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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

All Genetic Testing Policies are effective 7/1/2022.

Ambetter Pharmacy Policies Listing

Medicaid Clinical Policies Listing

All Genetic Testing Policies are effective 7/1/2022.

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

Policy Number Policy Title Revision Notes

WA.CP.MP.84

Cell-free Fetal DNA Testing

Policy retired

WA.CP.MP.511 Gene Expression Profile Testing for Cancer Tissue Policy retired
CP.MP.89 Genetic and Pharmacogenetic Testing Policy retired
CP.MP.215 Genetic Testing Aortopathies & Connective Tissue Disorder New Policy
CP.MP.216 Genetic Testing Cardiac Disorder New Policy
CP.MP.217 Genetic Testing Dermatologic Conditions New Policy
CP.MP.218 Genetic Testing Epilepsy, Neurodegenerative and Neuromuscular Disorders New Policy
WA.CP.MP.219 Genetic Testing Exome and Genome Sequencing  New Policy - replaces WA.CP.MP.524 - Whole Exome Sequencing
CP.MP.220 Genetic Testing Eye Disorders New Policy
CP.MP.221 Genetic Testing Gastroenterologic Disorders (non-cancerous) New Policy
CP.MP.222 Genetic Testing General Approach to Genetic Testing New Policy
CP.MP.223 Genetic Testing Hearing Loss New Policy
CP.MP.224 Genetic Testing Hematologic Conditions (non-cancerous) New Policy
CP.MP.225 Genetic Testing Hereditary Cancer Susceptibility New Policy
CP.MP.226 Genetic Testing Immune, Autoimmune and Rheumatoid Disorders New Policy
CP.MP.227 Genetic Testing Kidney Disorders New Policy
CP.MP.228 Genetic Testing Lung Disorders New Policy
CP.MP.229 Genetic Testing Metabolic, Endocrine and Mitochondrial Disorders New Policy
CP.MP.230 Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay New Policy
WA.CP.MP.230 Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay New Policy – incorporates WA.CP.MP.512 - Genomic Microarray Testing. Revised section on Chromosomal Microarray Analysis to mirror Washington State Health Technology Assessment criteria. Updated reference.
WA.CP.MP.231 Genetic Testing Non-Invasive Prenatal Screening (NIPS)  New Policy - replaces WA.CP.MP.84 – Cell-free Fetal DNA Testing
CP.MP.232 Genetic Testing Pharmacogenetics New Policy
CP.MP.233 Genetic Testing Pre-Implantation New Policy
CP.MP.234 Genetic Testing Prenatal and Preconception Carrier Screening New Policy
CP.MP.235 Genetic Testing Prenatal Diagnosis (via Amniocenteses, CVS or PUBS) and Pregnancy Loss New Policy
CP.MP.236 Genetic Testing Skeletal Dysplasia and Rare Bone Disorders New Policy
WA.CP.MP.512 Genomic Microarray Testing Policy retired
CP.MP.86 Neonatal Abstinence Syndrome Guidelines Annual review. Description updated. Added cocaine, SSRIs, and caffeine to the NAS symptom onset table. In I.B, replaced portion of note reflecting a 6 hour dosing interval with a 4 hour morphine dosing interval. Added requirement in I.C.2 discharge criteria that infant is consolable with appropriate measures 24-48 hours after the last dose of morphine prior to discharge, based on gestational age, with note about morphine half-lives applicable to a range of gestational ages. Noted in background section A.3.b regarding screening that meconium and umbilical blood reflect drug use for 20 weeks of gestation and later. Background: Changed background heading “Observation/Assessment” to “ B. Observation location//Assessment tool/Level of Care,” and in that section: expanded information regarding LOC for Finnegan scoring, and added section for LOC for ESC scoring; in 3.c, added that polysubstance use should correspond to observation for 5-7 days, and added note that when more than 1 scoring system is used, LOC should be determined according to the scoring system driving the care decisions. In nonpharmacologic treatment section, changed recommendation from frequent feedings of calorie dense formular or fortified breastmilk to “breastfeeding or formula feeding as indicated.” Added c under pharmacologic treatment regarding ESC assessment categories. Added details regarding morphine, clonidine, and phenobarbital weaning. Added additional background to “ESC Assessment Approach.” References reviewed and updated.
CP.MP.237 Oncology Algorithmic Testing New Policy. Incorporates WA.CP.MP.511 - Gene Expression Profile Testing for Cancer Tissue.
CP.MP.238 Oncology Cancer Screening     New Policy
CP.MP.239 Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) New Policy
CP.MP.240 Oncology Cytogenetic Testing New Policy
CP.MP.241 Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies New Policy
WA.CP.MP.524 Whole Exome Sequencing Policy retired
Policy Number Policy Title Revision Notes

CP.MP.173

Implantable Intrathecal or Epidural Pain Pump

Annual review. Reference reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Updated “Refer to” note. In I. added “epidural or” intrathecal administration. In I.A.1. added Inadequate response “to or intolerable side effects from.” II.A added when “the above criteria for” the preliminary trial is met “and the following: Body size is sufficient to support the weight and bulk of the device; No other implanted programmable devices for which the interaction between devices may inadvertently change the prescription; No known allergy or hypersensitivity to the drug being used.” II.A. added “Note: The trial requirement for a percutaneous intrathecal or epidural drug delivery system for pain of malignant origin may be reviewed on a case-by-case basis for instances of advanced disease, when survival time is limited, or considered high risk for procedures.” II.B added “when the above criteria for the preliminary trial is met and all of the following.” Removed duplicate criteria from II.B “no active infection.” Updated policy title from "Implantable Intrathecal Pain Pump" to “Implantable Intrathecal or Epidural Pain Pump."

