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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.

Ambetter Clinical Policies Listing

Ambetter Pharmacy Policies Listing

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

Medicaid Payment Policies

Policy Revision Summary

Effective Date

Policy Number

Policy Title

Revision Notes

11/1/20

CP.MP.189

Thymus Transplantation

New Policy

11/1/20

WA.CP.MP.38

Ultrasound in Pregnancy

Policy is archived and replaced with CP.MP.38

11/1/20

CP.MP.38

Ultrasound in Pregnancy

New Policy

Effective Date

Policy Number

Policy Title

Revision Notes

10/1/20

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)

10/1/20

CP.MP.186

Burn Surgery

New policy

10/1/20

CP.MP.184

Home Ventilators

New policy

10/1/20

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.

10/1/20

WA.PP.800

Observation Status

Archived policy

10/1/20

CP.MP.188

Pediatric Oral Function Therapy

New policy

10/1/20

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.

Effective Date

Policy Number

Policy Title

Revision Notes

9/1/20

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.

9/1/20

CP.MP.96

Ambulatory EEG

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

9/1/20

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.

9/1/20

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.

9/1/20

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.

9/1/20

WA.CP.MP.523

Obstructive Sleep Apnea Diagnosis and Treatment

Clarified Attended Sleep Study criteria. Updated references.

9/1/20

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.

9/1/20

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. 

9/1/20

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.

9/1/20

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.

9/1/20

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.

Effective Date

Policy Number

Policy Title

Revision Notes

8/1/20

WA.CP.MP.185

Skin Substitutes for Chronic Wounds

New Policy

Effective Date

Policy Number

Policy Title

Revision Notes

7/1/20

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.

Effective Date

Policy Number

Policy Title

Revision Notes

6/1/20

WA.CP.MP.519

Administrative Days

Removed exclusion for custodial care days.

6/1/20

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.

6/1/20

CP.MP.183

2019 Novel Coronavirus Testing

Added CPT codes 86328 and 86769.

6/1/20

CP.MP.155

EEG in the Evaluation of Headache

Revised CPT 95813 description

6/1/20

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.

6/1/20

CP.MP.140

EpiFix

Archive policy

6/1/20

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

6/1/20

WA.CP.MP.54

Hospice Services

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

6/1/20

WA.CP.MP.505

Microprocessor-Controlled Lower Limb Prosthetics

Annual review.  Added L2006.

6/1/20

WA.CP.MP.517

Testosterone Testing

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

6/1/20

CP.MP.169

Trigger Point Injections for Pain Management

CPT 20560 and 20561 added as not supporting coverage criteria.

6/1/20

CP.MP.56

Ventriculectomy and Cardiomyoplasty

CPT codes added: 33426, 33542, and 33548.

Effective Date

Policy Number

Policy Title

Revision Notes

5/1/20

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. 

5/1/20

CP.MP.89

Genetic Testing

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

5/1/20

CP.MP.109

Panniculectomy

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

5/1/20

CP.MP.142

Urinary Incontinence Devices and Treatments

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

5/1/20

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

Effective Date

Policy Number

Policy Title

Revision Notes

4/1/20

 

CP.MP.103

Fractional Exhaled Nitric Oxide

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

4/1/20

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

Effective Date

Policy Number

Policy Title

Revision Notes

3/1/20

CP.MP.27

Hyperbaric Oxygen Therapy

Policy archived

3/1/20

CP.MP.91

OB Home Health Program

Pre-eclampsia program: I.H changed dipstick reading from 1+ to 2+.  Updated background with ACOG’s statement on administration of Hydroxyprogesterone Caproate.  Specialist review.

3/1/20

CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Removed restriction of TFESI to lumbar region. Added the statement to all TFESI indications that for cervical TFESI, non-particulate steroid must be used and the procedure must be conducted with real-time imaging, such as fluoroscopy. Revised the not medically necessary statement regarding TFESI for all other indications and locations to only note all other indications.

3/1/20

WA.CP.MP.171

Facet Joint Interventions

Revised wording of section I.A. to match corporate policy. No change to criteria. Updated reference.

