through O60.12X9, O60.13X0 through O60.13X9, O60.14X0 through O60.14X9, O98.012 through O98.019, O98.112 through O98.119, O98.919, O99.280, O99.282 through O99.283, O99.330, O99.332 through O99.333, O99.512 through O99.519, O9A.112 through O9A.119, U07.1, Z20.821, Z20.822, and Z21. References reviewed and updated. Internal specialist reviewed.
WA.CP.MP.70	Proton and Neutron Beam Therapies	Annual Review. Updated criteria I.G. to, unresectable benign or malignant central nervous system tumors to include but not limited to primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations. Added criteria I.H., Pituitary neoplasms. Restructured and added section A. and B. to criteria II. References reviewed and updated.
CP.MP.142	Urinary Incontinence Devices and Treatments	Annual review. Added note under Description to refer to CP.MP.133 Posterior Tibial Nerve Stimulation for Voiding Dysfunction for posterior tibial nerve stimulation treatment for urinary incontinence. Updated criteria I.B. from, urinary retention have been present for at least 12 months, to, urinary retention have been present for at least 6 months. Minor rewording in Criteria with no clinical significance. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.
CP.MP.151	Transcatheter Closure of Patent Foramen Ovale	Annual review. Minor rewording in Background section with no impact on criteria. References reviewed and updated.
CP.MP.180	Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea	Annual review. Edits were made to criteria to align with the FDA updates issued June 8, 2023, for the Inspire Upper Airway Stimulation System. Updated criteria B. from "Age > 22 years" to "BMI ≤ 40 kg/m2"; changed C. from "BMI < 35 kg/m2" to "One of the following:" adding C.1 to C.3, indicating the updated age ranges and associated criteria. Contraindications were updated to I.D.a to I.D.g. The original criteria points I.E to I.I were removed. Background updated with no clinical significance. References reviewed and updated. Reviewed by external specialist.
CP.MP.181	Polymerase Chain Reaction Respiratory Viral Panel Testing	Updated description of Table 2 as Table 6 was removed. Added ICD-10 codes J15.61 and J15.69 to Table 4. Added ICD-10 codes J44.81 and J44.89 to Table 5. Deleted Table 6 from policy.
CP.MP.206	Skilled Nursing Facility Leveling	Retire
CP.MP.247	Transplant Service Documentation Requirements	Annual review. Minor rewording throughout Criteria with no impact on criteria. Criteria I.B.2. and Criteria I.B.3. updated to say “provider” instead of “physician.” Criteria I.B.5. updated to include documentation. C-peptide removed from Criteria I.B.5.e. Criteria I.B.5.f. updated to remove “no specific additional testing” and added documentation of failed total parenteral nutrition. Criteria I.B.10.g. updated to say rapid plasma reagin. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist.

Policy Number	Policy Title	Revision Notes
CP.BH.124	ADHD Assessment and Treatment	Annual Review. Changed reference number for the policy from “CP.MP.124” to “CP.BH.124”. Added the following statement to section I and II: “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. In criteria point II. A. 1. replaced “Actometer” with “Actigraphy”. In criteria point I.A. 2. added “Acoustic reflex testing”. In criteria point I.A.12: removed Magnetic resonance imaging, brain functional MRI as it is already captured in I.A.16: under MRI. Removed I.A.14. “Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping”. In criteria point I.A.16. added “brain mapping” to the brain imaging section. In Criteria point I.A. 24 removed “Triiodothyronine T3 levels in the blood” and reworded as “Measures of thyroid hormones”. Removed II.A.18 “neuropsychological testing from the insufficient evidence list”, with corresponding codes also removed. In criteria point II. B.2., added “Application of modality (e.g. hot or cold packs, traction, mechanical, electrical stimulation (unattended), vasopneumatic devices, paraffin bath, whirlpool, diathermy (eg, microwave), infrared, ultraviolet, electrical stimulation (manual), iontophoresis, contrast baths, ultrasound, hubbard tank)”. Removed education interventions from criteria point II.B.19. and added policy statement III. “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that interventions that are strictly educational in nature (e.g., classroom environmental manipulation, academic skills training training) are not medically necessary as they are not considered medical interventions”. Added criteria point II.B.19. “EndeavorRx®”. Replaced instances of dashes (-) with the word “to” within the CPT description code list. Coding reviewed. Added the following codes and related indications as not medically necessary when billed with a sole diagnosis of ADHD: 70496, 70554, 70555, 78610, 84436, 84437, 84439, 84442, 84443, 84445, 84478, 84479, 84481, 92568, 92569, 92570, 95954, 96020, 96902, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036. References reviewed and updated. Policy reviewed by internal specialist. Policy reviewed by an external specialist.
CP.MP.108	Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia	Annual review. Added note at end of Description regarding criteria related to Zynteglo. Criterion I.C.3. removed related to lack of adequate support system. Expanded Criteria II.A. and Criteria II.B. to specify not in the context of gene therapy. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal and external specialist.
CP.MP.31	Cosmetic and Reconstructive Procedures	Annual review. Minor edits to I.A.4.b with no clinical significance. Updated pharmacy policies for Serostim (somatropin) in note. Removed CPT code 11310. References reviewed and updated. Reviewed by internal specialist.
CP.MP.101	Donor lymphocyte infusion	Annual review. Minor rewording in Description with no impact on criteria. Criteria II.B. updated to state grade 2 or higher acute graft versus host disease (GvHD). Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. Updated policy description. Updated all criteria in statements I. and II.
CP.MP.209	GI Pathogen Nucleic Acid Detection Panel Testing	Annual review completed. Replaced previous criteria with current in sections I. and II. and removed section III. Background updated with no impact to criteria. Reworded some extraneous language with no clinical significance. Moved code 87506 from Table 1 to Table 2. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 to include ICD-10 diagnosis codes which support medical necessity. References reviewed and updated.
CP.MP.250	Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy	New policy
CP.MP.123	Laser Therapy for Skin Conditions	Annual review. Added medically necessary indications I.C. atopic dermatitis and I.D. cutaneous T-cell lymphoma. Removed II.B. atopic dermatitis from insufficient evidence section. Added codes L20.81, L20.82, L20.89, C84.00 through C84.09, and C84.10 through C84.19 to table of ICD-10-CM diagnosis codes that support coverage criteria. References reviewed and updated.
CP.MP.57	Lung Transplantation	Revised adult and pediatric criteria to align with ISHLT 2021 consensus document. References reviewed and updated.
CP.MP.202	Orthognathic Surgery	Annual review. Added CPT codes 21248 and 21249. References reviewed and updated.
CP.MP.109	Panniculectomy	Annual Review. Combined criteria I.D. and E. into criteria I.D.1. and 2. Removed CPT code 00802 from policy. References reviewed and updated. Reviewed by external specialist.
CP.MP.138	Pediatric Heart Transplant	Annual review. Added additional criteria I.A.1.b.vi.a., pulmonary hypertension and a potential risk of developing fixed, irreversible elevation of pulmonary vascular resistance that could preclude orthotopic heart transplantation in the future. Updated I.D.1. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2. Expanded I.D.2. with qualifying criteria for members who are HIV positive. Updated I.D.21. to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background reviewed and updated. References reviewed and updated. Reviewed by external specialist.
CP.MP.246	Pediatric Kidney Transplant	Annual review. Description updated to include source information for policy criteria. Updated Criteria I.A.1. from glomerular filtration rate (GFR) ≤ 15 mL/min/1.73m2 to GFR < 15 mL/min/1.73m2 to align with Kidney Disease: Improving Global Outcomes (KDIGO) guidance and Organ Procurement Transplant Network (OPTN) guidance. Updated Criteria I.A.2. to include members/enrollees with CKD stage 4 with GFR < 30 mL/min/1.73m2 who are expected to reach end stage renal disease (ESRD) to align with KDIGO guidance and OPTN guidance. Updated contraindications in I.B. consistent with KDIGO guidelines. References reviewed and updated.
CP.MP.150	Phototherapy for Neonatal Hyperbilirubinemia	Annual review. Reworded criteria I.C. for inclusive language. References reviewed and updated.
CP.MP.181	Polymerase Chain Reaction Respiratory Viral Panel Testing	Annual review. Replaced prior criteria in sections I. and II. with current criteria. Removed policy statement III. Background updated with no impact on criteria. Updated verbiage in Table 2 description to include new diagnosis code requirements. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 which include ICD-10 diagnosis codes. References reviewed and updated.
CP.MP.98	Urodynamic Testing	Annual review. Added criteria I.D.5. for 4.5. Prostate nodule, asymmetry or other suspicion of prostate cancer. Moved N40.3 from ICD-10 Table 2 to ICD-10 Table 1. References reviewed and updated.
WA.CP.MP.527	Vitamin D Testing	Annual review. Updated references.