Policy Number Policy Title Revision Notes

CP.MP.124

ADHD Assessment and Treatment Annual review. “Experimental/investigational” verbiage replaced in policy statement with “there is insufficient evidence to support”. References reviewed, updated, and reformatted. Duplicate reference removed. Changed “review date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision date”. Added “Findings from clinical trials studying adults with noncomorbid ADHD suggest amphetamines as first-line treatment when compared to other medications or cognitive-behavioral therapy (CBT). Methylphenidate is also the first option of treatment for adults with moderate or severe ADHD; however, the evidence on the effects of immediate-release (IR) methylphenidate is limited and controversial in the treatment of the adult population” and “Suggested first line treatment for adults with ADHD is medication rather than cognitive-behavioral therapy (CBT)” to the Background section with no impact to criteria. Revised description of CPT-81229, 92065, 96366, 96367 and 97814.
CP.MP.100 Allergy Testing and Therapy Removed codes 86160, 86161 and 86162 from the not medically necessary table. Added ICD-10 Table 7 with codes that do not support medical necessity for 86160-86162.
CP.MP.96 Ambulatory EEG Policy retired
WA.CP.MP.513 Cardiac Stents Annual review. Reference updated. Removed codes to mirror HCA Billing Guideline. Replaced all occurrences of “member” with “member/enrollee”.
CP.BH.201 Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder Annual review of policy. Changed “Review Date” in header to “Date of Last Revision” and “Date” in revision log header to “Revision Date.” Confirmed current CPT codes for TMS and ICD-10 codes for OCD, and updated policy with grammar and format revisions.
WA.CP.MP.50 Drugs of Abuse: Definitive Testing References reviewed and updated. Added “It is the policy of  Coordinated Care…” to criteria III. Updated background with no impact to criteria. Description updated for CPT code 80370. Reviewed by specialist.
CP.MP.106 Endometrial Ablation Annual review completed. Added “or HPV testing” to I.B. References reviewed and updated. Background updated with no impact to criteria.
CP.MP.209 GI Pathogen Nucleic Acid Detection Panel Testing Annual review. References reviewed, updated, and reformatted.
CP.MP.121 Homocysteine Testing Annual review. References reviewed and updated. Updated description and background with no impact on criteria. Reviewed by specialist.
CP.MP.123 Laser Therapy for Skin Conditions Annual review. Background updated with no impact to policy statement. Specialist reviewed. References reviewed and updated.
WA.CP.MP.505 Microprocessor-Controlled Lower Limb Prosthetics Annual review. No changes made.
CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing Annual review. References reviewed and updated. Updated background with no clinical significance. Specialist reviewed.
CP.MP.149 Testing for Rupture of Fetal Membrane Policy retired
WA.CP.MP.517 Testosterone Testing Annual review. Reference updated. Added coverage criteria for gender dysphoria. Updated language regarding services outside of the scope of this policy. Added a note about gender dysphoria benefits.
CP.MP.189 Thymus Transplantation Policy retired
CP.BH.200 Transcranial Magnetic Stimulation for Treatment Resistant Major Depression Review of recent research and annual review of policy by the CABH CPSC.  Revisions included Policy/Criteria, initial sessions revised from 30 to 20; Section II, additional sessions revised from 20 to 10; and a statement was added to the background section in reference to a randomized clinical trial published by J.A. Yesavage et al (2018), Effect of Repetitive Transcranial Magnetic Stimulation on Treatment-Resistant Major Depression in US Veterans to reflect the reference supports CABH exclusion criteria related to treatment of ongoing SUD, PTSD, and comorbidity disorders. Changed “Review Date” in header to “Date of Last Revision” and “Date” in revision log header to “Revision Date.” References updated.
WA.CP.MP.520 Tympanostomy Tubes Annual review. Updates to section II to mirror HCA Billing Guideline. References updated.
CP.MP.38 Ultrasound in Pregnancy Annual review. Removed table 5, diagnosis codes supporting medical necessity for TVU, which was included in the previous version in error. Added “detailed “ to criteria statement, section III: “Further detailed anatomic ultrasounds…..” for clarification. References reviewed and updated. Specialist review.
CP.MP.98 Urodynamic Testing References reviewed and updated. In 1.D.1, changed “incontinence associated with recurrent UTI” to “Urinary incontinence.” Codes checked. Updated background with no impact to policy statement.
CP.MP.177 Video Electroencephalography (V-EEG) Policy retired
Policy Number Policy Title Revision Notes

WA.CP.MP.521

Behavioral Health Personal Care Services

Annual review. Reference updated.

WA.CP.MP.502 Cochlear Implants: Bilateral vs. Unilateral Annual review. Reference updated.
WA.CP.MP.501 Continuous Glucose Monitoring System Annual review. References updated.
CP.MP.211 Electromyography and Nerve Conduction Studies Policy retired in favor of InterQual criteria.
WA.CP.MP.36 Experimental Technologies Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”  References updated. Corrected logo.

WA.CP.MP.130

Fertility Preservation Annual review. Reference updated.
WA.CP.MP.46 Ventricular Assist Devices Annual review. Updated Description. Added age for pediatric services. Updated Background. Reviewed and updated References.
CP.MP.132 Heart-Lung Transplant Annual review. References reviewed, updated, and reformatted. Updated 1.C. with some contraindications from ISHLT 2021 guidelines. Background updated with no clinical significance.
CP.MP.34 Hyperemesis Gravidarum Treatment Annual review. References reviewed, updated with AMA format. Updated background with no impact to criteria. Changed “Last Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date." Specialist reviewed.
CP.MP.58 Intestinal and Multivisceral Transplant Edited contraindications: Replaced “non-hepatic malignancy…” with malignancy with high risk of recurrence or death…”; added GFR restriction, added HIV infection with detectable viral load, added stroke, acute coronary syndrome, or MI; added acute renal failure…; added septic shock; added progressive cognitive impairment; replaced “untreatable significant dysfunction of another major organ system…” with “Other severe uncontrolled medical condition expected to limit survival after transplant;” slightly reworded substance use contraindication; removed “acute medical instability…”; removed “uncorrectable bleeding diathesis.”
CP.MP.57 Lung Transplantation Annual review. Added “or surgical therapy” to I and noted that maximal medical therapy includes pulmonary rehab when applicable. Updated the following based on ISHLT 2021 guidelines; removed criteria “High (> 80%) likelihood of surviving at least 90 days after lung transplantation.”, updated I.C., I.D.1.a, I.D.1.b., I.D.1.c., I.D.1.d., I.D.1.f., I.D.2.a, I.D.2.b. Clarified nicotine and tobacco abstinence contraindication. Added CPT codes 32850, 32855, and 32856. References reviewed, updated, and reformatted. Reviewed by specialist.
CP.MP.141 Non-Myeloablative Allogenic Stem Cell Transplants Annual review. Rephrased criteria I.A.3. from “aplastic anemia” to “acquired bone marrow failure such as severe aplastic anemia.” Added new indication I.A.4., “Familial bone marrow syndromes such as….” Removed “molecular remissions induced by Gleevec” from I.A.8.” Added criteria points 13. and 14. to criteria I.A. “Experimental/investigational” verbiage in criteria II. replaced with descriptive language. Sorted list of non-supported indications in criteria II. into 3 subcategories, solid tumors, autoimmune disorders and hemoglobinopathies. In criteria I.C., combined and rephrased contraindications 2. and 3. and updated verbiage regarding substance abuse and dependence in 4. Minor rewording in description and background with no impact on criteria. Removed ICD-10 codes D57.00-D57.819 for sickle-cell disorders from ICD-10 table of codes to support coverage. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Reviewed by specialist.
CP.MP.102 Pancreas Transplantation  Annual review. References reviewed and updated. Updated description and background with no clinical significance. Updated all contraindications in criteria I.C. “Experimental/investigational” verbiage replaced in criteria IV. statement with descriptive language. Specialist reviewed.
CP.MP.138 Pediatric Heart Transplant Moved criterion “all reversible causes of heart failure have been ruled out…” to I.C, and moved contraindications to I.D. Edited contraindications: added GFR rate; added “Acute liver failure or cirrhosis…”, added acute renal failure; added HIV infection with detectable viral load; added septic shock; added progressive cognitive impairment; replaced “untreatable significant dysfunction of another major organ system..” with “Other severe uncontrolled medical condition expected to limit survival after transplant”; slightly reworded substance use contraindication; removed “acute medical instability…” and “uncorrectable bleeding diathesis;” replaced “malignancy, except for non-melanoma…” with “Malignancy with high risk of recurrence or death related to cancer.”
CP.MP.120 Pediatric Liver Transplant Edited contraindications: Replaced “non-hepatic malignancy…” with malignancy with high risk of recurrence or death…”; added GFR restriction, added HIV infection with detectable viral load, added stroke, acute coronary syndrome, or MI; added acute renal failure…; added septic shock; added progressive cognitive impairment; replaced “untreatable significant dysfunction of another major organ system…” with “Other severe uncontrolled medical condition expected to limit survival after transplant;” slightly reworded substance use contraindication.
WA.CP.MP.503 Private Duty Nursing Services Updated to reflect the decision to move to Interqual criteria vs. current policy.  Removal of all MATLOC criteria, insertion of Social Factors assessment for additional hours.  Updated references. Replaced “member” with “member/enrollee” in all instances.
WA.CP.MP.523 Sleep Apnea Diagnosis and Treatment Corrected I.B. to indicate “HFrEF of 40% or less”    
CP.MP.162 Tandem Transplant Replaced contraindications “Inadequate cardiac, renal, pulmonary, or hepatic function and significant, uncorrectable, life-limiting medical condition” with those concerning GFR, acute liver failure…, acute renal failure…, septic shock, active extrapulmonary or disseminated infection, active tuberculosis infection, HIV infection with detectable viral load, progressive cognitive impairment, other severe uncontrolled medical condition…Updated references.
Policy Number Policy Title Revision Notes

