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Clinical & Payment Policies

Clinical Policies

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

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

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

Ambetter Clinical Policies Listing

 

 

Ambetter Pharmacy Policies Listing

 

 

 

Medicaid Clinical Policies Listing

Medicaid Pharmacy Policies Listing

 

 

 

Payment Policies

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

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

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

Ambetter Payment Policies

 

Medicaid Payment Policies

Policy Revision Summary (Clinical)

Policy Number

Policy Title

Revision Notes

CP.MP.40

Gastric Electrical Stimulation

Annual review. Updated description and background with no clinical significance. Added I.A. "Member/enrollee is ≥ 18 years of age". Updated I.B. to include "diabetic or" in describing type of gastroparesis. Updates made to CPT code descriptions. References reviewed and updated.

CP.MP.132

Heart-Lung Transplant

Annual review. Added indication to criteria I.A.1.j. Expanded criteria I.C.1. to I.C.1.a. through c. Removed contraindication I.C.17., active peptic ulcer disease. References reviewed and updated.

CP.MP.141

Non-Myeloablative Allogenic Stem Cell Transplants

Annual review. Removed Hodgkin’s lymphoma from Criteria I.A.9. per updated National Comprehensive Cancer Network (NCCN) recommendations. Added Criteria I.A.13.e. to include polycythemia vera. Updated Criteria I.B.4.b. from diffusing capacity of the lung for carbon monoxide (DLCO) ≤ 50% of predicted value to DLCO ≤ 60% of predicted value. Removed absolute contraindications in Criteria I.C. References reviewed and updated. Reviewed by internal specialist and reviewed by external specialist.

WA.CP.MP.185

Skin and Soft Tissue Substitutes for Chronic Wounds

Annual review. References reviewed and updated. Reviewed by external specialist. Policy description updated with no impact on criteria. Section V corrected to reflect “all indications in section I-III.” HCPCS covered and non-covered coding tables removed and added note for providers to contact Coordinated Care for current coding implications and coverage determinations.

Policy Number

Policy Title

Revision Notes

WA.CP.BH.521

Behavioral Health Wraparound Support (BHWS)

Annual review. Renamed policy from “Behavioral Health Personal Care Services” in preparation for July contract change. Updated Description. Policy criteria rewritten to match new contract language. Reference updated. Changed policy number to WA.CP.BH.521 from WA.CP.MP.521 to reflect behavioral health nature of the policy.

WA.CP.MP.513

Cardiac Stents

Annual review. References reviewed and updated. CPT codes added per HCA Billing Guidelines: 92933, 92934, 92937, 92938, 92941, 92943 and 92944.

WA.CP.MP.504

Elective Deliveries Before 39 Weeks

Annual review. References updated. Added reference for WAC 182-500-0030. Removed all ICD-10 diagnosis codes with instruction to reference the current Joint Commission document for a complete list of diagnosis codes for Conditions Possibly Justifying Elective Delivery.

CP.MP.248

Facility Based Sleep Studies for Obstructive Sleep Apnea

Annual review. Updated description and included “Notes”. Added non-Medicare to all policy statements. Added superscript citations throughout policy. In I.B.8.a. added "documentation". Updated I.B.8.a.i. to "Moderate to severe, chronic pulmonary disease". Removed criteria I.B.8.a.i.a) and b). Updated I.B.8.a.ii. to "Congestive heart failure...". Updated I.B.8.a.v. to "Concern for significant non-respiratory sleep disorder(s)...". Added I.B.8.a.vi "Hypoventilation syndrome". Updated I.B.8.b.ii to "Daytime sleepiness...". Added I.B.8.b.ii.a "Habitual loud snoring". Removed I.B.8.b.iv. "Significant oxygen desaturation...". Updated III.A. to "Meets criteria in section I...". Removed III.C and D. for central sleep apnea. References reviewed and updated. Internal and external specialist reviewed.

CP.MP.62

Hyperhidrosis treatments

Annual review. Minor rewording of pharmacy policy title (in description). Changed order of criteria. Added criteria point III.I. regarding counseling on risks. Background updated with no clinical significance. Removed CPT codes 64802 through 64823. References reviewed and updated. Reviewed by external specialist.

WA.CP.MP.27

Hyperbaric Oxygen Therapy

Annual review. References reviewed and updated. Section II. G. wording updated to align with billing guidelines. Section I. multiple punctuation corrections, no impact on criteria. 