Effective Date

Policy Number

Policy Title

Revision Notes

2/1/20

 CP.MP.179

Antithrombin III (Atryn, Thromate)

New policy

2/1/20

CP.MP.180

Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

New policy

Effective Date

Policy Number

Policy Title

Revision Notes

1/1/20

CP.MP.106

Endometrial Ablation

Added codes F64.0, F64.8 and F64.9 for transgender indication. Expanded the menorrhagia indication to instead say “abnormal uterine bleeding” and added the following corresponding codes: N92.5, N92.6, N93.8, N93.9.

1/1/20

CP.MP.134

Evoked Potentials

Removed age limit in I.B.6 and replaced with “infants and preverbal children or children with developmental delay or intellectual disability.” References reviewed and updated.  ICD-10 codes deleted in 2019: H81.41, H81.42, H81.43, H81.49.  Specialist review.

1/1/20

CP.MP.137

Fecal Incontinence Treatments

Added recommendation from ACOG to background.   References reviewed and updated.  CPT code 46762 deleted.  Added CPT code 64566 and HPCPS code L8605 as codes that do not support medical necessity. Revised description of CPT codes 95970, 95971 and 95972. Reviewed by specialist.

1/1/20

CP.MP.85

Neonatal Sepsis Management Guidelines

Edits to background information regarding identification and treatment of the newborn per new AAP guidelines.

1/1/20

CP.MP.170

Nerve Blocks

Peripheral/Ganglion Nerve Blocks: Section A indication added for peripheral nerve blocks for malignant pain; section B.1. and 2. added indication for diagnosis or treatment of post-herniorrhaphy pain and therapeutic post-herniorrhapy pain; section C added peripheral nerve blocks for prevention or treatment of headaches, including migraines, refractory migraines in pregnancy, and short-lasting unilateral neuralgiform headaches as not medically necessary.  Background and references updated accordingly.

1/1/20

WA.PP.800

Observation Stay

New Policy

1/1/20

CP.MP.49

PT, OT, ST Services

New Policy

1/1/20

CP.MP.146

Sclerotherapy for Varicose Veins

Added perforating veins under a current or healed ulcer as an indication; Edited previous criteria for saphenous veins to apply to saphenous veins or perforating veins.

1/1/20

CP.MP.151

Transcatheter Closure of Patent Foramen Ovale

Annual review. Added Gore Cardioform as an FDA-approved device appropriate for medically necessary closure of PFO. Reviewed by specialist.

1/1/20

CP.MP.142

Urinary Incontinence Devices and Treatment

Separated out criteria for trial and placement of SNM, with trial criteria being the same as permanent placement, excluding the permanent placement requirement for a positive response to the trial.

1/1/20

CP.MP.98

Urodynamic Testing

Added ICD-10-CM code R39.14 to support medical necessity of all procedure codes. Added ICD-10-CM code R35.1 to support medical necessity for CPT 51798.

Effective Date

Policy Number

Policy Title

Revision Notes

12/1/19

WA.CP.MP.12

Vagus Nerve Stimulation

Moved to state-specific policy. Updated language to reflect Health Technology Assessment.

Effective Date

Policy Number

Policy Title

Revision Notes

11/1/19

WA.CP.MP.516

Carotid Artery Stenting

New Policy, HTA guideline

11/1/19

WA.CP.MP.525

Catheter Ablation for SVTA

New Policy, HTA guideline

11/1/19

WA.CP.MP.514

EMCO Therapy

New Policy, HTA guideline

11/1/19

WA.CP.MP.515

Fecal Microbiota Transplantation

New Policy, HTA guideline
       

11/1/19

CP.MP.40

Gastric Electrical Stimulation

Reference reviewed and updated. Removed contraindications of alcohol dependency, dialysis, and cancer w/limited life span.  Specialist review.

11/1/19

WA.CP.MP.511

Gene Expression Profile Testing

New Policy, HTA guideline

11/1/19

WA.CP.MP.512

Genomic Microarray Testing

New Policy, HTA guideline

11/1/19

WA.CP.MP.69

IMRT

New Policy, HTA guideline

11/1/19

CP.MP.86

Neonatal Abstinence Syndrome Guidelines

References reviewed and updated.  Updated description regarding NAS and NOWS. Updated background information regarding rooming-in and Eat, Sleep, Console.  Reviewed by Neonatologist.