CP.MP.179

Antithrombin III (Atryn, Thomate)

Policy is retired.

WA.CP.MP.525

Catheter Ablation for SVTA

Annual review. References updated.

WA.CP.MP.515

Fecal Microbiota Transplantation

Annual review. Changed “not covered” to “not medically necessary”. Changed “members” to “members/enrollees”. Updated references.

CP.MP.62

Hyperhidrosis Treatments

Annual review. References reviewed and updated. Reviewed by specialist. Changed "Last Review Date" in the header to "Date of Last Revision" and "Date" in revision log to "Revision Date". “Experimental/investigational” verbiage replaced in policy statement and background with descriptive language. Updated reference to CP.PHAR.09 to CP.PHAR.230 and CP.PHAR.232 as well as CP.PMN.117 to CP.PMN.177.

WA.CP.MP.500

Mandibular Advancement Devices

Annual review. Reference reviewed.

CP.MP.202

Orthognathic Surgery

New policy

CP.MP.206

Skilled Nursing Facility Leveling

Added corresponding revenue codes to each level’s “care requirements” section in I.C and II.C.

WA.CP.MP.523

Sleep Apnea Diagnosis and Treatment

Added reference to new policy CP.MP.202 – Orthognathic Surgery

WA.CP.MP.526

Stem Cell Therapy for Musculoskeletal Conditions

Annual review. Changed headings to “Date of Last Revision” and added “Effective Date”. Replaced “not covered” with “not medically necessary”. Updated references.

CP.MP.22

Stereotactic Body Radiation Therapy

Annual Review. In II.A., clarified that “one of the following” must be met. Removed “SBRT” from the note about proximity to cranial nerves in II.F. “Experimental/investigational” verbiage replaced in criteria III. with descriptive language. Changed "Last Review Date" in the header to "Date of Last Revision" and "Date" in revision log to "Revision Date". Reviewed by specialist.

WA.CP.MP.510

Tinnitus Treatment

Annual review. Replaced "not covered" with "not medically necessary". References updated.

CP.MP.177

Video Electroencephalography (V-EEG)

Annual review. References reviewed and updated. Minor wording changes in background with no clinical significance.

WA.CP.MP.177

Video Electroencephalography (V-EEG)

Policy archived and replaced with CP.MP.177

WA.CP.MP.524

Whole Exome Sequencing

Annual review. Expanded Description.  Added Effective Date. Added 0036U, 0214U, 0215U, 81417.

Policy Number Policy Title Revision Notes

WA.CP.MP.508

Bone Growth Stimulator

Policy retired and replaced with CP.MP.194 – Osteogenic Stimulation
CP.MP.186 Burn Surgery Annual review. References reviewed and updated. Changed, “review date,” in the header to, “date of last revision,” and, “date,” in the revision log header to, “revision date." Removed criteria III. Stating burn surgery was, “not medically necessary when duplicating another provider’s procedure, product, or service.”  Reviewed by specialist.
CP.MP.203 Diaphragmatic/Phrenic Nerve Stimulation

Annual review. References reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Replaced investigational verbiage with “evidence is limited in supporting safety and efficacy.” Added CPT 64580 and 64590 and HCPCS L8680, L8682, L8683, L8695, and L8696

CP.MP.107 Durable Medical Equipment (DME)

Annual review. References reviewed and updated. Added burn garment HCPCS codes A6502, A6503, A6504, A6505, A6506, A6508, A6509, A6510, A6512 and A6513 to policy. Made note for HCPCS code K0108 to refer to CP.MP.99 for wheelchair seating in Specialized supply or Equipment section.

CP.MP.89 Genetic and Pharmacogenetic Testing Annual review. Updated verbiage in Description section. Under Notes: added “clinical policies” to bullet point 1 and updated bullet point 3 to state “Requests for genetic panels will be reviewed to determine if all included gene analyses are medically necessary.” In I.A. added “having inherited” and “or genetic disorder.” Updated verbiage in I.C from “consistent with community standards” to “when available”. In I.E., removed requirement for technical performance verification in the literature. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated, and reformatted. Specialist reviewed.
CP.MP.209 GI Pathogen Panel Testing

In the note below table 3, replaced “PCR” with “GI pathogen panel testing.”

CP.MP.113 Holter Monitor Added note: "This policy provides medical necessity guidelines for Holter monitoring up to 48 hours. For Holter monitoring beyond 48 hours, see clinical decision support criteria."
WA.CP.MP.54 Hospice Services

Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed.

WA.CP.MP.69

Intensity-Modulated Radiotherapy Annual review. Revised criteria to more closely mirror the HCA Billing Guideline. References updated.
CP.MP.170 Nerve Blocks for Pain Management Revised policy title from “Nerve Blocks for Pain Management” to “Nerve Blocks and Neurolysis for Pain Management.” Added VII. Insufficient evidence to determine the safety and effectiveness of intraosseous radiofrequency nerve ablation of basivertebral nerve.  Updated background and references accordingly.