CP.MP.173

Implantable Intrathecal or Epidural Pain Pump

Annual review. Restructured and reformatted criteria section. In I.B. and II.B. added contraindications to include known allergies to materials in the implant; active alcohol or drug abuse, including but not limited to opioid addiction and intravenous drug abuse, diagnosis of dementia or psychosis; active systemic infection, active infection at the site of implantation. Background updated with no impact to criteria. References reviewed and updated.

CP.MP.243

Implantable Loop Recorder (Implantable Cardiac Monitor)

Annual review. Added criteria III. to include requests for replacement implantable loop recorders. Background updated with no impact to criteria. References reviewed and updated. Reviewed by external specialist.

CP.MP.82

NICU Apnea Bradycardia Guidelines

Annual review. Minor rewording throughout criteria with no impact on criteria. Added clarifying language to Criteria I.A.1.c. and updated oxygen saturation percentage from < 85% to ≤ 85%. Updated wording in Criteria I.A.2.a. for clarity and flow. Updated Criteria I.A.2.b. to include verbiage for significantly reducing the severity and duration of bradycardia or apnea events. Updated Criteria I.A.3.d. to include that parents or caregivers agree with the plan of care. Added Criteria I.A.3.e. regarding the home situation being assessed and deemed adequate. Expanded information on CPR requirement in Note section at end of Criteria. Updated Note section at end of Criteria to include when additional observation days may be needed. Minor rewording in Background with no impact on criteria. References reviewed and updated. Criteria I.A.1.c., Criteria I.A.2.a., and Criteria I.A.2.b. reviewed by internal specialist

CP.MP.22

Stereotactic Body Radiation Therapy

Annual review. Updated cancer staging in Criteria I.A. to align with National Comprehensive Cancer Network (NCCN) guidelines. Criteria II.C. updated to include details regarding positive clinical indications regarding stable systemic disease, Karnofsky Performance Score, survival expectations, and Eastern Cooperative Oncology Group (ECOG) Performance Status to align with ASTRO 2022 Model Policy for SRS. Criteria II.J. added to include trigeminal neuralgia and select cases of medically refractory epilepsy, movement disorders such as Parkinson’s disease and essential tremor, and hypothalamic hamartomas to align with 2022 ASTRO Model Policy for SRS. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.

Policy Number

Policy Title

Revision Notes

WA.CP.MP.501

Continuous Glucose Monitor

Annual review. References updated. Updated section I. and Background to include reference to HCA Billing Guidelines.

WA.CP.MP.50

Drugs of Abuse:  Definitive Testing

Annual review. Updated policy statements in I. and II.. Updated background with no clinical significance. References reviewed and updated. Internal specialist review.

WA.CP.MP.36

Experimental Technologies

Annual review. Added updated background with no clinical significance. References reviewed and updated. Removed definition of Humanitarian Use Device (HUD) from section 11. a. and updated language to correspond with WAC 182-501-0165.

CP.MP.62

Hyperhidrosis Treatments

Added note regarding the normal line of medical therapy back into policy after erroneously removing during January 2024 annual policy review.

CP.MP.250

Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy

Added note to description regarding Medicare policy version. Removed maximum age requirement from Criteria I.A.

WA.CP.MP.505

Microprocessor-Controlled Lower Limb Prosthetics

Annual review. References updated. Removed HCPCS L2006 and L5973 per previous revision.

CP.MP.102

Pancreas Transplantation

Annual review. Expanded criteria I.B. to I.B.a. through c. Updated description and background with no clinical significance. Coding reviewed. References reviewed and updated. Reviewed by external specialist

WA.CP.MP.503

Private Duty Nursing

Annual review. References reviewed and updated. Section III. A. updated reference HCA Billing Guidelines. Section III. C. wording updated to include EPSDT WAC and clarified hours for limitation extension/EPSDT requests. EPSDT WAC added to references. Struck references to social/economic factors.

CP.MP.162

Tandem Transplant

Annual review. Added a. through c. to I.B.10.; a. CD4 cell count > 200 cells/mm3, b. Absence of active AIDS-defining opportunistic infection, and c. Member/enrollee is currently on effective ART (antiretroviral therapy). Updated background info on testicular cancer with no impact on criteria. References reviewed and updated.

WA.CP.MP.517

Testosterone Testing

Annual review. References updated.

CP.MP.163

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

Annual review completed. Minor rewording in Criteria section with no clinical significance. Background updated with no impact to criteria. References reviewed and updated. External specialist reviewed.

WA.CP.MP.520

Tympanostomy Tubes

Annual review. References updated.

WA.CP.MP.46

Ventricular Assist Devices

Annual review. References reviewed and updated. Minor rewording in description with no impact on criteria. Added FDA approval requirement to Sections I and II per billing guidelines. Updated section I. A. language for clarity, no impact on criteria.