Policy Number	Policy Title	Revision Notes
CP.MP.129	Fetal Surgery in Utero for Prenatally Diagnosed Malformations	Annual review. Criteria I.F.3. updated to include confirmation on fetal MRI. Added clarifying language to Criteria I.F.4. Background updated with no impact on criteria. Added CPT code 59072. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.50	Drugs of Abuse: Definitive Testing	Annual Review. Added an example of synthetic cannabinoids to I.A.1., drugs for which presumptive testing is not reliable. Coding reviewed. Replaced all instances of dashes (-) with the word “to” within the CPT and HCPCS codes. Added 0082U to the CPT codes that do not support coverage criteria list. Removed table of ICD-10 CM codes. Updated background information to include information regarding American Society of Addiction Medicine (ASAM). Other minor wording changes made to background with no clinical significance. References reviewed and updated. Policy reviewed by an internal specialist. Removed deleted codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U from table of CPT codes that do not support coverage criteria.

Policy Number

Policy Title

Revision Notes

CP.MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Annual review. Criteria I.F.3. updated to include confirmation on fetal MRI. Added clarifying language to Criteria I.F.4. Background updated with no impact on criteria. Added CPT code 59072. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist.

WA.CP.MP.50

Drugs of Abuse: Definitive Testing

Annual Review. Added an example of synthetic cannabinoids to I.A.1., drugs for which presumptive testing is not reliable. Coding reviewed. Replaced all instances of dashes (-) with the word “to” within the CPT and HCPCS codes. Added 0082U to the CPT codes that do not support coverage criteria list. Removed table of ICD-10 CM codes. Updated background information to include information regarding American Society of Addiction Medicine (ASAM). Other minor wording changes made to background with no clinical significance. References reviewed and updated. Policy reviewed by an internal specialist.