CP.MP.194

Osteogenic Stimulation

New policy

CP.MP.138 Pediatric Heart Transplant

Annual review.  References reviewed and updated. Reviewed by specialist.

CP.MP.182

Short Inpatient Hospital Stay Replaced 2020 inpatient only list with 2022 inpatient only list in I.A. and updated references accordingly.
Policy Number Policy Title Revision Notes

CP.MP.108

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

Annual review. References reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” “Experimental/investigational” verbiage replaced in policy statement with, “there is insufficient evidence regarding the safety and efficacy." Reviewed by specialist.

CP.MP.31

Cosmetic and Reconstructive Procedures

Clarified in I.A.1. failure of conservative therapy “(unless conservative therapy is not standard of care for the condition, or is contraindicated).” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Added the following codes from the retired Craniofacial Surgery policy; 21120, 21121, 21122, 21123, 21137, 21138, 21139, 21159, 21160, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21230, 21235, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, and craniectomy/craniotomy codes for craniosynostosis.

Clarified in I.A.4.a. “Post-mastectomy,*  medically necessary lumpectomy, or other medically necessary breast surgery.” Updated II.R. “Mastopexy (except for breast reconstruction post-mastectomy, medically necessary lumpectomy, other medically necessary breast surgery resulting in significant asymmetry). In II.E., changed “InterQual” to “Decision Support Criteria.” Added II.U. “Breast reconstruction for fibroadenomas or other benign lesions, unless medically necessary per clinical decision support criteria” to not medically necessary procedures. Added codes 19330 and 19499. Annual review. References reviewed, updated, and reformatted.

WA.CP.MP.208

Drugs of Abuse: Presumptive Testing

Policy retired

WA.CP.MP.50

Drugs of Abuse: Definitive Testing

Annual review. Deleted note referring to WA.CP.MP.208 Drugs of Abuse, Presumptive Testing. References updated and coding reviewed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

CP.MP.103

Fractional Exhaled Nitric Oxide

Policy retired

CP.MP.180

Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Annual review. References reviewed and updated. Changed "Last Review Date" in the header to "Date of Last Review" and "Date" in revision log to "Revision Date." Added CPT code 64585. Reviewed by specialist.

CP.MP.170

Nerve Blocks for Pain Management

Annual review. Added refractory chronic pancreatitis as an indication for celiac plexus block to section III and updated background accordingly.  Added ICD -10 codes K86.0 & K86.1 to support coverage criteria.  Changed “Experimental/investigational” language in section V. and VI.E. to “insufficient evidence to support…”.Under section VI, moved “Note” for visibility. Added insufficient evidence to support peripheral nerve block for treatment of trigeminal neuralgia to VI.D, removed G50.0 from list of ICD 10 codes that support coverage criteria and updated background accordingly. References reviewed, reformatted and updated.  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Reviewed by specialist.

CP.MP.109

Panniculectomy

Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated, and reformatted. Minor verbiage changes with no clinical significance. Reviewed by specialist.

WA.CP.MP.70

Proton and Neutron Beam Therapy

Annual review. References reviewed and updated. Updated background. Changed "Last Review Date" in the header to "Date of Last Review" and "Date" in revision log to "Revision Date". Replaced “not covered” in III with “not medically necessary”.

CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management

Annual review. References reviewed and updated. In policy statement, removed option for procedures “without radiographic guidance.” Reviewed by specialist. Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date”.

CP.MP.151

Transcatheter Closure of Patent Foramen Ovale

Annual review. Reworded policy statement, adding “when used according to FDA labeled indications, contraindications, warnings and precautions.  Removed contraindications (I.B.4) since they are specific to the Amplatzer PFO device. Updated background with 2021 AHA/ASA  recommendations. Added AAN recommendation for patients who opt to receive medical therapy alone without PFO closure. “Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated and reformatted. Reviewed by specialist.

CP.MP.127

Total Artificial Heart

Annual review. Replaced investigational/experimental language in II & III with, “insufficient evidence to support the use of …” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated and reformatted.

CP.MP.142

Urinary Incontinence Devices and Treatments

Annual review. Replaced investigational language in IV, to “insufficient  evidence in the published peer-reviewed literature to support the use of UBA injection of autologous fat, non- FDA approved procedures, and any other circumstances than those specified above.” Added HCPCS code A4290. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated and reformatted. Reviewed by specialist.

Policy Number Policy Title Revision Notes

CP.MP.179

Antithrombin III (Atryn, Thomate)

Annual review. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” “Not medically necessary” verbiage replaced in policy statement with “current evidence does not support” verbiage.

CP.MP.156

Cardiac Biomarker Testing for Acute MI

Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date."  References reviewed, and updated. Reviewed by specialist.

WA.CP.MP.84

Cell-Free Fetal DNA Testing

Removed deleted CPT 0168U. Moved code 0060U from the coding table supporting medical necessity to the table of codes that do not support medical necessity.

CP.MP.105

Digital EEG Spike Analysis

Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated and reformatted. Reviewed by specialist.

CP.MP.125

DNA Analysis of Stool

Policy retired.

CP.MP.101

Donor Lymphocyte Infusion

Annual review. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” “Experimental/investigational” verbiage replaced with policy statement verbiage that “current evidence does not support” the use of DLI for the stated indications. Replaced “hematological” with “hematologic” throughout the policy.

CP.MP.155

EEG in Evaluation of Headache

Annual review complete. Coding reviewed. References reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Reviewed by specialist.

CP.MP.131

Essure Removal

Annual review. References reviewed and updated. Reviewed by Specialist.  Changed "Last Review Date" in the header to "Date of Last Review" and "Date" in revision log to "Revision Date."

CP.MP.150

Home Phototherapy for Neonatal Hyperbilirubinemia

Annual review. References reviewed and updated. Background updated, no clinical significance. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date."

CP.MP.153

H. Pylori Testing

Annual review.  References reviewed and updated. Reviewed by specialist. Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date”.

CP.MP.87

Inhaled Nitric Oxide

Added indications for case by case review of iNO initiation for preterm infants <34 weeks at birth to section II. Split continuation criteria into section III, and not medically necessary indications are now section IV. Minor rewording of background. Added reference 35. Changed “Review Date” in policy header to “Date of Last Revision,” and “Date” in the revision log table header to “Revision Date.”

CP.MP.70

Nerve Blocks for Pain Management

Edited note in section VI to state: If administered as part of a surgery or other procedure, coding for peripheral/ganglion nerve blocks should follow proper coding practices and would not be subject to prior authorization or payment separately from the procedure.

CP.MP.154

Thyroid Hormones and Insulin Testing in Pediatrics

Annual review.  References reviewed and updated.  Specialist review.  Changed "Last Review Date" in the header to "Date of Last Review" and "Date" in revision log to "Revision Date."

Policy Number Policy Title Revision Notes

CP.MP.100

Allergy Testing and Therapy

Annual review. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Criteria and coding reviewed by specialist.

