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

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
CP.MP.151	Transcatheter Closure of Patent Foramen Ovale	Annual 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.
CP.MP.180	Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea	Annual 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.

Policy Number	Policy Title	Revision Notes
CP.MP.202	Orthognathic Surgery	Annual review completed. Reformatted criteria II. and added II.B. as additional non-medically necessary indication. Additional minor rewording with no clinical significance. Background updated. CDT codes removed from policy. References revised and updated. Reviewed by external and internal specialists.
CP.MP.150	Phototherapy for Neonatal Hyperbilirubinemia	Annual review. Changed title from “Home phototherapy…” to “Phototherapy…” Updated criteria I.D. from 24-48 hours to 12-24 hours. Updated criteria to include the following: I.E. ≥48 hours old; I.F. An LED-based phototherapy device will be available in the home without delay; I.G. No previous phototherapy; I.H. TSB will be measured daily. Criteria I.I. #1 updated to include example of positive direct antiglobulin test for isoimmune hemolytic disease and to include glucose-6-phosphate dehydrogenase (G6PD) and other hemolytic disease. Criteria I.I. #2 updated to include hypoxic ischemia encephalopathy (HIE). Significant lethargy removed from Criteria I.I. Criteria I.I. updated to include the following: #13 Significant clinical instability in the previous 24 hours; #14 Clinical history of a parent or sibling requiring phototherapy or exchange transfusion; #15 Exclusive breastfeeding with suboptimal intake (≥10% weight loss); #16 Down syndrome; #17 Macrosomic infant of a diabetic mother. Added note below Table 1 that explains the values are conservative TSB values based on lower age range thresholds in inpatient criteria. Added clarification to II that extenuating circumstances can include lack of expected compliance with therapy at home. Added note below policy statement II stating: that infants should be admitted for inpatient phototherapy if the TSB concentration is more than 1 mg/dL above the AAP guidelines phototherapy treatment threshold per the bili risk tool, and that table 1 is consistent with AAP guidelines allowing treatment at lower levels per provider discretion; and that clinical decision support tools provider further criteria for inpatient phototherapy treatment. Updated background to include 2022 AAP clinical practice guidelines. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist.

Policy Number	Policy Title	Revision Notes
CP.MP.246	Pediatric Kidney Transplant	New policy
WA.CP.MP.117	Percutaneous Electrical and Peripheral Nerve Stimulation	Policy renumbered WA.CP.MP.117. References to spinal cord stimulation removed.
CP.MP.242	Pulmonary Function Testing	New policy

Policy Number	Policy Title	Revision Notes
CP.MP.186	Burn Surgery	Annual review completed. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated.
CP.MP.131	Essure Removal	Policy retired
CP.MP.209	Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing	Removed deleted code 0097U
WA.CP.MP.70	Proton and Neutron Beam Therapy	Annual review completed. Removed “treated in a hypofractionated regimen” from I. D. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated. External specialist reviewed.
CP.MP.182	Short Inpatient Hospital Stay	Annual review. Added I.C. “Acute hospital care at home.” Background updated with no clinical significance. References reviewed and updated.
CP.MP.142	Urinary Incontinence Devices and Treatments	Annual review. Updated criteria section to clarify abbreviations. Criteria I.D. # 1 updated to include continence-support pessaries as a conservative measure. Updated background with no impact on criteria. Removed ICD-10 codes. References reviewed and updated.