Removed deleted codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U from table of CPT codes that do not support coverage criteria.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.519	Administrative Days	Changed “denial” to “discharge” in Note.
CP.MP.100	Allergy Testing and Therapy	Annual review. Updated description and background with no clinical significance. References reviewed and updated. Coding reviewed. Reviewed by external specialist.
WA.CP.MP.37	Bariatric Surgery	Modified section II.B. to allow family practice in addition to internal medicine physicians conduct pre-operative assessments.
CP.MP.156	Cardiac Biomarker Testing	Annual review. Background updated with no impact on criteria. Coding reviewed. References reviewed and updated. Reviewed by external specialist.
CP.MP.105	Digital EEG Spike Analysis	Annual review. Minor rewording in Criteria I. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist
CP.MP.155	EEG in the Evaluation of Headache	Annual review. Edits to policy name in header. Background updated with no clinical significance. References reviewed and updated.
CP.MP.134	Evoked Potential Testing	Annual review. References reviewed and updated. Reviewed by external specialist.
CP.MP.153	Helicobacter Pylori Serology Testing	Annual review. References reviewed and updated. Reviewed by external specialist.
CP.MP.113	Holter Monitors	Annual review. Criteria I. updated to specify a Food and Drug Administration (FDA) approved Holter monitor device, and age in Criteria I. changed from > 18 years old to ≥ 18 years old. Criteria I.D. updated to include arrhythmogenic right ventricular cardiomyopathy (ARVC), hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy, or a first degree relative with HCM. Added Criteria I.O. for baseline or periodic screening for those with adult congenital heart disease. Criteria II. updated to specify an FDA approved Holter monitor device, and age in Criteria II. changed from ≤ 18 years old to < 18 years old. Minor rewording in background with no impact on criteria. References reviewed and updated. Reviewed by internal specialist.
CP.MP.102	Pancreas Transplantation	Added note to policy to see CP.MP.250 Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy for criteria related to Lantidra.
CP.MP.181	Polymerase Chain Reaction Respiratory Viral Panel Testing	Removed note after the policy description referring to CP.CPC.03 Preventive Health and Clinical Practice Guidelines for PCR testing for COVID-19. Added 0202U, 0223U and 0225U to CPT table 2.
CP.MP.154	Thyroid Hormones and Insulin Testing in Pediatrics	Annual review. Edits to title in header. References reviewed and updated. Reviewed by external specialist.
CP.MP.38	Ultrasound in Pregnancy	Annual review. Minor rewording in Description, in Table 1 under Criteria IV., and in Criteria V. Verbiage added to indicate list is not all inclusive under Classifications of fetal ultrasounds Section I. and Section II. Background updated with no impact on criteria. Updated Table 4 Coding description. The following retired code ranges were removed: O35.0XX0 through O35.0XX9 and O35.1XX0 through O35.1XX9. The following code ranges were added: O35.00X0 through O35.00X9, O35.01X0 through O35.01X9, O35.02X0 through O35.02X9, O35.03X0 through O35.03X9, O35.04X0 through O35.04X9, O35.05X0 through O35.05X9, O35.06X0 through O35.06X9, O35.07X0 through O35.07X9, O35.08X0 through O35.08X9, O35.09X0 through O35.09X9, O35.10X0 through O35.10X9, O35.11X0 through O35.11X9, O35.12X0 through O35.12X9, O35.13X0 through O35.13X9, O35.14X0 through O35.14X9, O35.15X0 through O35.15X9, O35.19X0 through O35.19X9, O35.AXX0 through O35.AXX9, O35.BXX0 through O35.BXX9, O35.CXX0 through O35.CXX9, O35.DXX0 through O35.DXX9, O35.EXX0 through O35.EXX9, O35.FXX0 through O35.FXX9, O35.GXX0 through O35.GXX9, O35.HXX0 through O35.HXX9. References reviewed and updated.

Policy Number	Policy Title	Revision Notes
CP.BH.500	Behavioral Health Treatment Documentation Requirements	Annual Review. No changes made to criteria. References reviewed and updated.
WA.CP.MP.516	Carotid Artery Stending	Annual review. References updated. Removed InterQual guidelines and edited section I. to reflect current HTA criteria.
CP.MP.203	Diaphragmatic/Phrenic Nerve Stimulation	Annual review. Product name updates in criteria II. and in background with no clinical significance. References reviewed and updated.
CP.MP.248	Facility Based Sleep Studies for Obstructive Sleep Apnea	Corrected I.B.8.a.i. to require either continuous, chronic nocturnal oxygen use or moderate to severe pulmonary function impairment instead of both.
WA.CP.MP.69	Intensity Modulated Radiation Therapy	Annual review. References updated.
CP.MP.167	Intradiscal Steroid Injections for Pain Management	Annual review. References reviewed and updated.
CP.MP.170	Nerve Blocks for Pain Management	Annual review completed. Examples added to I.B.1. and III.B.2. Minor rewording with no clinical significance. Background updated. Added CPT codes 64628. ICD-10 Diagnosis code table removed. References reviewed and updated. External specialist reviewed.
WA.CP.MP.507	Oral Enteral Nutrition	Added Exception to the Rule comment for adults requesting PKU formula
CP.MP.194	Osteogenic Stimulation	Annual review completed. Background and references reviewed and updated.
CP.MP.51	Reduction Mammoplasty and Gynecomastia Surgery	Annual review. Criteria I.A.1. updated for criteria for members/enrollees ≥ 18 years of age and members/enrollees < 18 years of age. Criteria I.A.2. updated to include note regarding medical director review on case-by-case basis when weight of tissue to be resected is less than the 22nd percentile minimum based on the Schnur Sliding Scale. Criteria I.A.3.b. updated to include pain in arm. Criteria II.A.1. updated to align with ASPS guidance regarding length of time gynecomastia persists in adolescents < 18 years. Criteria II.B.3. updated to align with ASPS guidance for length of time gynecomastia persists in adults ≥ 18 years. Removed Criteria II.B.6. regarding malignancy being ruled out. Minor rewording in background with no impact on criteria. ICD-10 codes removed. References reviewed and updated. Reviewed by internal specialist and external specialist.
CP.MP.182	Short Inpatient Hospital Stay	Annual review completed. Updated hyperlink to CMS inpatient only list in Criteria I.A. Added option in I.A. for procedure to be listed as an inpatient-only procedure in InterQual for those under 18 years of age, and noted that the CMS inpatient only list applies to those 18 years of age and older. Minor rewording with no clinical significance. References reviewed and updated. Internal specialist reviewed.
CP.BH.100	Substance Use Disorder Treatment and Services	Policy Retired
WA.CP.BH.200	Transcranial Magnetic Stimulation for Treatment Resistant Major Depression	Typos corrected
CP.MP.169	Trigger Point Injections for Pain Management	Annual review completed. Minor rewording with no clinical significance. Background updated. ICD-10 Diagnosis code table removed. References reviewed and updated.
CP.MP.12	Vagus Nerve Stimulation	Annual review completed. Removed II.B. “Obesity”. Additional minor rewording with no clinical significance. Background updated; moved “Removal of implant” section to background. ICD-10 Diagnosis code table removed. References reviewed and updated. External specialist reviewed.

