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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.

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Medicaid Clinical Policies Listing

Medicaid Pharmacy Policies Listing

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

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Policy Revision Summary

Policy Number

Policy Title

Revision Notes

WA.CP.MP.527

Vitamin D Testing

New policy.

Effective Date

Policy Number

Policy Title

Revision Notes

 

     

Effective Date

Policy Number

Policy Title

Revision Notes

5/1/21

CP.MP.203

Diaphragmatic/Phrenic Nerve Stimulation

New policy.

Policy Number

Policy Title

Revision Notes

WA.CP.MP.52

Behavioral Health Personal Care Services

Annual review. Reference updated.

WA.CP.MP.502

Cochlear Implants: Bilateral vs. Unilateral

Annual review. Added “Bilateral vs. Unilateral” to policy title. Reference updated.

WA.CP.MP.501

Continuous Glucose Monitoring

Annual review. Clarified policy is regarding long-term use of CGM. Removed criteria for pregnant woman who are not insulin-dependent to be consistent with state billing guideline. Removed CPT codes 95249-95251. Updated references.

WA.CP.MP.50

Drugs of Abuse: Definitive Testing

Changed name of policy from Outpatient Testing for Drugs of Abuse to Drugs of Abuse: Definitive Testing. Removed presumptive drug testing criteria from policy and created new policy, WA.CP.MP.208 Drugs of Abuse: Presumptive Testing. Removed codes for presumptive drug testing: 80305, 80306, 80307. Added CPT-0054U to list of codes that do not support coverage criteria.  Removed CPT-0006U, as code is deleted in 2021. 

WA.CP.MP.208

Drugs of Abuse: Presumptive Testing

New policy.

WA.CP.MP.130

Fertility Preservation

New policy.

CP.MP.34

Hyperemesis Gravidarum Treatment

Annual review. Removed criteria for TPN and codes S9364, S9365, S9365, S9366, S9367 and S9368. References checked and updated. Replaced “member” with “members/enrollees.”

CP.MP.141

Non-Myeloablative Allogeneic Stem Cell Transplants

Annual review completed.  References reviewed.  Codes checked.  Changed “member” to member/enrollee”.  Specialty review completed with no updates.

CP.MP.102

Pancreas Transplantation

Background updated to reflect current data. References reviewed and updated. Replaced “member” with “member/enrollee” in all instances. Under contraindication I.C. removed “malignancy metastasized to or extending beyond the margins of the kidney and/or pancreas” as this is inclusive to contraindication #1.

CP.MP.49

Physical, Occupational and Speech Therapy Services

Added criteria to section IV. for a formal reevaluation, requiring that there must be documentation of new clinical findings or a significant change in condition, or a failure to respond to therapeutic interventions outlined in the POC.  Replaced "member" with "member/enrollee." 

CP.MP.206

Skilled Nursing Facility Leveling

Added negative pressure wound therapy to I.B., “Examples of treatments appropriate to Level 2”

WA.CP.MP.46

Ventricular Assist Devices

Annual review. Added information regarding pediatric VADs. References reviewed and updated. Removed ICD-10 code Z94.1 and added Z76.82. Replaced all instances of “member” with members/enrollees. Revised description of CPT 33990, 33991 and 33992.

CP.MP.56

Ventriculectomy and Cardiomyoplasty

Policy is retired.

Policy Number

Policy Title

Revision Notes

CP.MP.100

Allergy Testing and Therapy

Added “(scratch, puncture, prick)” to description in I.C.1.  Updated IIIB.  adding several not medically necessary tests. Updated background, adding section on sublingual immunotherapy.  CPT codes added to not medically necessary CPT Table 2:  86160, 86161, 86162, 86332, 86343, 86485, 86628, 0165U, 0178U.  Revised description of ICD-10 codes Z88.0-Z88.9 in ICD-10 Tables 4 & 5.  References reviewed and updated.  Replaced member with member/enrollee in all instances.