11/1/19

WA.CP.MP.521

Personal Care Services

New Policy, replaced WA.UM.42

11/1/19

WA.CP.MP.70

Proton & Neutron Beam Therapy

New Policy, HTA guideline

11/1/19

WA.CP.MP.523

Sleep Apnea Diagnosis and Treatment

New Policy, HTA guideline

11/1/19

WA.CP.MP.517

Testosterone Testing

New Policy, HTA guideline

11/1/19

WA.CP.MP.520

Tympanostomy Tubes

New Policy, HTA guideline

11/1/19

CP.MP.98

Urodynamic Testing

References reviewed and updated. Added indication of complex anorectal malformation, along with accompanying diagnosis codes of Q42.0-Q42.3. Noted in investigational statement regarding asymptomatic patients, that evaluation of suspected urological abnormalities is appropriate in the presence of complex anorectal malformation.

11/1/19

WA.CP.MP.522

Varicose Vein Treatment

New Policy, HTA guideline

Effective Date

Policy Number

Policy Title

Revision Notes

10/1/19

WA.CP.MP.519

Administrative Days

Moved policy to new format and numbering scheme.

10/1/19

CP.MP.96

Ambulatory Electroencephalography

References reviewed and updated with two added.  Coding reviewed.  Specialty review completed.  Reviewed by neurologist.  Added last sentence, “Ambulatory EEG monitoring….” to the description.  Within criteria, removed “for classification of seizure type” from “B.” and updated “D.” with “To characterize seizure type…..”, also removing “To adjust antiepileptic medication levels”.  Removed “F. To identify and medicate absence seizures.”  Removed “G. To differentiate between epileptic and sleep disorder related episodes.”  Removed paragraph in Background section on psychogenic nonepileptic spells and the paragraph on analysis.

10/1/19

WA.CP.MP.119

Balloon Sinus Ostial Dilation

New Policy

10/1/19

WA.CP.MP.37

Bariatric Surgery

Restructured criteria in section I. Medical History. Moved codes 43842 and 43847 to table of codes that do not support medical necessity. Added the following codes to the table that does not support medical necessity: 43647, 43881, 64590.

10/1/19

WA.CP.MP.508

Bone Growth Stimulator

New Policy

10/1/19

WA.CP.MP.513

Cardiac Stents

New Policy

10/1/19

CP.MP.164

Caudal or Interlaminar Epidural Steroid Injections

In section D regarding second or subsequent ESI for chronic pain that improved from the diagnostic injections, changed requirement for 3 months having passed from the previous injection to 2 months. Anticoagulation indication moved to policy/criteria section as it is applicable to all injections in this policy.

10/1/19

CP.MP.84

Cell-free Fetal DNA Testing

Moved 81422 and 81479 to a table for codes that do not support medical necessity. Clarified that between “10 and 22 weeks gestation” is ≥ 10 weeks and < 23 weeks gestation.

10/1/19

CP.MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

SCT: removed requirement for hydrops and included option for minimally invasive approach. CPAM/BPS: removed requirement for hydrops.

10/1/19

CP.PHAR.05

Hyaluronate Derivatives

Added preferencing for two of the three preferred options per SDC and prior clinical guidance.

10/1/19

WA.CP.MP.518

Negative Pressure Wound Therapy for Home Use

New Policy

10/1/19

CP.MP.170

Nerve Blocks for Pain Management

Annual review.  References reviewed and updated (added International Headache Society and Practice Guidelines for Chronic Pain Management). Specialty review completed.  Removed CPT 64508 as code was inactive 1/1/2019. Added CPT 64620 for intercostal neurolysis. Specified that the following codes DO NOT support medical necessity: 64400, 64402, 64408, 64410, 64413, 64415, 64417, 64418, 64425, 64430, 64435, 64445, 64447, 64450, 64505.

1/1/20

WA.PP.800

Observation Stay

New Policy

10/1/19

WA.CP.MP.506

Psychological Testing

Moved policy to new format and numbering scheme.