Policy Number	Policy Title	Revision Notes
CP.MP.14	Cochlear Implant Replacements	Annual review completed. Changed verbiage in I.C. from “A sound processor replacement if the current processor is at least five years old” to “C. The existing component has reached the limit of its reasonable useful life. The reasonable useful life of a sound processor is not less than five years”. Minor rewording with no clinical significance. Background updated with no impact to criteria. ICD-10-CM Diagnosis Code table removed. References reviewed and updated. External specialist reviewed.
WA.CP.MP.514	Extra-Corporeal Membrane Oxygenation Therapy (ECMO)	Annual review. References updated.
CP.MP.137	Fecal Incontinence Treatments	Annual review. Removed “≥ 4 years age” criteria and added “in a member/enrollee that has previously achieved bowel control” to I.A. Also removed “more than twelve months after vaginal childbirth” from definition of severe, chronic fecal incontinence in I.A. Description and background section updated with no clinical significance. References reviewed and updated. External specialist reviewed.
WA.CP.MP.54	Hospice Services	References updated. Background information updated. Removed statement regarding previous investigational treatment from Initial Request paragraph. Updated Initial Request Section I. language to correspond to HCA billing guidelines. Updated Initial and Subsequent Request sections II. Continuous Homecare and General Inpatient descriptions to correspond to HCA billing guidelines. Removed debility and failure to thrive exclusion from section III. Updated section III. D. language re: hospice discharge per HCA billing guidelines. Covered and non-covered services sections updated to correspond to HCA billing guidelines.
CP.MP.127	Total Artificial Heart	Annual review. Removed criteria III. Updated background with no clinical significance. Removed ICD-10 code table. References reviewed and updated.
WA.CP.BH.200	Transcranial Magnetic Stimulation for Treatment Resistant Major Depression	New policy.
WA.CP.MP.522	Varicose Vein Treatment	Annual review. References reviewed and updated. Section I. medical necessity criteria revised to align with HTA/HCA billing guidelines. Removed ligation/stripping procedures from policy description and criteria. Added note below section II. regarding use of InterQual criteria for review of ligation/stripping procedures. Removed ligation procedure codes 37780 and 37785 from CPT code table. Updated section B. contraindications to correspond to HTA/billing guidelines and current corporate sclerotherapy/EVLA policy CP.MP.146. Updated section C. Venaseal requirements per CP.MP.146. Background updated with no impact on criteria. . Removed table of codes that do not support medical necessity.
V2.2023	CG Aortopathies and Connective Tissue Disorders	Annual review. Policy number change from CP.MP.215
V2.2023	CG Cardiac Disorders	Annual review. Policy number change from CP.MP.216
V2.2023	CG Dermatologic Conditions	Annual review. Policy number change from CP.MP.217
V2.2023	CG Epilepsy Neurodegenerative and Neuromuscular Conditions	Annual review. Policy number change from CP.MP.218
V2.2023	CG Exome and Genome Sequencing for DX of Genetic Disorders	Annual review. Policy number change from CP.MP.219
V2.2023	CG Eye Disorders	Annual review. Policy number change from CP.MP.220
V2.2023	CG Gastroenterologic Disorders Non-cancerous	Annual review. Policy number change from CP.MP.221
V2.2023	CG General Approach to Genetic Testing	Annual review. Policy number change from CP.MP.222
V2.2023	CG Hearing Loss	Annual review. Policy number change from CP.MP.223
V2.2023	CG Hematologic Conditions Non-cancerous	Annual review. Policy number change from CP.MP.224
V2.2023	CG Hereditary Cancer Susceptibility	Annual review. Policy number change from CP.MP.225
V2.2023	CG Immune Autoimmune and Rheumatoid Disorders	Annual review. Policy number change from CP.MP.226
V2.2023	CG Kidney Disorders	Annual review. Policy number change from CC.MP.227
V2.2023	CG Lung Disorders	Annual review. Policy number change from CC.MP.228
V2.2023	CG Metabolic Endocrine Mitochondrial Disorders	Annual review. Policy number change from CP.MP.229
WA.CP.MP.230	CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay	Annual review.
WA.CP.MP.231	CG Non-Invasive Prenatal Screening	Annual review.
V2.2023	CG Oncology Algorithmic Testing	Annual review. Policy number change from CP.MP.237
V2.2023	CG Oncology Cancer Screening	Annual review. Policy number change from CP.MP.238
V2.2023	CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy	Annual review. Policy number change from CP.MP.239
V2.2023	CG Oncology Cytogenetic Testing	Annual review. Policy number change from CP.MP.240
V2.2023	CG Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies	Annual review. Policy number change from CP.MP.241
V2.2023	CG Pharmacogenetics	Annual review. Policy number change from CP.MP.232
V2.2023	CG Preimplantation Genetic Testing	Annual review. Policy number change from CP.MP.233
V2.2023	CG Prenatal and Preconception Carrier Screening	Annual review. Policy number change from CP.MP.234
V2.2023	CG Prenatal Diagnosis Pregnancy Loss	Annual review. Policy number change from CP.MP.235
V2.2023	CG Skeletal Dysplasia Rare Bone Disorders	Annual review. Policy number change from CP.MP.236

Policy Number	Policy Title	Revision Notes
CP.MP.93	Bone-anchored Hearing Aid	Annual review. Removed Criteria II. stating "BAHAs for any other indication are considered not medically necessary." Updated background with no clinical significance. Added new CPT codes 69728, 69729, and 69730 and removed ICD-10 codes from policy. References reviewed and updated. Reviewed by external specialist.
CP.MP.94	Clinical Trials	Annual review completed; policy reformatted. Minor rewording with no clinical significance. References reviewed and updated.
CP.MP.115	Discography	Annual review. Background updated with no impact on criteria. References reviewed and updated.
CP.MP.248	Facility-Based Sleep Studies for Obstructive Sleep Apnea	Revised criteria III.B. by removing requirement to meet criteria for facility-based sleep study and rewording failed APAP trial statement.
CP.MP.184	Home Ventilators	Annual review completed. Minor rewording with no clinical significance. Background updated with no clinical significance. References reviewed and updated.
CP.MP.249	Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy	New Policy
CP.MP.49	Physical, Occupational and Speech Therapy Services	Annual review. Minor rewording throughout Criteria section with no impact on policy criteria. Removed Criteria I.F.6.a. and added as a notation. Added Criteria I.F.8. that member/enrollee agrees to participation and plan of care. Added Criteria I.H. and Criteria II.B. regarding treatment to be performed in the home. Removed Criteria V. and Criteria VI. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist.
CP.MP.142	Urinary Incontinence Devices and Treatments	Removed continence support pessaries from criteria I.D.1. Revised order in which conservative therapies are listed in I.D.2.