CP.MP.156

Cardiac Biomarker Testing for Acute MI

Added “or myocardial injury due to other mechanisms” in addition to acute myocardial infarction for approval in criteria I. References reviewed and updated. Coding reviewed. Replaced “member” with “member/enrollee” in all instances.

WA.CP.MP.525

Catheter Ablatiofor Supraventricular Tachyarrhythmia

Annual review. References updated.

WA.CP.MP.84

Cell-Free Fetal DNA Testing

New Policy

CP.MP.31

Cosmetic and Reconstructive Procedures

Added applicable CPT codes: 15771, 15772

CP.MP.105

Digital EEG Spike Analysis

Replaced “members” with “members/enrollees’ in all instances. References reviewed and updated.

WA.CP.MP.515

Fecal Microbiota Transplantation

Annual review. References updated.

CP.MP.62

Hyperhidrosis Treatments

Combined criteria points in II. H. and III. C to read “failed one of the following: 1. Iontophoresis or 2. Trial of botulinum toxin.” References reviewed and updated. Replaced “members” with “members/enrollees” in all instances.

WA.CP.MP.500

Mandibular Advancement Devices

Annual review. References updated.

CP.MP.120

Pediatric Liver Transplant

Clarified in I.B.5.e, neonatal hemochromatosis is now referred to as Gestational alloimmune liver disease.  References reviewed and updated.  Revised description of ICD-10 code E72.53.

WA.CP.MP.523

Sleep Apnea Diagnosis and Treatment

Added III. D. indicating titration can be requested after the testing is completed.

WA.CP.MP.526

Stem Cell Therapy for Musculoskeletal Conditions

New Policy

CP.MP.22

Stereotactic Body Radiation Therapy

Annual review of policy. References reviewed and updated.  Added CPT- 61800.  Replaced “member” with "member/enrollee” in all instances.

WA.CP.MP.510

Tinnitus Treatment

New Policy

WA.CP.MP.524

Whole Exome Sequencing

New policy

Policy Number

Policy Title

Revision Notes

WA.CP.MP.69

Intensity-Modulated Radiation Therapy

Added indications by cancer site and associated ICD-10-CM diagnosis codes. Removed references to Health Technology Assessment (HTA). Added Background. References reviewed and updated. Replaced “members” with “members/enrollees’ in all instances.

CP.MP.139

Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy

Renamed policy to Low Frequency Ultrasound Therapy and Noncontact Normothermic Wound Therapy for Wound Management. Added criteria and background for noncontact normothermic wound therapy. References reviewed and updated. Replaced “members’ with “members/enrollees” in all instances.

CP.MP.91

OB Home Health Programs

Archived policy

WA.CP.MP.507

Oral Entral Nutrition

Annual review. Updated reference. Added E1399 and K0739.

CP.MP.206

SNF Leveling

New policy

Policy Number

Policy Title

Revision Notes

CP.MP.183

Diagnostic Testing Guidelines for 2019-Novel Coronavirus

Policy being retired.

CP.MP.180

Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Added codes 61886 and 61888. Replaced “member” with “member/enrollee” in all instances. References reviewed and updated.

CP.MP.87

Inhaled Nitric Oxide

Corrected calculation of Oxygen Index in I.A.2.IV.  Updated background with no impact on criteria. References added.  Replaced “member” with “member/enrollee.”

CP.MP.181

Polymerase Chain Reaction Respiratory Viral Panel Testing

New Policy

WA.CP.MP.70

Proton and Neutron Beam Therapies

Replaced all instances of “member” with “member/enrollee”. References reviewed and updated. Changed title to Proton and Neutron Beam Therapies

CP.MP.182

Short Inpatient Hospital Stay

Added to the description that “medical necessity criteria for day one and day two of an inpatient hospital stay, excluding behavioral health and obstetrical delivery admissions.” Clarified that the medical necessity statement in I. applies to the first and second days of an inpatient stay. Added section II., stating that days 3 and beyond are medically necessary per nationally-recognized clinical decision support tools. Replaced all instances of member with member/enrollee.

