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

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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

Medicaid Payment Policies

Policy Revision Summary

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

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

Clinical & Payment Policies

Clinical Policies

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Medicaid Clinical Policies Listing

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Policy Revision Summary

August 2020

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December 2019

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July 2019

June 2019