1/1/20

WA.CP.49

PT, OT, ST Services

New Policy

10/1/19

CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Revised frequency interval of TFESI in II.C.3 to at least 2 months apart.  Reference reviewed and updated.  Anticoagulation indication moved to policy/criteria section as it is applicable to all injections in this policy. Minor wording changes to match ESI clinical policy.  Removed the following codes from the policy as they relate to cervical spine:  CPT-64479, 64480. ICD10-G56.00-G56.93, M50.00-M50.93, M54.12, M54.13, Specialist review

10/1/19

WA.CP.MP.509

Upper GI Endoscopy for GERD

New Policy

12/1/19

WA.CP.MP.12

Vagus Nerve Stimulation

Moved to state-specific policy. Updated language to reflect Health Technology Assessment.

Policy Date

Policy Number

Policy Title

Revision Notes

9/1/19

CP.MP.26

Articular Cartilage Defect Repairs

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.114

Disc Decompression Procedures

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.106

Endometrial Ablation

Added additional FDA approved devices (i.e., Mara, Minerva) to table 1.

9/1/19

WA.CP.MP.171

Facet Joint Interventions

Moved to state-specific policy. Updated language to reflect Health Technology Assessment.

9/1/19

CP.MP.89

Genetic Testing

Added note that this criteria should only be used if there is no specific clinical decision support criteria available.

9/1/19

CP.MP.173

Implantable Intrathecal Pain Pump

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.85

Neonatal Sepsis Management

Edits to background information regarding identification and treatment of the mother, and identification and treatment of the newborn, per new ACOG and AAP guidelines.

9/1/19

CP.MP.148

Radial Head Implant

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.174

Selective Dorsal Rhizotomy

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.117

Spinal Cord Stimulation

Archived policy. Replaced with TurningPoint policy

Policy Date

Policy Number

Policy Title

Revision Notes

8/1/19

 

CP.MP.100

Allergy Testing and Therapy

Added to III.A, testing of the following antigens as not medically necessary: cornstarch, cotton, formaldehyde and smog.  References reviewed and updated.  Added 86008 to in vitro testing, and CPT code table 1 and relevant to ICD-10 code table 1.  Added B44.81 to ICD-10 code table 1. Added T88.6XXA – T88.6XXS to ICD-10 code table 5.

8/1/19

WA.CP.MP.37

Bariatric Surgery

Updated policy to reflect no coverage in patients under 18 years of age.

8/1/19

CP.MP.14

Cochlear Implant Replacements

Removed CPT 69717and 69718 and replaced with CPT 69949

8/1/19

WA.CP.MP.115

Discography

Moved to state-specific policy. Updated language to reflect Health Technology Assessment.

8/1/19

CP.MP.107

DME

Changed section “Parenteral pumps and supplies” to “Parenteral pumps for medication administration”, changed criteria from TPN use only to uninterrupted medication administration, per code description. In implantable infusion pump, replaced chronic non-malignant pain criteria with a reference to CP.MP.173 intrathecal pain pumps. Other minor rewording for clarity with no clinical significance.

Updated flexion/extension devices according to current InterQual availability: removed E1801 and added E1802 & E1812

Added E1399 miscellaneous component code criteria under Gait Trainers; Added E1399, K0108, and K0739 as miscellaneous equipment codes requiring physician or therapy advisor review under Specialized Supply or Equipment. Removed E1811, E1815, and E1818 for flexion/extension devices, as they are included in CP.MP.144 Mechanical Stretch devices.

8/1/19

WA.CP.MP.36

Experimental Technologies

Moved policy to new format and numbering scheme. Added information related to RCW 69.77.060

8/1/19

WA.CP.MP.54

Hospice Services

Moved policy to new format and numbering scheme. Added language regarding investigational services

8/1/19

WA.CP.MP.503

Private Duty Nurse

New Policy

8/1/19

WA.CP.MP.38

Ultrasound in Pregnancy

Added O28.3, O28.5, O99.310 – O99.313.  Expanded code range of R93.811 – R93.89

8/1/19

WA.CP.MP.46

Ventricular Assist Devices

Moved policy to new format and numbering scheme. Updated language to reflect Health Technology Assessment.

8/1/19

CP.PHAR.225

Dalteparin (Fragmin)

Updated FDA approved indication section to reflect pediatric indication expansion for treatment of symptomatic VTE.