CP.MP.127

Total Artificial Heart

In I.G, removed specifications about chest size related to the device, and added that the requested device is FDA approved and will be used according to FDA indications, which include chest measurements. Background updated.  Specialist review.  Replaced “member” with “member/enrollee” in all instances.

CP.MP.169

Trigger Point Injections for Pain Management

I.B.4: Changed maximum of 6 injections/year to 4.  Added ICD-10 code M79.18 and changed M79.1 to M79.12.  References reviewed and updated.

WA.CP.MP.177

Video Electroencephalography (V-EEG)

New Policy

WA.UM.23

Video Electroencephalography (V-EEG)

Policy is archived and replaced with WA.CP.MP.177

Policy Number

Policy Title

Revision Notes

WA.CP.MP.37

Bariatric Surgery

Specified that H. Pylori screening should be conducted using a urea breath test or stool antigen test. Added the following ICD-10 code ranges:  M17.0-M17.9, M19.171-M19.179 and M19.271-M19.279.  10/1/20 ICD 10 updates:  Replaced category K21.0-K21.9 with K21.00- K21.9.  Removed “member” from II.C.4. and II.G.  Reworded II.G with no impact on criteria.  Replaced “member” with “member/ enrollee” in all other instances. Add guidance around case management. Updated references.

CP.MP.98

Urodynamic Testing

Code update:  ICD-10 N40.1 and R35.1, no longer specific to 51798 and moved to list of codes that support medical necessity.  Added ICD-10 codes that support medical necessity: A18.13, G82.21, G82.22, 539.11, S14.0XXA-S14.9XXS, S24.0XXA-S24.9XXS.

CP.MP.101

Donor Lymphocyte Infusion

Description updated. Specified in I.A. that DLI is indicated to reduce the risk of relapse. Added to I.B. that DLI is intended to convert recipient cells from mixed to full chimerism, if there is a risk of relapse. Added to II. “higher than grade 2 acute graft-versus-host-disease (GvHD)” and “total host chimerism.” Removed not medically necessary indication from section II. of a second DLI when benefits were not noted from the first. References reviewed and updated.  Specialist review.  Replaced “member” with “member/enrollee” in all instances.

CP.MP.150

Home Phototherapy for Neonatal Hyperbilirubinemia

Added criterion that “if the mother is breastfeeding, she has been offered lactation support from a qualified professional.” References reviewed and updated. Specialist review. Replaced “member” with “member/enrollee in all instances.

CP.MP.154

Thyroid Hormones and Insulin Testing in Pediatrics

References reviewed and updated.  10/1/20 ICD-10 code updates:  Revised ICD-10 codes Z68.52, Z68.53, and Z68.54: code set revised changing parenthesis around BMI to brackets with no change in code descriptor.  Replaced “member” with “member/enrollees” in all instances in the disclaimer.

CP.MP.184

Non-invasive Home Ventilator

Removed code E0467. Replaced all instances of “member” with “member/enrollee,” or removed them where possible.

Policy Number

Policy Title

Revision Notes

CP.MP.108

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia

Revised ICD-10 code range for sickle cell disorders to codes that expand sickle cell categorization.  Removed “member” from policy statement in I. and replaced “member” with “member/enrollee” in all other instances.

WA.CP.MP.119

Balloon Sinus Ostial Dilation

In I.B.2, gave an option for when corticosteroids are contraindicated.  References reviewed and updated.

CP.MP.31

Cosmetic and Reconstructive Procedures

Clarified in II.N. that hair transplant is not medically necessary, when not performed to correct permanent hair loss caused by disease or injury.  Added the following applicable CPT codes:  15220,15221, 15775, 15776. Supporting references added.