WA.CP.MP.119

Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis

Policy retired.

CP.MP.164

Caudal or Interlaminar Epidural Steroid Injections for Pain Management

In policy statement, changed “with or without radiographic guidance” to “with imaging, except in rare instances.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed and updated. Replaced “member” with “member/enrollee” in all instances.  Specialist review.

WA.CP.MP.84

Cell-free Fetal DNA Testing

Annual review. Added “Effective Date”. Added codes 0168U and 0060U. Separated code tables.

CP.MP.107

Durable Medical Equipment and Orthotics and Prosthetics Guidelines

Removed requirement for replacement requests not due to physiological changes to meet existing criteria and reformatted criteria. Contents table renumbered.

CP.MP.40

Gastric Electrical Stimulation

Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date."

CP.MP.136

Home Birth

Annual review. Added to I.A.2.b an option for family practice physicians who have completed an OB fellowship to attend a home birth without a supervising OB. Removed WHO background information on home birth, and supporting reference. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date."  References reviewed, reformatted, and updated.

WA.CP.MP.27

Hyperbaric Oxygen Therapy

Policy updated to reflect HCA Billing Guideline. “Members” updated to “Members/Enrollees”. References updated.

CP.MP.57

Lung Transplantation

8/21: Replaced contraindications of “severely limited functional status with poor rehabilitation potential” and those regarding past or current nonadherence to medical therapy, and psychological condition associated with the inability to comply with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “review date” in header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.”       

9/21: Annual review. References reviewed and updated. Reviewed by specialist.

CP.MP.86

Neonatal abstinence syndrome guidelines

Annual review. References reviewed, updated and reformatted.  Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date.” Website for Modified Finnegan scoring added to the background under B.1.Clarifying edits added to I.A.1 regarding “duration of observation for symptoms.” Clarifying edits added to Note in I.B regarding “medications to treat withdrawal symptoms.” 

CP.MP.51

Reduction Mammoplasty and Gynecomastia Surgery

In I.A.2., changed “No change in cup size for at least 6 months” to “For adolescents, no breast growth equivalent to a change in cup size for at least 6 months.” Updated background regarding gigantomastia of pregnancy with no impact on criteria.

WA.CP.MP.523

Sleep Apnea Diagnosis and Treatment

Moved section III on CPAP titration to be section II and expanded this section. Added qualifying statements to I.A., I.H. and I.I. Added language for sleep-related hypoventilation. Made minor changes to Description. Updated references. Replaced “members” with “members/enrollees”.

WA.CP.MP.177

Video Electroencephalography (V-EEG)

Annual review. Updated verbiage for outpatient video encephalography (EEG) monitoring in the home to indicate no or unclear support for its use. Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date”.  Reviewed by specialist. References reviewed and updated. Replaced “members” with “members/enrollees’ in all instances.

Policy Number Policy Title Revision Notes

CP.MP.93

Bone-Anchored Hearing Aid

Annual review. Reworded I.B. with no clinical significance. Revised I.E from “threshold of 20dB” to “threshold of < 20dB.” In I.F.4., added idiopathic causes to the list of causes of unilateral deafness. Revised description of HCPCS L8691 and added L8694. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Replaced “member” with “member/enrollee.” References reviewed, updated and reformatted. Reviewed by specialist.

WA.CP.MP.516

Carotid Artery Stenting

Annual review. References updated. Added additional criteria for “high risk” from HCA Billing Guideline. Changed statement regarding intracranial stents from not covered to not medically necessary. Removed 37217, 37218, 0075T and 0076T from code list.

CP.MP.107

Durable Medical Equipment and Orthotics and Prosthetics Guidelines

Reorganized Standing Frame criteria and required that replacement requests also meet existing criteria for the initial request. For initial request under 18, added "and one of the following: Developmental delay in ambulation and ≥ 18 months of age; Documented neurological or neuromuscular impairments and ≥ 1 year of age.” Required that documentation supports meeting height and weight requirements, alert and responsive to stimuli, no contraindications to standing program, and caregiver trained, available, and able to safely assist. Removed requirement for “able to tolerate upright position.” Added informational note.

CP.MP.134

Evoked Potential Testing

Annual review completed. Minor typo corrections. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated, and reformatted. Coding reviewed and updated. Removed intraoperative CPT codes 95940, 95941, and HCPCS code G0453.

CP.MP.132

Heart-Lung Transplant

In B.2., removed “adequate functional status with the ability for rehabilitation.” Replaced contraindications of “history of history of psychological, behavioral, or cognitive disorders, poor family support structures, or documented noncompliance with previous therapies that could interfere with successful performance of care regimens after transplantation” and “current non-adherence to medical therapy…” with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “Review Date” in policy header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.”

CP.MP.58

Intestinal and Multivisceral Transplant

Replaced contraindications of “severely limited functional status with poor rehabilitation potential” and those regarding past or current nonadherence to medical therapy, and psychological condition associated with the inability to comply with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “review date” in header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.”

CP.MP.167

Intradiscal Steroid Injections for Pain Management

Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”  References reviewed, reformatted and updated. Replaced “member” with “member/enrollee” in all instances. Specialist review.

CP.MP.128

Optic Nerve Decompression Surgery

Revised language in II from “investigational” to “insufficient evidence to support…” References reviewed, updated and reformatted.    Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Replaced member with member/enrollee.

CP.MP.102

Pancreas Transplantation

Removed contraindication of “severely limited functional status with poor rehabilitation potential.” Replaced “Psychiatric or psychological condition associated with the inability to cooperate or comply with medical therapy” and the contraindication regarding non-compliance with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “Review Date” in header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.”

CP.MP.138

Pediatric Heart Transplants

In I.C., replaced “adequate functional status with ability for rehabilitation” and contraindications regarding past or current nonadherence to medical therapy, and psychological condition associated with the inability to comply with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “review date” in header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.”

CP.MP.120

Pediatric Liver Transplant

Replaced contraindications regarding psychological condition preventing compliance with medical therapy and “current non-adherence to medical therapy” with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “Review Date” in header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.”

CP.MP.181

Polymerase Chain Reaction Respiratory Viral Panel Testing

Removed criteria specific to Covid 19 testing in I.A.

CP.MP.210

Repair of Nasal Valve Compromise

New policy.

CP.MP.166

Sacroiliac Joint Interventions for Pain Management

Annual review completed. References reviewed, updated, and reformatted.

CP.MP.88

Sickle Cell Disease Observation

Policy retired in favor of InterQual criteria.

CP.MP.206

Skilled Nursing Facility Leveling

Annual review. In I.B.1 and II.B.I, corrected list of appropriate oversight to include doctors. References reviewed and updated. Reviewed by specialist.

CP.MP.162

Tandem Transplant

Replaced contraindications regarding past or current nonadherence to medical therapy, and psychological condition associated with the inability to comply with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.”