Policy Number	Policy Title	Revision Notes
CP.MP.108	Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia	Added contraindication criteria I.C.1. through 4. Removed ICD-10 code table from policy.
WA.CP.MP.37	Bariatric Surgery	Revised policy sections I and II to mirror WAC 182-531-1600 requirements. Added note to section II indicating extensions may be granted to 6-month time period. Removed section III. Contraindications for surgical weight loss procedures, as this is a standard part of bariatric COE pre-operative evaluations.
CP.MP.101	Donor lymphocyte infusion	Added contraindication criteria I.C.1. through 4.
WA.CP.MP.36	Experimental Technologies	Annual review. Clarifying changes made to description and notes. Policy statement updated to require both of the following, A. and B. Criteria describing technology for experimental or investigational, originally under A-C, is now I.A.1 and 2. Statement “It does not have final clearance…and credible evaluation.” was removed. Medical necessity for technology has been restructured and indicated under I.B.1 through 10. Removed “the technology should be used…. life-threatening condition.” Added criteria points B.8.-10. Added note regarding severity of condition being considered as part of request. References reviewed and updated. Internal specialist review completed.
WA.CP.MP.130	Fertility Preservation	Annual review. Reference updated.
CP.MP.40	Gastric Electrical Stimulation	Annual review. “Dietary modifications” added to I.C. and “FDA specifications” added as I.E. Updated verbiage in note at the end of criteria I. and added additional note about humanitarian device exemptions. ICD-10 code table removed. References reviewed and updated. External specialist reviewed.
CP.MP.132	Heart-Lung Transplant	Annual review completed. Removed pediatric indication of Alpha- 1 antitrypsin deficiency. Added “Lung transplantation alone will restore right ventricular function” to I.C. Updated I.C.10. to include “unless being considered for multi-organ transplant”. Criteria I.C.16. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. ICD-10 diagnosis code table removed. Minor rewording with no clinical significance. References reviewed and updated. External specialists reviewed.
CP.MP.58	Intestinal and Multivisceral Transplant	Annual review. Updated verbiage in II.B.13. to “Active substance use or dependence including current tobacco use, vaping, marijuana use (unless prescribed by a licensed practitioner), or IV drug use without convincing evidence of risk reduction behaviors (unless urgent transplant timelines are present, in which case a commitment to reducing behaviors is acceptable).” References reviewed and updated.
CP.MP.244	Liposuction of Lipedema	Annual review. Removed Criteria I.H. Added clarifying language to Criteria I.J. Minor rewording to Background with no impact on criteria. Removed ICD-10 codes. References reviewed and updated.
CP.MP.116	Lysis of Epidural Lesions	Annual review. Background updated with no impact on Policy Criteria section. ICD-10 codes removed. Changed, “review date,” in the header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.” References reviewed and updated.
WA.CP.MP.518	Negative Pressure Wound Therapy for Home Use	Annual review. References reviewed and updated. Addition of codes to policy note following section III.
CP.MP.86	Neonatal Abstinence Syndrome Guidelines	Annual review. Minor rewording in description and criteria. Updated criteria I.C.7. to include family medicine provider. Added criteria I.C.8. regarding follow up appointment with the primary care pediatrician or family medicine provider scheduled prior to discharge. Background updated with no impact on criteria. References reviewed and updated.
CP.MP.128	Optic Nerve Decompression Surgery	Policy retired.
CP.MP.102	Pancreas Transplantation	Annual review. Removed criterion I.A. stating that medical treatment does not exist or has failed. Removed C-peptide values and BMI requirements from Criteria I.B.1 and I.B.2. Noted in I.B.1. that member/enrollees with requirements for insulin over one unit/kg should be closely evaluated as they may be less likely to benefit from pancreas transplant compared to those with lower insulin doses Added indication in I.B.2 for exocrine pancreatic insufficiency. Added indication I.B.3. for requirement for the procurement or transplantation of a pancreas as part of a multiple organ transplant for technical reasons; Changed “chronic” to “active” in infection contraindication in I.C.7. Removed acute renal failure contraindication. Criteria I.C.12. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Added chronic, non-healing wounds as contraindication in Criteria I.C.13. Added contraindication of significant comorbidities in Criteria I.C.14. Clarified in I.C.1.b that problems with insulin could be clinical or clinical and emotional. Added in I.C.2.c. that the GFR does not have to be the most recent value. Added Criteria I.D.1.c. requirement for being medically managed by an endocrinologist for at least 12 months for pancreas transplant alone. Added requirements for SPK and PAK that PTA criteria also needs to be met for those procedures. ICD-10 codes removed. Background updated with no impact on criteria. References reviewed and updated.
CP.MP.120	Pediatric Liver Transplant	Annual review. Criteria I.B.1.a.ii. updated to remove “beyond 3 months from procedure” and added a) Total bilirubin > 6 mg/dL beyond three months from hepatoportoenterostomy b) Total bilirubin remains between 2 to 6 mg/dL. Updated Criteria I.B.1.b. to add “if partial external biliary diversion or ileal exclusion failed or could not be performed.” Removed “acute liver failure associated with encephalopathy” in Criteria I.B.3.a. and added I.B.3.a.i. and ii. Added Criteria I.B.3.c. Budd-Chiari Syndrome. Added, “At the time of diagnosis…” to I.B.4.a.ii. Updated Criteria I.B.4.d. to infantile hemangioma as well as verbiage in I.B.4.d.i. and ii. Removed “that is not responsive to medical therapy” in criteria I.B.5.h. and added I.B.5.h.i. through iv. Criteria I.B.5.m.ii. changed from “hyper-ammonia” to “hyperammonemia.” Criteria I.B.7.b. updated to Factor VII and updated to state, “with complications from or failure of medical management.” Removed “that has failed medical therapy” from Criteria I.B.7.c. and added sub criteria i. and ii. Removed “Budd-Chiari Syndrome” from I.B.7.d. Added Hepatopulmonary syndrome (HPS) as I.B.7.d. and added sub criteria i. and ii. Criteria I.C.1. updated from “chronic” to “active” infection. Criteria I.C.3. updated and added note for exclusion of malignancies that transplant could sufficiently address. Criteria I.C.8. updated to remove age requirement. Criteria I.C.18. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background updated with no impact on criteria. ICD-10 codes removed. References reviewed and updated. Reviewed by internal specialist and external specialist.
CP.MP.188	Pediatric Oral Function Therapy	Annual review. Updated Criteria I.A. to include anatomic conditions and removed “severe” and “complex” verbiage. Minor rewording in Criteria section with no impact on criteria. Listed disorders and impairments in Criteria I.B. for clarity. Added Criteria I.H. to include complex medical conditions with concern for feeding difficulty. Background updated with no impact on criteria. References reviewed and updated.
CP.MP.210	Repair of Nasal Valve Compromise	Annual review completed. Updated Criteria I.C.3. to include nonallergic rhinitis with examples. Background updated with no impact to clinical criteria. Dashes removed from ranges. CPT Code 30469 added to Codes That Do Not Support Coverage table. ICD-10 diagnosis code table removed. References reviewed and updated. External specialist reviewed.
CP.MP.162	Tandem Transplant	Updated verbiage I.3.b.ii., I.3.c.i. through iii., and I.A.3.d. Added substance use contraindication I.B.15. Removed criteria IV. stating, current evidence does not support tandem transplants for any other indication than what is listed above.
WA.CP.MP.509	Upper GI Endoscopy for GERD	Annual review. References reviewed and updated. Section II. A. language updated to mirror billing guidelines.