CP.MP.107

Durable Medical Equipment (DME)

Under Wound Care, removed HCPCS code Q4111, GammaGraft, as code is included in CP.MP.185 Skin Substitutes for Chronic Wounds 

CP.MP.134

Evoked Potential Testing

Reorganized section IV and added indications when visual evoked potentials are not medically necessary. Revised IV.C, “Treatment of all other conditions than those specified above” to “evaluation/assessment of all other conditions…” Added additional ICD 10 codes A39.82, H35.54, R44.1 and R48.3 as supporting medical necessity. Removed code H54.7 from list of medically necessary codes. References reviewed and updated.

CP.MP.136

Home Birth

Added to I.A.1.a., “and practicing within an integrated and regulated health system”; Added to I.E that singleton pregnancy “is estimated to be appropriate for gestational age.” Revised criteria in I.G:  Changed “Spontaneous labor in a pregnancy that has lasted at least 38 weeks” to specify 37 0/7 weeks clarified that no more than 41 weeks is no more than 41 6/7 weeks.  Added separate criteria for home birth in a pregnancy induced as an outpatient. Updated section in background, American Academy of Pediatrics (AAP), with most current recommendations.  References reviewed and updated.

WA.CP.MP.27

Hyperbaric Oxygen Therapy

Policy reactivated to meet HTA requirements. Previously archived 3/1/2020.  Criteria-using InterQual-remain the same.

CP.MP.116

Lysis of Epidural Lesions

Revised ICD-10 code G96.19 to G96.198 per 10/1/20 ICD-10 code updates. Replaced “member” with “member/enrollee” in all instances.

CP.MP.86

Neonatal Abstinence Syndrome Guidelines

In asymptomatic infants section: specified that transitional care or newborn level 1 is appropriate if being assessed with modified Finnegan’s scoring; added an alternative option for Level 2 nursery if being assessed and treated using ESC. Updated background relating to ESC. References review and updated. Reviewed by neonatologists.

CP.MP.120

Pediatric Liver Transplant

10/1/20 ICD-10 code update:  replaced code range K74.0-K74.69 with K74.00- K74.69 to include new codes included in this range.  Replaced “member” with “member/enrollee” in all instances

WA.CP.MP.523

Sleep Apnea Diagnosis and Treatment

Highlighted definitions of hypopnea and apnea. Added comments and criteria on CPAP titration. Clarified guidelines when home study fails.

CP.MP.189

Thymus Transplantation

New Policy

WA.CP.MP.38

Ultrasound in Pregnancy

Policy is archived and replaced with CP.MP.38.

CP.MP.38

Ultrasound in Pregnancy

New Policy

Per 10/1/20 ICD-10 code updates, code set Z68.35 – Z68.45  was revised changing parenthesis around BMI to brackets with no change to code descriptor. Removed “member” from I.A and replaced “member” with “member/enrollee” in all instances.

CP.MP.98

Urodynamic Testing

References reviewed and updated. Added ICD-10 codes: C70.1, C72.0, C72.1, D33.4.

CP.MP.99

Wheelchair Seating

Typo corrected in II.B- Should be K0860-K0864, rather than K0860, K0864.  For clarity, added the codes included in this range. References reviewed and updated.

Policy Number

Policy Title

Revision Notes

CP.MP.124

ADHD Assessment & Treatment

Policy reviewed. References reviewed and updated. Updated Section I.A. to include “collection of collateral information” and “toxicology screen.” Updated Section I.B. to include “ongoing assessment and application of standardized scales to assess treatment benefit.” Updated Section II. “investigational or unproven” assessments and treatments with the following: pharmacogenetic tools; Cannabidiol oil; cognitive training; external trigeminal nerve stimulation (eTNS); mindfulness; and supportive counseling, to reflect the 2019 version of American Academy of Pediatrics (AAP) Clinical Practice Guidelines. Edited Section II.A.19. to read “Neuro Biofeedback/EEG Biofeedback.” Updated AAP recommended treatment modalities. Added information regarding The Society for Developmental and Behavioral Pediatrics (SDBP) Clinical Practice Guidelines and Process of Care Algorithms for Assessment and Treatment of Children and Adolescents with Complex ADHD. Updated Background section to include most recent prevalent statistics and the necessity of treatment by Primary Care Providers.