CP.MP.169

Trigger Point Injections for Pain Management

Annual review. Referenced reviewed and updated. Updated criteria II. to replace “not medically necessary” with “current evidence does not support.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Replaced member with member/enrollee. Reviewed by specialist.

CP.MP.12

Vagus Nerve Stimulation

Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Background updated with additional study on nVNS for migraine headaches. References reviewed and updated. Reviewed by specialist.

WA.CP.MP.522

Varicose Vein Treatment

Clarified in III to cyanoacrylate is used in endovenous ablation and not sclerotherapy. Updated background accordingly. Changed “review date” in policy header to “date of last revision,” and “date” in the revision log header to “revision date.” Updated references.

Policy Number

Policy Title

Revision Notes

CP.MP.96

Ambulatory EEG

Annual review completed. References reviewed, updated, and reformatted. Replaced all instances of member with member/enrollee. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Background updated with no clinical significance. Specialist reviewed.

WA.CP.BH.104

Applied Behavior Analysis

Annual review. Reference list reviewed and updated. Changed “Review Date” in the header to “date of last revision” and “date” in the revision log header to “Revision date.” Corrected typo

CP.MP.14

Cochlear Implant Replacements

Annual review. References reviewed and updated. Coding reviewed, added codes L8621 and L8622. Replaced all instance of “member” with “member/enrollee.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Sent for specialist review.

WA.CP.MP.208

Drugs of Abuse: Presumptive Testing

Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Removed diagnosis code listing. Removed reference to WA.CP.MP.50, Drugs of Abuse, Definitive Testing.

CP.MP.107

Durable Medical Equipment (DME)

Added criteria for enclosed beds to “Other Equipment” section of policy. Added references and codes E0316, E1399 and E0328 or E0329 (when combined with E0316 or E1399) for enclosed beds. Replaced “investigational” with “not proven safe and effective” in the following sections: Pneumatic compression devices, neuromuscular stimulator, and peroneal nerve stimulators.

Updated policy to remove neuromuscular stimulator, functional neuromuscular stimulator, and peroneal nerve stimulator, which was transferred to CP.MP.48 Neuromuscular Electrical Stimulation (NMES). Replaced existing Standing Frames criteria with new initial request and replacement request criteria. Revised section on pneumatic compression devices to state that they are not proven safe and effective for lymphedema of the abdomen, trunk, chest, genitals, or neck; and for arterial insufficiency. Added criteria for Wheelchair-mounted Assistive Robotic Arm (JACO). Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Removed archived Hayes references.

CP.MP.106

Endometrial ablation

Annual review completed.  References reviewed and updated and reformatted for AMA style.  Changed “members” to “members/enrollees.”  Removed “experimental and investigation” from II, changing to “insufficient evidence.”  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”  Specialty review completed.  Added ThermaChoice to Table 1 per UpToDate reference “3”. 

WA.CP.MP.514

Extra-Corporeal Membrane Oxygenation (ECMO) Therapy

Annual review. References updated. “Members” replaced with “Members/Enrollees”

CP.MP.211

Electromyography and Nerve Conduction Studies

New policy.

WA.CP.MP.171

Facet Joint Interventions for Pain Management

Clarified that radiographic guidance is required for the injections. Noted maximum of 3 injections. Removed requirements for injection that were in the neurotomy criteria. Clarified clinically significant improvement for second neurotomy. Indicated neurotomy of the thoracic region is not medically necessary rather than not covered. Updated references.

CP.MP.137

Fecal Incontinence Treatments

Annual review completed. References reviewed, updated, and reformatted. “Experimental/investigational” verbiage replaced in policy statement with “have not been proven effective for the treatment of fecal incontinence, although they continue to be evaluated in clinical studies”. Replaced all instances of “member” with “member/enrollee”. "Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Minor verbiage changes to background with no clinical significance.

CP.MP.137

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Annual review. References reviewed and updated. Coding reviewed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Replaced all instance of “member” with “member/enrollee.” Added, “D. Placement of a thoraco-amniotic shunt for pleural effusion with or without secondary fetal hydrops,” to criteria set I. Added criteria set, “II. It is the policy of health plans affiliated with Centene Corporation that all repeat utero fetal surgery procedures require secondary review.” Reviewed by specialist.

WA.CP.MP.511

Gene Expression Profile Testing

Annual review. Expanded Description. References updated. Replaced “members” with “members/enrollees”. Added codes 81522, 81542, 81552, 0045U, 0089U, 0090U, 0153U. Multiple myeloma and colon cancer testing changed from not covered to not medically necessary.

WA.CP.MP.512

Genomic Microarray Testing

Annual review. References updated. Removed reference to Whole Exome Sequencing in Description. Replaced statement about non-coverage with “not medically necessary”. Replaced “members” with “members/enrollees”.

CP.MP.85

Neonatal Sepsis Management

Annual Review. Removed “or level 1 nursery (rev code 171),” from II.D: “Asymptomatic infants with a positive blood culture and no other indications are appropriate for transitional care or level 1 nursery (rev code 171).” Added sentence to note under criteria point II.D. to say, “It is difficult to administer intravenous antibiotics in the home with home health care due to the challenge of keeping very small catheters in place and patent.” References reviewed and updated. Replaced all instances of “member” with “member/enrollee”.  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Sent for specialist review.

CP.MP.51

Reduction Mammoplasty and Gynecomastia Surgery

Annual review. Deleted “for non-cosmetic reasons” from the policy statement in I, as it is redundant given the symptom criteria required. Replaced "and/or" with "or" in I.A.1. Reworded paragraph under  Medical Record Documentation Requirements for both reduction mammoplasty and gynecomastia, and changed requirement of photographic documentation to “photographic documentation may be requested to support written documentation.”  References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Specialist reviewed.

CP.MP.162

Tandem Transplant

Annual review. References updated. Minor wording changes with no clinical significance. Coding reviewed. Replaced all instance of “member” with “member/enrollee.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Sent for specialist review.

CP.MP.98

Urodynamic testing

Annual review completed. Codes checked.  References updated and reformatted for AMA style. Changed “Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” Specialty review completed.

WA.CP.MP.528

Whole Exome Sequencing

New policy.