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

WA.CP.MP.200

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression

Revised to reflect updated Billing Guideline and revised HTA

CP.MP.186

Psychological Testing

Archived

Policy Number

Policy Title

Revision Notes

CP.BH.104

Applied Behavioral Analysis

Annual review. Replaced all instances of “DSM-5” with “DSM-5 TR”. Added requirement for a comprehensive diagnostic evaluation to have been conducted within the past five years in I.A.1. Added Social Skills Improvement System (SSIS) as an additional skill assessment option in I.E.1.b.ii.e. In I.E.,2.b. deleted “comprehensive.” Deleted I.E.,2.b.ii.e). and replaced it as a “note” under I.2.b.ii.d). In I.E.2.c.vi. deleted “in the home or community activities.” Added I.E.2.f.i. “Behavioral health outpatient services” to the list. Added statement to I.E.3.b. “Assessments are performed consistent with criteria in I.E.1. b.” Rearranged criteria point in I.E.3 for clarity. In II.A. added statement “… and generally involve a gradual step-down in services.” In II.C. Removed the statements “Services may be appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care.” Removed ICD 10 chart. Updated description and background with no clinical significance. References reviewed and updated. Annual review. Replaced all instances of “DSM-5” with “DSM-5 TR”. Added requirement for a comprehensive diagnostic evaluation to have been conducted within the past five years in I.A.1. Added Social Skills Improvement System (SSIS) as an additional skill assessment option in I.E.1.b.ii.e. In I.E.,2.b. deleted “comprehensive.” Deleted I.E.,2.b.ii.e). and replaced it as a “note” under I.2.b.ii.d). In I.E.2.c.vi. deleted “in the home or community activities.” Added I.E.2.f.i. “Behavioral health outpatient services” to the list. Added statement to I.E.3.b. “Assessments are performed consistent with criteria in I.E.1. b.” Rearranged criteria point in I.E.3 for clarity. In II.A. added statement “… and generally involve a gradual step-down in services.” In II.C. Removed the statements “Services may be appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care.” Removed ICD 10 chart. Updated description and background with no clinical significance. References reviewed and updated.

CP.BH.105

Applied Behavioral Analysis Documentation Requirements

 New Policy

CP.MP.186

Burn Surgery

Annual review. Added criteria II.C. that burn must be deep partial-thickness or full-thickness. Added used according to FDA indications to II.D.3. References reviewed and updated. Reviewed by internal specialist.

CP.MP.105

Digital EEG Analysis

Added new for 2024 ICD-10 codes G40.C11 and G40.C19 to ICD-10 coding table.

WA.CP.MP.515

​Fecal Microbiota Transplantation

Annual review. References updated.

WA.CP.MP.130

Fertility Preservation

Annual review. Reference updated.

CP.MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Updated criteria I.G.6. to maternal body mass index of ≥ 40 and added supportive references.

CP.MP.136

Home Birth

Annual review. Minor rewording in Criteria and Background sections with no impact on policy criteria. References reviewed and updated.

CP.MP.81

NICU Discharge Guidelines

Annual review. References reviewed and updated.

CP.MP.86

Neonatal Abstinence Syndrome Guidelines

Annual review. Updated description, criteria and background with equitable and inclusive language and no impact on criteria. References reviewed and updated. Reviewed by external specialist.

CP.MP.85

Neonatal Sepsis Management

Annual review. Reworded description with no clinical significance. Reworded criteria under I.A.2. "when meeting all of the following criteria" with no impact to criteria. Expanded criteria under I.A.2.a. and I.B.2.a. “Signs of neonatal sepsis (e.g.: hypotonia, lethargy, poor oral feeding, tachycardia, bradycardia, grunting, nasal flaring, cyanosis).  Reworded criteria under II.D.1., II.D.3. and II.E. with no impact to criteria. References reviewed and updated. Reviewed by external specialist.

WA.CP.MP.117

Percutaneous Electrical and Peripheral Nerve Stimulation

Annual review. Added section II.D. to correspond to CP.MP.117. Coding reviewed and updated. References reviewed and updated. Updated description and background with no clinical significance.

WA.CP.MP.526

​Stem Cell Therapy for Musculoskeletal Conditions

Annual review. References updated. Background updated to include HCA Billing Guidelines.

WA.CP.MP.510

Tinnitus Treatment

Annual review. References updated. Background updated to include HCA Billing Guidelines.