CPT Code Updates: Removed 78607, 95827, 97127. Added 78803, 81171, 81172, 92547, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726, 96121, 97129, 97130.

HCPCS Code Updates: Added G0176.  (All code changes relate to non-covered services)

CP.MP.93

Bone-anchored Hearing Aid

References reviewed and updated.  Removed HCPCS code L8613, added L8692.  Added ICD-10 code H61.111-H61.119

CP.MP.186

Burn Surgery

New policy

CP.MP.184

Home Ventilators

New policy

CP.MP.121

Homocysteine Testing

References reviewed and updated. Revised I.A from “Borderline vitamin B12 deficiency” to “Borderline low or inconclusive Vitamin B12 deficiency, or discordant with the clinical picture.”

Changed borderline B12 deficiency and idiopathic VTE/thromboembolism indications from medically necessary to investigational. Added supporting background information and references. Removed from the list of ICD-10 codes supporting coverage criteria: D51.0-D51.9, E53.8, I26.01-I26.99, I81, I82.0-I82.91, Z86.711, Z86.718.

CP.MP.170

Nerve Blocks for Pain Management

For occipital nerve block, added “trigger point at the emergence of the greater occipital nerve or in the distribution of C2” as an alternative to tenderness at the affected nerve branch. References reviewed and updated. 

WA.PP.800

Observation Status

Archived policy

CP.MP.188

Pediatric Oral Function Therapy

New policy

CP.MP.166

Sacroiliac Joint Interventions for Pain Management

Added Patrick’s test/FABER test as an acceptable pain provocation test in I.A3. References reviewed and updated.

CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management

Clarified criteria in II.B, C, and D.1 that a request for TFESI is for one level bilaterally or up to two levels unilaterally.  References reviewed and updated.

CP.MP.182

Short Inpatient Hospital Stay

Renumbered from WA.PP.800 and renamed.

Observation status will be approved for stays of 48 hours or less, unless one of the policy exceptions is noted.

Intermediate/step down level of care is now part of the observation exclusion list.

WA.CP.MP.12

Vagus Nerve Stimulation

Lowered minimum age to 4 years. Called out non-covered services. Added additional investigational indications for VNS to section II.  Removed ICD-10 Codes: G40.001, G40.009, G40.201, G40.209, G40.309, G40.A09, G40.409, G40.509, G40.802, G40.909, G40.911 and G40.919.  Added ICD-10: G40.813, G40.814. References reviewed and updated. 

WA.CP.MP.522

Varicose Vein Treatment

Revised policy statement adding Varithena as an example of a foam irritant. Added 36468 to code list not medically necessary. In I.A.2., added tributary and accessory vein treatment as indications when meeting the established criteria.

Policy Number

Policy Title

Revision Notes

WA.CP.BH.104

ABA Therapy

Annual Review.  Renumbered policy, was WA.CP.MP.104.  Moved to standard corporate policy, with state-specific requirements for Center of Excellence, DSM Checklist and use of HCPCS H2020.

CP.MP.96

Ambulatory EEG

Annual review completed.  References reviewed and updated.  Added the following ICD-10 codes:  R40.4, R55  

CP.MP.107

Durable Medical Equipment

Code E0780 added to criteria for ambulatory infusion pump. Moved ambulatory and implantable infusion pump criteria into pumps section. Updated table of contents.

CP.MP.137

Fecal Incontinence Treatment

Additional criteria added for sacral nerve stimulators from local coverage article (A53017). Clarified definition of chronic fecal incontinence as greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth. Added additional criteria requiring a successful percutaneous test stimulation, condition not be related to anorectal malformation and/or chronic inflammatory bowel disease, incontinence not be related to another neurologic condition and contraindications for device. Added sacral nerve stimulation for the treatment of chronic constipation or chronic pelvic pain to the not medically necessary section II.