Policy Number

Policy Title

Revision Notes

WA.CP.MP.37

Bariatric Surgery

Section I:  Added BMI criteria for Asian ethnicity to I.B.1 and I.B.3. Section II: Removed criteria for ECG during cardiac clearance except for high risk, corrected typos; in II.B, added note about medical director review if A1C ≥8 and removed blood glucose requirements;  in II.C., Pulmonary Evaluation removed requirement of chest x-ray and specific criteria for PSG, noting that PSG is warranted if OSA screening is positive in; In II.D, added examples of nutritional tests to be conducted, and that malabsorptive procedures may require further testing; Removed requirement of 1 year abstinence of drug & alcohol use and urine drug screen if history of abuse in II.F; added “current drug and alcohol abuse” to list of contraindications; added II.I, clinically significant GI symptoms should be evaluated & treated prior to surgery. In III.A.2.e, removed option for non-compliance with post-operative regimen if completing a multidisciplinary bariatric program. In III.A.2.f., removed option for non-compliance. Reworded V, replacing “investigational” with “current medical literature is inadequate to determine the safety, efficacy and long-term outcomes” and added one-anastomosis gastric bypass; endoscopic sleeve gastroplasty; transoral endoscopic surgery; vagus nerve blocking (e.g., Maestro) and gastric balloon (e.g., ReShape Duo, Orbera intagastic balloon, Obalon Balloon) to this list.  Updated background.  Added the following CPT codes as not supporting medical necessity: 43648, 43882, 64595, 0312T, 0313T, 0314T, 0315T, 0316T and 0317T.  References reviewed, updated and reformatted.  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

CP.MP.83

Carrier Screening in Pregnancy

Policy retired.

CP.MP.94

Clinical Trials

References reviewed, updated and reformatted. Replaced all instances of “member” with “member/enrollee.”  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

CP.MP.115

Discography

Replaced WA.CP.MP.115

WA.CP.MP.115

Discography

Archived and replaced with CP.MP.115

CP.MP.209

GI Pathogen Nucleic Acid Detection Panel Testing

New policy.

WA.CP.MP.207

Home Prothrombin Time Monitoring

New policy.

CP.MP.123

Laser Therapy for Skin Conditions

Annual review. “Experimental/investigational” verbiage replaced in policy statement with “evidence is insufficient to draw conclusions.” Replaced all instances of “member” with “member/enrollee.” Coding reviewed. References reviewed and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

CP.MP.170

Nerve Blocks for Pain Management

Added the following note to VI. Peripheral/ganglion nerve blocks: Peripheral/ganglion nerve blocks may be approved without prior authorization when used during another medically necessary procedure (i.e. as anesthesia during surgery).

CP.MP.82

NICU Apnea Bradycardia Guidelines

In I.A.1 and I.3.B., changed requirement for no clinically significant events before discharge from “5” to “5-7” days.  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

CP.MP.81

NICU Discharge Guidelines

Added I.A.3 regarding weight lost in preterm infants less than a week old. Added a note regarding gastrostomy tube placement recovery/education to I.B.2.d.ii.  Updated II.A with temperature range and in note changed 1600 grams to1800 grams. Added “Chronic Lung Disease/” to “Bronchopulmonary dysplasia” for condition in III.B.3.a. Added note under III.B.3.b.i explaining stability on home ventilator in hospital prior to discharge. Removed V.A and B, updating the “free of infection” criteria statement. Added new section VI regarding caregiver competency. In section VII: clarified in A “should be approved for any of….”; added A.5 regarding caffeine for apnea; added B regarding parent/caregiver refusal to sign; added C.1 and 2 regarding nondenial of care; updated the note under describing rooming-in. In Discharge Recommended Practices: Added “immunoglobulin” to C.2 ;updated C.3 with influenza injection; added “hospital developed education program” under D; added E.1-4 regarding car seats. Replaced all instances of “members” with “members/enrollees.”  References reviewed and updated to AMA format. Reviewed by neonatologist.  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

CP.MP.49

Physical, Occupational and Speech Therapy Services

In I.B, noted that treatment order can come from “other qualified health professional” as well as a physician; added “other qualified healthcare professional to II.A.9, and the background. References reviewed, updated, and reformatted. Revised wording with no clinical significance.  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

WA.CP.MP.503

Private Duty Nursing

Annual review. Reference updated. Minor changes to section I. Removed T1030 from HCPCS table. Updates “Members” to “Members/Enrollees” in Important Reminder.

CP.MP.166

Sacroiliac Join Interventions for Pain Management

Updated I.A. to specify that the criteria applies to therapeutic injections as well as diagnostic. Updated I.B. to state “A second diagnostic or confirmatory sacroiliac joint injection when pain was improved by at least 75% after the first diagnostic SIJ injection”, rather than that pain did not improve. I.C. was updated to specify “therapeutic” SIJ injection. II was changed from 50% to 75%. Replaced member with member/enrollee in all instances.  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

CP.MP.206

Skilled Nursing Facility Leveling

Updated therapy requirement verbiage for SNF Level 1 from “skilled therapy for up to 2 hours per day” to “skilled therapy 1-2 hours per day.” For SNF Levels 1 and 2, changed requirement from skilled nursing hours and therapy hours to skilled nursing hours or therapy hours.  Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

CP.MP.189

Thymus Transplantation

Annual review complete. References reviewed, updated and reformatted. Replaced all instances of member with member/enrollee. Specialty review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”

CP.MP.38

Ultrasound in Pregnancy

Section IV.Table 1, revised note * Increase frequency to weekly in women with TVU cervical length of 25 to 29 mm, to 26 to 29mm and changed “If < 25 mm before 24 weeks…” to < = 25mm; edited maximum # TVU to 11 for prior preterm birth at 14-27 weeks, and 9 for prior preterm birth at 28 to 36 weeks. Changed total number of allowed TVUS per pregnancy to 13. Removed “experimental” from section V. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed and updated. 

Policy Number

Policy Title

Revision Notes

CP.MP.124

ADHD Assessment and Treatment

Revised language in I.A.5.d. to specify ECG can be performed only if clinically indicated. Added applicable CPT codes 93000, 93005 and 93010 to not medically necessary table when billed with a sole diagnosis of ADHD.  Added assessment of serum lipid profiles to II.A, as well as applicable codes 80061, 83718, 83719, 82721, 83722 and 84475 to not medically necessary table when billed with a sole diagnosis of ADHD.  Removed CPT-92585, 92586- codes deleted in 2021. Replaced with 92650, 92651, 92652 and 92653. Revised description of CPT- 95930.   Replaced all instances of “member” with “member/enrollee.”

CP.MP.186

Burn Surgery

Removed ICD-10 codes from policy.  References reviewed and updated.  Replaced “member” with “member/enrollee.”

CP.MP.121

Homocysteine Testing

In the policy statement in section II, replaced “investigational” with the statement that homocysteine testing has not been proven to improve outcomes compared to other technologies. References and coding reviewed and updated. Replaced all instances of “member” with “member/enrollee.”

CP.MP.58

Intestinal and Multivisceral Transplant

References reviewed and updated. All instances of “member” changed to “member/enrollee.”

CP.MP.116

Lysis of Epidural Lesions

Revised policy statement to state, “current medical literature does not support the efficacy of lysis of epidural lesions,” and removed “investigational.”  References review and updated.

WA.CP.MP.518

Negative Presure Wound Therapy for Home Use

References reviewed and updated. Added A7000 and note about benefit limit. Replaced all instances of “member” with “member/enrollee”.

CP.MP.82

NICU Apnea Bradycardia Guidelines

References reviewed and updated.