Policy Number	Policy Title	Revision Notes
CP.BH.104	Applied Behavior Analysis	New Policy
WA.CP.BH.104	Applied Behavior Analysis	Policy archived
CP.MP.164	Caudal or Interlaminar Epidural Steroid Injections for Pain Management	Policy archived
NIA_CG_300	Epidural Spine Injections	New Policy on NIA site
NIA_CG_301	Facet Joint Injections	New Policy on NIA site
NIA_CG_302	Facet Joint Denervation	New Policy on NIA site
WA.CP.MP.171	Facet Joint Interventions for Pain Management	Policy archived
WA.CP.BH.506	Psychological Testing	Annual review. Renumbered policy from WA.CP.MP.506 to WA.CP.BH.506. Replaced “member” with “member/enrollee’ in all instances. References updated.
CP.MP.166	Sacroiliac Joint Interventions for Pain Management	Policy archived
NIA_CG_305	Sacroiliac Joint Injection	New Policy on NIA site
CP.MP.165	Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management	Policy archived
WA.CP.MP.248	Sleep Apnea Diagnosis and Treatment	Policy archived
CP.BH.200	Transcranial Magnetic Stimulation for Treatment Resistant Major Depression	Ad hoc Review. Policy restructured. Added additional information to the description section with no impact to the policy. Replaced all instances of the statement “It is the policy of health plans affiliated with Centene Corporation®” with “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. Deleted criteria point I.D as the information was redundant to I.B. In criteria subsection I.I. (5), clarified that three months or less of remission constitutes a contraindication. Added the statement “requests for 6 tapered final sessions of TMS (over a 3-week period)” to the revised criteria point II. Added criteria point II.A to indicate that “all initial criteria must be met prior to request for additional sessions”. Deleted what was criteria III as the information was redundant to criteria II. In criteria section III, replaced “maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it” with “It is the policy of health plans affiliated with Centene Corporation that maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it”. Added criteria point IV.A to indicate that “criteria for initial TMS treatment guidelines continues to be met”. Added semicolons throughout the criteria section. References reformatted. Replaced all instances of “dashes (-) in page numbers to the word “to”.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.37	Bariatric Surgery	Annual review. Updated policy format. Updated policy statement in I, I.A.1, and I.A.1.a. In I.A.1.a.i updated policy statement and BMI threshold to ≥ 35 or ≥ 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults. In I.A.1.a.ii BMI threshold was updated to "BMI ≥ 30 and < 35 kg/m², or < 27.5 kg/m2 and < 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults and policy statements in I.A.1.a.ii, I.A.1.a.ii.a), and c). Moved Type 2 diabetes mellitus (DM) to I.A.1.a.ii.b) as an absolute co-morbidity. Added "pseudotumor cerebri" and "disqualification from other surgeries..." to I.A.1.a.ii.c). Updated policy statement in I.A.1.b.ii. Updated I.B.2 to "Glycemic control evaluation to include A1c and fasting blood glucose". Removed criteria I.B.5.c. requiring prescribed exercise program as part of nutritional counseling. Moved IV. Contraindications to I.C and added "severe cardiac disease with prohibitive anesthetic risks," "uncontrolled and untreated eating disorders (eg, bulimia)," "inability on the part of the patient or parent/guardian to comprehend the risks and benefits of the surgical procedure," and "a medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens or impairs decisional capacity." Background updated with no clinical impact. Removed deleted CPT codes 0312T- 0317T and added CPT codes 43290, 43291, and 43632 to not medically necessary table. Removed ICD-10 codes and table. References reviewed and updated. Reviewed by internal and external specialists. Section III: updated abbreviations in III.3 with no clinical significance; added indication for SG to RYGB or BPD-DS DS as a bridging procedure for BMI ≥ 50 kg/m² in III.4.
CP.MP.107	Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines	Annual review. Updated policy statement in I. and added general criteria I.A.1. and I.A.2. Removed ambulatory assist products and updated I.B. policy table. Retired gait trainers and standing frame criteria, defer to standard IQ criteria. Updated pneumatic compression device criteria and added non-pneumatic compression device criteria. Added "one month’s rental for a standard manual wheelchair is considered medically necessary if a member/enrollee owned wheelchair is being repaired" to wheelchair repair. Added foot orthotics, custom criteria and codes. Removed "male" from male vacuum erection device. Added criteria section for walkers. Minor verbiage and formatting updates with no impact on criteria. References reviewed, updated, and reformatted. Internal specialist review.