CP.MP.85

Neonatal Sepsis Management Guidelines

Under section III. Discharge criteria, added E. Follow-up planned with provider within 48 hours of discharge. In background section I.G., changed ≥ 10^5 CFU to ≤ 10^5 CFU. References reviewed and updated.

WA.CP.MP.523

Obstructive Sleep Apnea Diagnosis and Treatment

Clarified Attended Sleep Study criteria. Updated references.

WA.CP.MP.50

Outpatient Testing for Drugs of Abuse

In II.B, added that “Tests are only for the specific drug(s) or number of drug classes for which the presumptive test is expected to be positive.” Added CPT 80366. Reinstated notes regarding PA not being required for children < 6 years of age, and a 10 day post-test window for PA.

CP.MP.51

Reduction Mammoplasty and Gynecomastia Surgery

Added note to reference CP.MP.95 for breast surgeries pertaining to gender affirming procedures. Added criteria for breast reduction for females that cup size has not changed in 6 months. Added criteria for adolescent males requiring that adult testicular size has been attained. References reviewed and updated. 

CP.MP.162

Tandem Transplant

Changed contraindication of significant systemic or multisystem disease to “significant, uncorrectable, life-limiting medical condition. Removed substance abuse or dependence contraindication. Background updated with no impact on criteria.  References reviewed and updated.

CP.BH.200

Transcranial Magnetic Stimulation

Renumbered policy, was WA.CP.MP.172.  Policy/Criteria section updated to clarify that Section I. refers to initial approval of TMS sessions. Updated item I.B. to reflect “Oversight of treatment is provided by a licensed psychiatrist.” Updated I.C. to include “Other standardized scale indicating moderately severe to severe depression.” Added Section I.I., “The initial request can be reviewed for up to 20 TMS sessions.” Added Section II. to include criteria for authorization of additional TMS sessions.

CP.MP.183

2019 Novel Coronavirus Testing

Modified criteria to reflect CDC testing guidelines as of 7/20/20. Added criteria for neonatal testing. Added criteria for discontinuation of transmission-based precautions, home isolation, and for return to work for healthcare providers. Changed antibody/serology testing medical necessity statement to medically necessary for those presenting late in illness, in conjunction with viral testing, and when post-acute infection syndrome is suspected. Removed background statement about antibody testing not being appropriate for diagnosis of acute infection. Added antibody testing code 86328 to the table supporting medical necessity, as well as codes 0202U, 0223U, 0224U. References updated.

Policy Number

Policy Title

Revision Notes

WA.CP.MP.37

Bariatric Surgery

Added Coronary artery disease as a comorbidity under A.1.b.ii. Edits made to ICD-10 codes; M54-M54.9 now M54.00-M54.9; T81.1X+-T81.9X now T81.10X+ - T81.9XX+; and T85.59 – T85.59 now T85.590+ - T85.598+.   References reviewed and updated.  Updated coverage statement to reflect WAC that allows only laparoscopic gastric band procedures for adults 18-21 years of age.

CP.MP.94

Clinical Trials

Added reference to CP.MP.36 Experimental Technologies. References reviewed and updated.

WA.CP.MP.115

Discography

Revised I. to “not a covered benefit” and II. to indicate all other conditions are “not medically necessary”. References reviewed and updated.

WA.CP.MP.36

Experimental Technologies

References reviewed and updated. Added note regarding Clinical Trials policy. Clarified Humanitarian Use Device and Institutional Review Board exceptions.

CP.MP.123

Laser Therapy for Skin Conditions

Revised indication from “Mild, moderate, or severe psoriasis with < 10% body surface area (BSA) involvement” to “Localized plaque psoriasis <10% body surface area (BSA) involvement, individual lesions, or with more extensive disease.” Background updated with recent guidelines from AAD.   References reviewed and updated.