8/1/19

CP.PHAR.310

Daratumumab (Darzalex)

Criteria added for new FDA indication: in combination with lenalidomide and dexamethasone in newly diagnosed MM patients who are ineligible for autologous stem cell transplant; references reviewed and updated.

Policy Date

Policy Number

Policy Title

Revision Notes

7/1/19

CP.MP.87

Inhaled Nitric Oxide

Newborn hypoxic respiratory failure: removed exclusion of infant with congenital heart defect; added clinical evidence of PH as a diagnostic option; added that congenital diaphragmatic hernia is excluded except when a bridge to surgical repair. Perioperative criteria: combined indications into I.A.2; specified criteria applies to infants ≥34 weeks of age and children; removed restriction that congenital heart defect criteria applies only in the presence of pulmonary hypertension; added perioperative stabilization and management of hypoxia as an indication for members with congenital heart defect; removed requirement that iNO be delivered via endotracheal tube; for pulmonary hypertensive crisis associated with heart or lung surgery, added immediate pre-op treatment of congenital diaphragmatic hernia; to all perioperative criteria, added requirement that alternative vasodilators must be initiated with the intent to wean iNO. For Continuation criteria: removed restriction to newborns only; removed restriction to one week of iNO or less. Added note applying to all indications that iNO administration beyond 48 hours requires medical director review. Reviewed by a pediatric pulmonologist, pediatric critical care physician, and pediatric emergency medicine physicians. Added ICD-10- CM codes I16.0-I16.9 and Z98.890.

Added requirement that iNO be delivered via endotracheal tube or tracheostomy.

7/1/19

CP.MP.83

Carrier Screening in Pregnancy

Updated authorization protocol to allow for 10 business days retro review instead of 5. For clarification, revised I.B to state Pregnancy < 23 weeks gestation rather than < 22 weeks gestation. References reviewed and updated.

7/1/19

CP.MP.84

Cell-free Fetal DNA Testing

Changed period in which authorizations can be requested from 5 days post-service to 10 days.

7/1/19

CP.MP.89

Genetic Testing

Changed period in which authorizations can be requested from 5 days post-service to 10 days.

7/1/19

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.

Removed option in I.A. for preterm infants to be free of clinically significant events for 7 days vs. 5. Moved section III on home cardiorespiratory monitoring to background, except for requirement that caregiver attends CPR class, which was moved to criteria in I.3. Reviewed by pediatric pulmonologist, pediatrician, and neonatologist.

7/1/19

CP.MP.148

Radial Head Implant

Added in I.A.1 “or fracture is considered irreparable intraoperatively” and in I.B.1 changed history of sepsis to untreated or unresolved sepsis in past 12 months. Specialty review.

7/1/19

CP.MP.174

Selective Dorsal Rhizotomy for Spasticity in CP

New Policy

 

Policy Date

Policy Number

Policy Title

Revision Notes

6/1/19

CP.MP.124

ADHD Assessment and Treatment

Added  AFF2 gene testing and measurement of peripheral brain-derived neurotrophic factor as investigational to II.A.   Code updates-deleted CPT 96101, 96102, 96103, 96118, 96119, 96120, and 97532.  Added CPT-96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, and 97127.  References reviewed and updated.  Specialist reviewed.

6/1/19

 

CP.MP.108

Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia

Sickle cell: specified that donor should be a first-degree relative, and that the conditioning regimen should be myeloablative. Beta thalassemia: added that cord blood is allowed if donated by a first-degree relative, added bone marrow as an acceptable source, and peripheral blood as an acceptable source if the donor is unable or unwilling to donate bone marrow; changed requirement for thalassemia specialist to “provider specializing in thalassemia”

6/1/19

CP.MP.31

Cosmetic and Reconstructive Surgery

Reorganized section 1 for clarity. Removed requirement that scar and keloid revisions must be in members under 18 years. Moved statement regarding documentation of medical records, photos. Removed specific mention of documentation of conservative therapies in the medical records criteria. Reorganized description and background sections.

6/1/19

CP.MP.132

Heart-Lung Transplant

Added contraindication of “Active peptic ulcer disease”.