CP.MP.106	Endometrial ablation	Annual review completed. Added requirement in I.F. that thyroid disorders have been treated or ruled out. Removed contraindication “previous classic cesarean or other transmural surgery” from I.G. Background and Table 1 updated. Minor rewording with no clinical significance. References reviewed and updated. Internal specialist reviewed.
CP.MP.121	Homocysteine Testing	Annual review. References reviewed and updated.
WA.CP.MP.505	Microprocessor Controlled Lower Limb Prosthetics	Annual review. References updated. Removed HCPCS L2006 and L5973 as these services are not covered by HCA.
CP.MP.242	Pulmonary Function Testing	Annual review. Updated Criteria I.B.1. to include type and degree of pulmonary dysfunction. Minor rewording to Criteria I.B.2. and I.B.4. without clinical significance. Minor rewording to Criteria C. Background updated with no impact on criteria. References reviewed and updated.
WA.CP.MP.517	Testosterone Testing	Annual review. Reference updated. Grammatical changes to mirror billing guideline.
CP.MP.247	Transplant Service Documentation Requirements	New policy
WA.CP.MP.520	Tympanostomy Tubes in Children	Annual review. References updated. Criteria updated to mirror billing guideline.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.519	Administrative Days	Added section III for Newborn Subsequent Days. References updated.
WA.CP.BH.521	Behavioral Health Personal Care Services	Annual review. Changed policy number from WA.CP.MP.521 to WA.CP.BH.521. References updated.
WA.CP.MP.502	Cochlear Implants: Bilateral vs. Unilateral	Annual review. references updated. Removed L8614.
WA.CP.MP.501	Continuous Glucose Monitoring	Annual review. References updated. Updated all HCPCS
CP.MP.34	Hyperemesis Gravidarum Treatment	Policy archived
CP.MP.180	Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea	Annual review completed. I.C. Changed BMI to 35 kg/m2; I.E. Adjusted AHI to ≥15 to ≤ 65 events per hour; I.F.1. Adjusted 20 to 15. Added criteria I.I.5. and I.I.8. through 14. Background updated and minor rewording with no clinical significance. Added CPT codes 64582, 64583, and 64584. Removed CPT codes 0466T, 0467T, 0468T, 61886, 61888, 64568, 64569, 64570, and 64585.
CP.MP.57	Lung Transplantation	Annual review. Criteria I.C.14. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Added pediatric indication for end-stage emphysema due to alpha-1 trypsin deficiency. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist
CP.MP.85	Neonatal Sepsis Management	Annual review completed. Description and background updated. Minor rewording with no clinical significance. References reviewed and updated.
CP.MP.81	NICU Discharge Guidelines	Annual review. Updated the note in section II. from "1800 grams” to “1600 to 1800 grams.” References reviewed and updated. Reviewed by external specialist.
CP.MP.141	Non-Myeloablative Allogenic Stem Cell Transplants	Annual review completed. Criteria I.C.4. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background updated; minor rewording with no clinical significance. ICD-10 diagnosis code table removed. References reviewed and updated.
WA.CP.MP.503	Private Duty Nursing Services	Annual review. Added HCA definition of Private Duty Nursting to the Description section. Added minimum hours to section I. Updated sections II.A and II.B to add clarity and examples. Reworded III.A. to add billing instructions for patient’s home in addition to the instructions for billing when in a group home. Clarified billing instructions in IV. Updated references.
CP.MP.187	Radiofrequency Ablation of Uterine Fibroids	Policy archived
CP.MP.151	Transcatheter Closure of Patent Foramen Ovale	Annual review. Updated description to include newest FDA-approved device: AmplatzerTM TalismanTM PFO Occluder. Clarfied in I.B. that age requirements are in years. Updated Criteria I.B. # 2 to state that cryptogenic stroke caused by a presumed paradoxical embolism, and a possible, probable, or definite likelihood that the stroke was causally related to PFO based on the PFO-associated stroke causal likelihood (PASCAL) classification system with a Risk of Paradoxical Embolism (RoPE) score > 6, and/or there is a large shunt or atrial septal aneurysm. Updated Criteria to include Criteria C. Device is FDA-approved for percutaneous transcatheter closure of PFO (eg AmplatzerTM PFO Occluder, AmplatzerTM TalismanTM PFO Occluder, and the Gore® Cardioform Septal Occluder). Background updated and includes information on PASCAL classification system and RoPE score. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist.
WA.CP.MP.46	Ventricular Assist Devices	Annual review. Background and note updated with no clinical significance. Section III reworded. Removed ICD codes. References updated.