CP.MP.81

NICU Discharge Guidelines

Revised II.A “from normal ambient temperature (23.9 to 25º C)” to "(20 – 25 º C.)” References reviewed and updated. Specialist review.

WA.CP.MP.523

Obstructive Sleep Apnea Diagnosis and Treatment

Attended sleep study criteria added. Title changed to include “Obstructive”. References reviewed and updated.

WA.CP.MP.50

Outpatient Testing for Drugs of Abuse

Clarified Not Medically Necessary vs. Not Covered items in code tables.

CP.MP.49

Physical, Occupational and Speech Therapies

Removed section on school based services from I.E.1. References reviewed and updated.

WA.CP.MP.503

Private Duty Nurse

Annual review. References updated. Removed statement about SNF placement with no SNF bed available.

WA.CP.MP.185

Skin Substitutes

New policy

WA.CP.MP.509

Upper GI Endoscopy for GERD

Annual review. References updated. CPT 43200, 43202 and 43239 added.

Policy Number

Policy Title

Revision Notes

WA.CP.MP.508

Bone Growth Stimulator

Annual review. References updated. Added “separated by a minimum of 90 days” to section III.A.1.

WA.CP.MP.513

Cardiac Stents

Annual review. References updated. Clarified that policy applies to both bare metal and drug eluting stents. Added C1874 through C1877

CP.MP.31

Cosmetic and Reconstructive Procedures

Added criteria for dermal injections and autologous fat injections for HIV-associated FLS. Changed policy title and medical necessity statements to state “cosmetic procedures” or “reconstructive procedures” instead of “cosmetic surgery” or “reconstructive surgery.” Added CPT and HCPCS codes for specified medically necessary indications.  Added note to refer to CP.MP.95 Gender Affirming procedures for procedures related to treatment of gender dysphoria

CP.MP.87

Inhaled nitric oxide

Annual review completed.  Codes and references checked and updated. P29.3 changed to P29.30-P29.38 and I27.2 changed to I27.20 - I27.29.

Added iNO as medically necessary for adults with COVID-19, severe ARDS, and hypoxemia despite optimized ventilation and other rescue strategies.  Updated background.  Added the following ICD-10 codes:  J80, J96.01, U07.1 and U07.2

CP.MP.58

Intestinal and Multivisceral Transplant

Edited malignancy contraindication to not specify within 2 years, and added exceptions early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk.  References reviewed and updated. 

CP.MP.57

Lung Transplantation

Edited malignancy contraindication to not specify within 2 years, and added exceptions of early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk.

CP.MP.82

NICU Apnea Bradycardia Guidelines

Restructured guidelines and specified that these are “guidelines.” In discharge criteria for significant events and on home respiratory monitoring, added that the infant has no other conditions requiring inpatient care. Reworded sections headings and organized information accordingly.  Changed all instances of “parents” to “parents or caregivers.” Combined caffeine criteria section into the “discharge for significant cardiorespiratory events” section.

WA.CP.MP.50

Outpatient Testing for Drugs of Abuse

Revised policy to state that HCPCS codes G0482 & G0483 are not medically necessary. Updated references.

CP.MP.102

Pancreas Transplantation

Edited malignancy contraindication to not specify within 2 years, or low Gleason score, and added exceptions early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk.

CP.MP.138

Pediatric Heart Transplant

Edited malignancy contraindication to not specify within 2 years, and added exceptions of cancer that has been completely resected, or that has been treated and poses acceptable future risk.

CP.MP.120

Pediatric Liver Transplant

Edited malignancy contraindication adding exceptions: cancer that has been completely resected, or that has been treated and poses acceptable future risk.

CP.MP.183

2019 Novel Coronavirus Testing

Updated description. Changed medical necessity statement to replace persons under investigation language with evaluation and laboratory testing for COVID-19. Modified criteria to reflect priorities for testing per 3/24/20 CDC update. Added that state and local health departments may adapt

Policy Number

Policy Title

Revision Notes

WA.CP.MP.519

Administrative Days

Removed exclusion for custodial care days.