V1.2024

All Genetic Testing Policies

Twice-per-year review

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

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

Policy NumberPolicy TitleRevision Notes
CP.BH.124ADHD Assessment and TreatmentAnnual Review. Changed reference number for the policy from “CP.MP.124” to “CP.BH.124”. Added the following statement to section I and II: “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. In criteria point II. A. 1. replaced “Actometer” with “Actigraphy”. In criteria point I.A. 2. added “Acoustic reflex testing”.  In criteria point I.A.12: removed Magnetic resonance imaging, brain functional MRI as it is already captured in I.A.16: under MRI. Removed I.A.14. “Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping”.  In criteria point I.A.16. added “brain mapping” to the brain imaging section. In Criteria point I.A. 24 removed “Triiodothyronine T3 levels in the blood” and reworded as “Measures of thyroid hormones”. Removed II.A.18 “neuropsychological testing from the insufficient evidence list”, with corresponding codes also removed.  In criteria point II. B.2., added “Application of modality (e.g. hot or cold packs, traction, mechanical, electrical stimulation (unattended), vasopneumatic devices, paraffin bath, whirlpool, diathermy (eg, microwave), infrared, ultraviolet, electrical stimulation (manual), iontophoresis, contrast baths, ultrasound, hubbard tank)”. Removed education interventions from criteria point II.B.19. and added policy statement III. “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that interventions that are strictly educational in nature (e.g., classroom environmental manipulation, academic skills training training) are not medically necessary as they are not considered medical interventions”. Added criteria point II.B.19.  “EndeavorRx®”. Replaced instances of dashes (-) with the word “to” within the CPT description code list. Coding reviewed. Added the following codes and related indications as not medically necessary when billed with a sole diagnosis of ADHD: 70496, 70554, 70555, 78610, 84436, 84437, 84439, 84442, 84443, 84445, 84478, 84479, 84481, 92568, 92569, 92570, 95954, 96020, 96902, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036. References reviewed and updated. Policy reviewed by internal specialist. Policy reviewed by an external specialist.
CP.MP.108Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-ThalassemiaAnnual review. Added note at end of Description regarding criteria related to Zynteglo. Criterion I.C.3. removed related to lack of adequate support system. Expanded Criteria II.A. and Criteria II.B. to specify not in the context of gene therapy. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal and external specialist.

WA.CP.MP.502

Cochlear Implants

Annual review. References updated. Removed “Bilateral vs. Unilateral” from policy title. Removed use of InterQual criteria for unilateral implants as the HTA/HCA Billing Guideline covers unilateral and bilateral. Policy description edited to reflect unilateral and bilateral implants. Section I. removed “bilateral.” Section I. A. age parameters updated per Billing Guideline. Section I. C. minor grammatical error corrected with no impact on criteria. Policy note added per Billing Guideline that implantation may be performed unilaterally or bilaterally. Added note referencing CP.MP.14.