Policy Number	Policy Title	Revision Notes
CP.BH.500	Behavioral Health Treatment Document Requirements	Edited policy statement I to apply to Centene Advanced Behavioral Health as well as plans affiliated with Centene.
NIA.CG.062	CT Coronary Angiography	Added the following statement, "Low probability patients will be directed to exercise stress test over CCTA unless other criteria for imaging studies are met."
WA.CP.MP.515	Fecal Microbiota Transplantation	Annual review. Updated references
CP.MP.136	Home Births	Annual review completed. Removed criteria II. regarding all other indications not medically necessary. Minor rewording with no clinical significance. ICD-10 codes removed. References reviewed and updated. Internal and external specialist reviewed.
CP.MP.62	Hyperhidrosis Treatments	Annual review. Updated Criteria II.B. to greater than 55 beats per minute. Removed “is relatively healthy” in criteria II.F. Background updated with no impact on criteria. ICD-10 codes removed. References reviewed and updated.
CP.MP.173	Implantable Intrathecal or Epidural Pain Pump	Annual review. References reviewed and updated. ICD-10 code table removed. Minor rewording with no clinical significance. Reviewed by external specialist.
CP.MP.202	Orthognathic Surgery	Annual review completed. Reformatted criteria II. and added II.B. as additional non-medically necessary indication. Additional minor rewording with no clinical significance. Background updated. CDT codes removed from policy. References revised and updated. Reviewed by external and internal specialists.
CP.MP.150	Phototherapy for Neonatal Hyperbilirubinemia	Annual review. Changed title from “Home phototherapy…” to “Phototherapy…” Updated criteria I.D. from 24-48 hours to 12-24 hours. Updated criteria to include the following: I.E. ≥48 hours old; I.F. An LED-based phototherapy device will be available in the home without delay; I.G. No previous phototherapy; I.H. TSB will be measured daily. Criteria I.I. #1 updated to include example of positive direct antiglobulin test for isoimmune hemolytic disease and to include glucose-6-phosphate dehydrogenase (G6PD) and other hemolytic disease. Criteria I.I. #2 updated to include hypoxic ischemia encephalopathy (HIE). Significant lethargy removed from Criteria I.I. Criteria I.I. updated to include the following: #13 Significant clinical instability in the previous 24 hours; #14 Clinical history of a parent or sibling requiring phototherapy or exchange transfusion; #15 Exclusive breastfeeding with suboptimal intake (≥10% weight loss); #16 Down syndrome; #17 Macrosomic infant of a diabetic mother. Added note below Table 1 that explains the values are conservative TSB values based on lower age range thresholds in inpatient criteria. Added clarification to II that extenuating circumstances can include lack of expected compliance with therapy at home. Added note below policy statement II stating: that infants should be admitted for inpatient phototherapy if the TSB concentration is more than 1 mg/dL above the AAP guidelines phototherapy treatment threshold per the bili risk tool, and that table 1 is consistent with AAP guidelines allowing treatment at lower levels per provider discretion; and that clinical decision support tools provider further criteria for inpatient phototherapy treatment. Updated background to include 2022 AAP clinical practice guidelines. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist.
WA.CP.MP.248	Sleep Apnea Diagnosis and Treatment	Updated policy to reflect new Centene policy: significant changes to section I.B. and change in policy numbering from WA.CP.MP.523 to WA.CP.MP.248. Updated section II.A. to reflect consideration of titration studies. Added coverage statement about actigraphy. Added code 95803 to code list. Minor changes to company name. Updated references.
WA.CP.MP.526	Stem Cell Therapy for Musculoskeletal Conditions	Annual review. Updated references. Added CPT codes 38230 and 38232 and HCPCS code S2150.
CP.MP.22	Stereotactic Body Radiation Therapy	Annual review completed. Added I.F. “Recurrent malignant disease requiring palliation and/or as palliative treatment for liver-related symptoms”. Added I.J. “Extracranial oligometastatic disease: 1.One to three metastatic lesions involving the lungs, liver or bone; 2.Primary tumor is breast, colorectal, melanoma, non-small cell lung, prostate, renal cell, or sarcoma; 3.Primary tumor is controlled 4.No prior history of metastatic disease”. Background updated and minor rewording with no clinical significance. ICD-10 Code table removed. References reviewed and updated. Reviewed by external specialist.
CP.BH.100	Substance Use Treatment and Services	Ad-hoc review. Edited policy statement I. to note that it applies to health plans affiliated with Centene Corporation as well as CABH. Replaced all instances of “dashes (-)” in the CPT codes with the word “through”. Replaced all instances of “dashes (-) in page numbers to the word “to”.
CP.MP.162	Tandem Transplant	Annual review. References reviewed and updated. ICD-10 codes removed. Review completed by external specialist. Minor background edits with no change to criteria.
WA.CP.MP.510	Tinnitus Treatment	Annual review. Replaced all instances of “members” with “members/enrollees”. Added “repetitive” to transcranial magnetic stimulation in 2.B. Updated references.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.525	Catheter Ablation for Supraventricular Tachyarrhythmia	Annual review. References updated. Removed CPT 93650
CP.MP.203	Diaphragmatic/Phrenic Nerve Stimulation	Annual review. Criteria II.A.1.c. and Criteria II.A.2.b. updated to include “or by other radiographic techniques such as ultrasound” in addition to fluoroscopy. Background updated to include U.S. Food and Drug Administration premarket approval information regarding the Avery Spirit Diaphragm Pacing Transmitter. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.54	Hospice Services	Annual review. References updated. Reworded description of Pediatric Palliative Care.
WA.CP.MP.69	Intensity-Modulated Radiotherapy	Annual review. Updated references. Removed CPT 77370.
WA.CP.MP.500	Mandibular Advancement Devices	Annual review. Reference updated.
CP.MP.138	Pediatric Heart Transplant	Annual review. Appendix A tables updated to remove dashes. Removed ICD-10 codes. References reviewed and reformatted.
CP.MP.246	Pediatric Kidney Transplant	New policy
WA.CP.MP.117	Percutaneous Electrical and Peripheral Nerve Stimulation	Policy renumbered WA.CP.MP.117. References to spinal cord stimulation removed.
CP.MP.242	Pulmonary Function Testing	New policy

Policy Number	Policy Title	Revision Notes
CP.MP.186	Burn Surgery	Annual review completed. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated.
CP.MP.131	Essure Removal	Policy retired
CP.MP.209	Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing	Removed deleted code 0097U
WA.CP.MP.70	Proton and Neutron Beam Therapy	Annual review completed. Removed “treated in a hypofractionated regimen” from I. D. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated. External specialist reviewed.
CP.MP.182	Short Inpatient Hospital Stay	Annual review. Added I.C. “Acute hospital care at home.” Background updated with no clinical significance. References reviewed and updated.
CP.MP.142	Urinary Incontinence Devices and Treatments	Annual review. Updated criteria section to clarify abbreviations. Criteria I.D. # 1 updated to include continence-support pessaries as a conservative measure. Updated background with no impact on criteria. Removed ICD-10 codes. References reviewed and updated.

Clinical & Payment Policies

Clinical Policies

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GENETIC TESTING

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Medicaid Clinical Policies Listing

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GENETIC TESTING

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Payment Policies

Ambetter Payment Policies

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Policy Revision Summary (Clinical)

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