CP.MP.184

Non-Invasive Home Ventilator

References reviewed and updated. ICD-10 codes removed.

CP.MP.188

Pediatric Oral Function Therapy

Updated background. References reviewed and updated. Replaced all instances of member with member/enrollee. Removed ICD-10 codes.

WA.CP.MP.509

Upper GI Endoscopy for GERD

Annual review. Removed reference to gastro-intestinal symptoms in the Description and Section II to mirror Billing Guideline. References updated. Replaced all instances of “member” with “member/enrollee”.

WA.CP.MP.527

Vitamin D Testing

New policy. (Replaces CP.MP.152 and CP.MP.157)

Policy Number

Policy Title

Revision Notes

CP.MP.100

Allergy Testing and Therapy

Added J30.0 to ICD-10-CM Code Table 1. Minor revision to description of CPT-95070.  CPT-95071 deleted in 2021.

WA.CP.MP.508

Bone Growth Stimulator

Annual review. Typographical corrections. Replaced “member” with “member/enrollee’ in all instances. Updated references

WA.CP.MP.50

Drugs of Abuse:  Definitive Testing

Added 2021 CPT- 82077 to list of codes that support coverage criteria

WA.CP.MP.208

Drugs of Abuse, Presumptive Testing

Added 2021 CPT-0227U to table of codes that do not support coverage criteria.

CP.MP.155

EEG in the Evaluation of Headache

Added code 95822 to Table 1, and G43.A0 and G43.A1 to Table 2.  “Experimental/investigational” verbiage replaced in policy statement with descriptive language.

WA.CP.MP.504

Elective Deliveries Before 39 Weeks

Annual review. Replaced “member” with “member/enrollee’ in all instances. References updated.

CP.MP.134

Evoked Potentials

CPT code 92585 deleted 1/1/21.  Added replacement CPT codes 92652 and 92653.  “Experimental/investigational” verbiage replaced with descriptive language in in policy statement III.

WA.CP.MP.36

Experimental Technologies

Removed duplicative statement in Criteria A. regarding request for clinical trials. References reviewed and updated. Replaced all instances of member with “member/enrollee”.

CP.MP.89

Genetic and Pharmacogenetic Testing

Combined criteria notes into one notes section before criteria.

CP.MP.132

Heart-Lung Transplant

References reviewed and updated.  Replaced all instances of “member” with “member/enrollee.”

CP.MP.113

Holter Monitors

Replaced all instances of “member” with “member/enrollee.” References reviewed and updated. 

WA.CP.MP.54

Hospice Services

Replaced “member” with “member/enrollee’ in all instances.

CP.MP.87

Inhaled nitric oxide

References reviewed and updated.

CP.MP.24

Multiple Sleep Latency Testing

Replaced all instances of “member” with “member/enrollee.” References reviewed and updated. 

WA.CP.MP.507

Oral & Enteral Nutrition

Updated reference. Removed criteria for tube feedings

WA.CP.MP.506

Psychological Testing

Annual review. Moved non-covered items to section IV and added reference in section I to sections III and IV. Replaced “member” with “member/enrollee’ in all instances. References updated.

CP.MP.51

Reduction Mammoplasty and Gynecomastia Surgery

Revised description of CPT-19318. Replaced all instances of “member” with “member/enrollee”

CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Minor revision to description of  CPT 64479, 64480, 64483 and 64484.  Replaced “member” with “members/enrollee” in the disclaimer.

WA.CP.MP.185

Skin Substitutes for Chronic Wounds

References reviewed and updated.  All instances of “member” changed to “member/enrollee.”  HCPCS code listing updated. Non-covered codes reported separately.

CP.MP.163

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

Added indications for radiation enteritis, liver failure in children, liver failure in adults, and acute necrotizing pancreatitis in adults, in I.A.2.j – I.A.2.m., along with relevant ICD-10 codes (i.e., K52.0, K72.00-K72.91, K85.01, K85.02, K85.11, K85.12, K85.31, K85.32, K85.81, K85.82, K85.91, K85.92 and Z76.82. In I.B.2, changed “end-stage renal disease” to “stage 5 chronic kidney disease.” References reviewed and updated and coding reviewed.  Replaced member with member/enrollee in all instances. Replaced “experimental/ investigational” with “not proven safe and effective” in section II.

CP.BH.200

Transcranial Magnetic Stimulation

Changed medical necessity statements to require review by a medical director. Minor edits made for clarity of review process.

WA.CP.MP.12

Vagus Nerve Stimulation

Added new HCPCS code K1020 to a new table of codes that do not support coverage criteria. “Experimental/investigational” verbiage replaced with descriptive language. Removed duplicative reference to experimental and non-covered services. Replaced “member” with “member/enrollee”.

WA.CP.MP.522

Varicose Vein Treatment

“Experimental/investigational” verbiage replaced in policy statement with descriptive language. References reviewed and updated. Removed duplicate reference. Replaced all instances of member with member/enrollee.

Policy Number

Policy Title

Revision Notes

CP.MP.203

Diaphragmatic/Phrenic Nerve Stimulation

New policy.

WA.CP.MP.519

Administrative Days

Annual review. References updated.

WA.CP.MP.513

Cardiac Stents

Annual review. References updated. Minor grammatical change.

CP.MP.31

Cosmetic and Reconstructive Procedures

Annual review. Reviewed and updated references. CPT code description revised in 2021: 19318, 19325, 19328, 19340, 19342, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, and 19380.  CPT 19324 and 19366 deleted in 2021.

CP.MP.89

Genetic and Pharmacogenetic Testing

References reviewed and updated.  Removed section on authorization protocol.  Replaced member with member/enrollee in all instances.

CP.MP.109

Panniculectomy

Annual review. Replaces all instances of member with member/enrollee. Expanded criteria for complications related to pannus to include non-healing ulceration under panniculus, chronic maceration or necrosis of overhanging skin folds, recurrent or persistent skin infection under panniculus, intertriginous dermatitis or cellulitis or panniculitis. Added the following ICD 10 codes:  L03.319, L03.818, L98.499.  Separated “D.” into separate criteria points, D. and E, adding that bariatric surgery weight loss must be stable for 6 months.

CP.MP.182

Short Inpatient Hospital Stay

References reviewed and updated. I.A. was updated to specify “2020” Inpatient Only List. Background updated to include heading for CMS and information related to the Inpatient Only List and CY 2021 OPPS/ASC Final Rule.

WA.CP.MP.517

Testosterone Testing

Annual review. Reference updated. Updates to criteria to mirror billing guideline

WA.CP.MP.520

Tympanostomy Tubes in Children

Annual review. Updates to mirror HCA Billing Guideline. References updated.

CP.MP.142

Urinary Incontinence Devices and Treatments Annual review completed; references reviewed and updated, codes reviewed.  Specialist reviewed. Replaced “member” with “members/enrollees” in all instances.

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.