CP.MP.31Cosmetic and Reconstructive ProceduresAnnual review. Minor edits to I.A.4.b with no clinical significance. Updated pharmacy policies for Serostim (somatropin) in note. Removed CPT code 11310. References reviewed and updated. Reviewed by internal specialist.
CP.MP.101Donor lymphocyte infusionAnnual review. Minor rewording in Description with no impact on criteria. Criteria II.B. updated to state grade 2 or higher acute graft versus host disease (GvHD). Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. Updated policy description. Updated all criteria in statements I. and II. 
CP.MP.209GI Pathogen Nucleic Acid Detection Panel TestingAnnual review completed. Replaced previous criteria with current in sections I. and II. and removed section III. Background updated with no impact to criteria. Reworded some extraneous language with no clinical significance. Moved code 87506 from Table 1 to Table 2. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 to include ICD-10 diagnosis codes which support medical necessity. References reviewed and updated.
CP.MP.250Lantidra (donislecel): Allogeneic pancreatic islet cellular therapyNew policy
CP.MP.123Laser Therapy for Skin ConditionsAnnual review. Added medically necessary indications I.C. atopic dermatitis and I.D. cutaneous T-cell lymphoma. Removed II.B. atopic dermatitis from insufficient evidence section. Added codes L20.81, L20.82, L20.89, C84.00 through C84.09, and C84.10 through C84.19 to table of ICD-10-CM diagnosis codes that support coverage criteria. References reviewed and updated.
CP.MP.57Lung TransplantationRevised adult and pediatric criteria to align with ISHLT 2021 consensus document. References reviewed and updated. 
CP.MP.202Orthognathic SurgeryAnnual review. Added CPT codes 21248 and 21249. References reviewed and updated.
CP.MP.109PanniculectomyAnnual Review. Combined criteria I.D. and E. into criteria I.D.1. and 2. Removed CPT code 00802 from policy. References reviewed and updated. Reviewed by external specialist.
CP.MP.138Pediatric Heart TransplantAnnual review. Added additional criteria I.A.1.b.vi.a., pulmonary hypertension and a potential risk of developing fixed, irreversible elevation of pulmonary vascular resistance that could preclude orthotopic heart transplantation in the future. Updated I.D.1. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2. Expanded I.D.2. with qualifying criteria for members who are HIV positive. Updated I.D.21. to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background reviewed and updated. References reviewed and updated. Reviewed by external specialist.
CP.MP.246Pediatric Kidney TransplantAnnual review. Description updated to include source information for policy criteria. Updated Criteria I.A.1. from glomerular filtration rate (GFR) ≤ 15 mL/min/1.73m2 to GFR < 15 mL/min/1.73m2 to align with Kidney Disease: Improving Global Outcomes (KDIGO) guidance and Organ Procurement Transplant Network (OPTN) guidance. Updated Criteria I.A.2. to include members/enrollees with CKD stage 4 with GFR < 30 mL/min/1.73m2 who are expected to reach end stage renal disease (ESRD) to align with KDIGO guidance and OPTN guidance. Updated contraindications in I.B. consistent with KDIGO guidelines. References reviewed and updated.
CP.MP.150Phototherapy for Neonatal HyperbilirubinemiaAnnual review. Reworded criteria I.C. for inclusive language. References reviewed and updated.
CP.MP.181Polymerase Chain Reaction Respiratory Viral Panel TestingAnnual review. Replaced prior criteria in sections I. and II. with current criteria. Removed policy statement III. Background updated with no impact on criteria. Updated verbiage in Table 2 description to include new diagnosis code requirements. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 which include ICD-10 diagnosis codes. References reviewed and updated.
CP.MP.98Urodynamic TestingAnnual review. Added criteria I.D.5. for 4.5. Prostate nodule, asymmetry or other suspicion of prostate cancer. Moved N40.3 from ICD-10 Table 2 to ICD-10 Table 1. References reviewed and updated.
WA.CP.MP.527Vitamin D TestingAnnual review. Updated references.

Policy NumberPolicy TitleRevision Notes
CP.MP.129Fetal Surgery in Utero for Prenatally Diagnosed Malformations

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

 

WA.CP.MP.50Drugs of Abuse: Definitive Testing

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

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

Policy NumberPolicy TitleRevision Notes
WA.CP.MP.519Administrative Days

Changed “denial” to “discharge” in Note.

 

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

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

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

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

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

Policy NumberPolicy TitleRevision Notes
CP.BH.104Applied Behavior AnalysisNew Policy
WA.CP.BH.104Applied Behavior AnalysisPolicy archived
CP.MP.164Caudal or Interlaminar Epidural Steroid Injections for Pain ManagementPolicy archived
NIA_CG_300Epidural Spine InjectionsNew Policy on NIA site
NIA_CG_301Facet Joint InjectionsNew Policy on NIA site
NIA_CG_302Facet Joint DenervationNew Policy on NIA site
WA.CP.MP.171Facet Joint Interventions for Pain ManagementPolicy archived
WA.CP.BH.506Psychological Testing Annual review. Renumbered policy from WA.CP.MP.506 to WA.CP.BH.506. Replaced “member” with “member/enrollee’ in all instances. References updated.
CP.MP.166Sacroiliac Joint Interventions for Pain ManagementPolicy archived
NIA_CG_305Sacroiliac Joint InjectionNew Policy on NIA site
CP.MP.165Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain ManagementPolicy archived
WA.CP.MP.248Sleep Apnea Diagnosis and TreatmentPolicy archived
CP.BH.200Transcranial Magnetic Stimulation for Treatment Resistant Major DepressionAd hoc Review. Policy restructured. Added additional information to the description section with no impact to the policy.  Replaced all instances of the statement “It is the policy of health plans affiliated with Centene Corporation®” with “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. Deleted criteria point I.D as the information was redundant to I.B. In criteria subsection I.I. (5), clarified that three months or less of remission constitutes a contraindication. Added the statement “requests for 6 tapered final sessions of TMS (over a 3-week period)” to the revised criteria point II. Added criteria point II.A to indicate that “all initial criteria must be met prior to request for additional sessions”. Deleted what was criteria III as the information was redundant to criteria II. In criteria section III, replaced “maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it” with “It is the policy of health plans affiliated with Centene Corporation that maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it”. Added criteria point IV.A to indicate that “criteria for initial TMS treatment guidelines continues to be met”. Added semicolons throughout the criteria section.  References reformatted. Replaced all instances of “dashes (-) in page numbers to the word “to”.  

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

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