6/1/19

CP.MP.34

Hyperemesis gravidarum treatment

Added pyridoxine and doxylamine dosing options for 10/10 mg tabs 2-4 times daily, and 20/20mg tabs 1-2 times daily, per ACOG. Updated background regarding ondansetron use.

6/1/19

CP.MP.62

Hyperhidrosis treatments

Added topical glycopyrronium to normal line of medical therapy for axillary hyperhidrosis, in the note under III.  References reviewed and updated.

6/1/19

CP.MP.69

Intensity-Modulated Radiotherapy

Added thyroid and tonsils as subtypes to head and neck cancer list; added cervical, vulvar, perianal cancer indications per NCCN. Updated background. Removed option for CNS, spinal, and head and neck tumors to be metastatic. Replaced descriptive breast cancer indication criteria with specific radiation parameters. Removed deleted CPT code 0073T and added HCPCS G6016. Specialist reviewed.

Coding updates: Removed deleted CPT 77418; updated ICD-10-CM codes per 02/19 criteria updates.

6/1/19

CP.MP.141

Non-Myeloablative Allogeneic Stem Cell Transplants

Updated description. Moved beta thalassemia and sickle cell anemia from the list of approved indications to the list of E/I indications. Removed age restriction from myelodysplastic syndromes. Added to the multiple myeloma indication that an RIC/NMA approach is appropriate post –autologous or fully myeloablative stem cell transplant. Removed diffuse large b-cell lymphoma from E/I list. Clarified that diffuse large cell lymphoma is diffuse large b-cell lymphoma, and added requirement that the patient is in remission following second-line therapy for relapsed or refractory disease. Specialist reviewed.

6/1/19

CP.MP.91

Obstetrical Home Health Care Programs

Specified that only preeclampsia without severe features is appropriate for home management, and removed diagnostic criteria which included severe features. Changed “Alere” to “Optum”

6/1/19

CP.MP.102

Pancreas transplant

Added “early prostate cancer with a low Gleason score,” as an exception to malignancy contraindication, I.b. Removed “and/or islet cell” from IV. A.  References reviewed and updated. Specialist reviewed.

6/1/19

CP.MP.120

Pediatric Liver Transplant

Added to the valproate-associated liver failure contraindication that it applies to children under 10. Specialist reviewed. References reviewed and updated.

6/1/19

CP.MP.70

Proton and Neutron Beam Therapy

Removed inactive CPT 77422

Clarified in II that neutron beam therapy is medically necessary for a patient who is medically inoperable and has salivary gland tumors, in addition to the existing criteria of a surgically unresectable salivary gland tumors.

6/1/19

CP.MP.146

Sclerotherapy for Varicose Veins

Updated description to include mention of glue irritants. Added contraindication for previous administration of sclerotherapy and syndrome/congenital abnormalities.  In “I.” added stipulation that liquid or foam agents to be used in sclerotherapy.  Added statement that cyanoacrylate adhesive is investigational with supporting background information.  In I.A.2.d. removed failure of  >3 weeks prescription dose analgesic medications for pain and added failure of  > 3 months of conservative treatment including compression therapy unless contraindicated.

6/1/19

CP.MP.22

Stereotactic Body Radiation Therapy

Added low to intermediate risk localized prostate cancer to section I. as medically necessary.  Updated background.  Revised coding section, combining ICD 10 codes into applicable categories.  References reviewed and updated.

6/1/19

CP.MP.172

Transcranial Magnetic Stimulation

Added contraindications to retreatment section III.

6/1/19

CP.MP.142

Urinary Incontinence Devices and Treatments

SNM: Changed order of criteria regarding symptoms and diagnosis. Added frequency/urgency as an acceptable symptom in I.B; added overactive bladder as an indication in I.A; added pharmacotherapy and self-catheterization, if tolerated, as required conservative measures for urinary retention in I.D; added to I.E. that urgency/frequency, or retention symptoms should be reduced by a trial of SNM by 50% if present.UBAs: Added an indication for post-bladder support surgery; in II.C. added not wishing to have surgery as a reason to have UABs injected.  Specialist reviewed. References reviewed and updated.

6/1/19

CP.MP.12

Vagus Nerve Stimulation

Updated background with additional information on non-implantable VNS