CP.MP.96

Ambulatory Electroencephalography

Removed CPT codes 95950, 95953-codes deleted 1/1/2020.  Added the following 2020 CPT codes:  95700, 95705, 95708, 95717, 95719, 95721, 95723, and 95725. Removed CPT codes from criteria note specifying which CPT codes should precede which ambulatory EEG codes.

CP.MP.183

2019 Novel Coronavirus Testing

Added CPT codes 86328 and 86769.

CP.MP.155

EEG in the Evaluation of Headache

Revised CPT 95813 description

WA.CP.MP.504

Elective Delivery Prior to 39 Weeks

Annual review.  Added WAC reference to background. Updated references. Added ICD-10 codes K83.5 and O26.

CP.MP.140

EpiFix

Archived policy

CP.MP.113

Holter Monitors

Annual review completed.  References and codes reviewed/updated.  ICD-10 codes I42.3-7 were added; R06.00-R06.09 description changes to Dyspnea

WA.CP.MP.54

Hospice Services

Annual review, references updated. Inclusion of transportation services added. Associated revenue code added to HCPCS table.

WA.CP.MP.505

Microprocessor-Controlled Lower Limb Prosthetics

Annual review.  Added L2006.

WA.CP.MP.517

Testosterone Testing

Annual review. Reference updated. Grammatical changes.  84410 added.

CP.MP.169

Trigger Point Injections for Pain Management

CPT 20560 and 20561 added as not supporting coverage criteria.

CP.MP.56

Ventriculectomy and Cardiomyoplasty

CPT codes added: 33426, 33542, and 33548.

Policy Number

Policy Title

Revision Notes

CP.MP.31

Cosmetic and Reconstructive Surgery

Removed “significant” in I.A.4.a. In II. N.changed “hair replacement” to “hair transplantation.”  Added additional not medically necessary indications i.e.,(mastopexy except for breast reconstruction post-mastectomy or lumpectomy resulting in significant asymmetry, correction of inverted nipples, and repair of diastasis recti. Specialist reviewed.  References reviewed and updated. 

CP.MP.89

Genetic Testing

Added general criteria for pharmacogenetic testing. Updated background on pharmacogenetic testing.  References reviewed and updated. 

CP.MP.109

Panniculectomy

ICD -10 codes added.  References reviewed and updated. Specialist reviewed.

CP.MP.142

Urinary Incontinence Devices and Treatments

References reviewed and updated.  Added ICD-10: R35.0.

CP.MP.183

Novel Coronavirus Testing

Modified medical necessity statement to state that testing following CDC guidelines is medically necessary. Changed criteria to reflect CDC guidelines as of 3/4/20

Policy Number

Policy Title

Revision Notes

CP.MP.103

Fractional Exhaled Nitric Oxide

Added that testing FeNO is investigational for all other conditions, in addition to asthma, with supporting sources.

CP.MP.107

DME

Under Ambulatory Assist Products: Added criteria for standers under codes E0637, E0638, E0639, E0641, and E0642; Under Heat, Cold & Light Therapy Equipment: Changed coverage recommendation for Cold Pad Pump to “Not medically necessary” based on current research; Under Orthopedic Care Equipment: Added criteria for traction equipment for codes E0849 and E0855 that target Temporomandibular Joint Dysfunction; Moved Fracture Frames with codes E0974 and E0984 to the section with Halo Procedure Equipment as criteria and indications are the same; Changed male vacuum erection devices from not medically necessary to medically necessary; Added hip labral tears as an indication for a Hip Orthotic; Added clarification to prosthetics an additions section to avoid inappropriate application; Under Other Equipment: Added criteria for E1399, K0108 and K0739 when they are used for wheelchair repairs; Added criteria for E2300 Seat Elevators; Under Stimulator Equipment: Added E0770 when the diagnosis is spinal cord injury to the coverage criteria detailed under Neuromuscular stimulator