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. Reviewed by internal specialist.
CP.MP.31	Cosmetic and Reconstructive Procedures	Annual review completed. Added to I.A.4.b. “poly-L-lactic acid” and “calcium hydroxylapatite microspheres”. Minor rewording with no clinical significance. References reviewed and updated. Reviewed by external specialist.
CP.MP.101	Donor Lymphocyte Infusion	Annual review. Background updated with no impact on criteria. ICD-10 codes removed. References reviewed and updated. Specialist review.
CP.MP.109	Panniculectomy	Annual review. Removed ICD-10 codes. References reviewed and updated.
WA.CP.MP.185	Skin Substitutes for Chronic Wounds	Updated description for code Q4128. Added new HCPCS codes that are covered and not covered.
CP.MP.127	Total Artificial Heart	Annual review. Background updated with no impact on criteria. Changed “date” in the revision log header to “revision date.” References reviewed and updated. Specialist review.
WA.CP.MP.527	Vitamin D Testing	Returned 0038U to policy. Deleted in error
WA.CP.MP.50	Drugs of Abuse: Definitive Testing	Changed title of tables from “CPT Codes That Do Not Support Coverage Criteria” to “CPT Codes That Are Not Covered per the HCA”. Updated ICD-10 codes to include code ranges. References updated. Added CPT 0328U to the list of CPT codes that are not covered by HCA. Updated parenthetic in policy statement II to indicate codes are examples.

Policy Number	Policy Title	Revision Notes
CP.MP.105	Digital EEG Spike Analysis	Annual review. References reviewed and updated.
CP.MP.106	Endometrial ablation	In I.A.2, reworded portion pertaining to abnormal bleeding in transgender members from “female to male transgender person” to “member/enrollee with a female reproductive system undergoing treatment for gender affirmation.”
CP.MP.113	Holter Monitors	Annual review completed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Minor rewording with no clinical significance. Added the following criteria to I.M. “Evaluation of recurrent chronic heart failure, when arrhythmia is suspected” and I.N. “Evaluation of possible arrhythmias post ablation procedures”. References reviewed and updated. Specialist review.
CP.MP.134	Evoked Potential Testing	Annual review. References reviewed and updated. Specialist reviewed.
CP.MP.153	H. Pylori Serology Testing	Annual review completed. Background updated and minor rewording with no clinical significance. References reviewed and updated.
CP.MP.154	Thyroid Hormones and Insulin Testing in Pediatrics	Annual review completed. Changed “Date of Last Review” to “Date of Last Revision” in the header. Background updated and minor rewording with no clinical significance. References reviewed and updated.
CP.MP.155	EEG in Evaluation of Headache	Annual review. References reviewed and updated. Reviewed by specialist.
CP.MP.156	Cardiac Biomarker Testing for Acute MI	Annual review. Background updated with no impact on criteria. References reviewed and updated.
CP.MP.194	Osteogenic Stimulation	Annual review completed. Added “electrical” to I. and II. Replaced “smoking habit” with “tobacco use” in criteria I.E.7., II.E.7., and III.B.7. Removed criteria point III.6.c. “The patient has failed more than one surgery and other medical therapies (e.g. immobilization and non-weight bearing status)”. Background updated and minor rewording with no clinical significance. References reviewed and updated. Specialist reviewed.
CP.MP.203	Diaphragmatic Phrenic Nerve Stimulation	Updated code G83.89 to G83.9.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.519	Administrative Days	Added Newborn Administrative Days section and Note regarding request.
WA.CP.BH.104	Applied Behavioral Analysis	Addition of treatment range for focused ABA and literature review in introduction. Addition of medical necessity criteria for behavioral assessment. Addition of intensity of services for ABA. Addition of "or appropriate diagnosis as otherwise specified according to state defined ABA criteria" and removal of "clinical professional counselor, marriage and family therapist, addition counselor", addition of "strengths-specific, family-focused, community-based, multisystem, culturally-competent, and least intrusive. And where specific target behaviors are clearly defined; frequency, rate, symptom intensity or duration" in criteria. Section III.D. updated definition. Addition of H, K, L, M in initiation of services criteria. Addition of K, L, M, N in continuation of ABA services criteria. Addition of transition planning section. Updated introduction and research studies including citations to Background. Addition of Screening Recommendations for ASD. Edit of verbiage for caregiver training goals to "Caregiver training is performance based and parent drive. Identifies measurable outcomes for every goal and objective."
CP.BH.500	BH Treatment Documentation Requirements	New Policy
WA.CP.MP.516	Carotid Artery Stenting	Annual review. References updated. Removed HTA criteria from policy.
CP.MP.167	Intradiscal Steroid Injections for Pain Management	Annual Review. Criteria section updated to single spacing. Background updated with no impact on criteria. References reviewed and updated. Specialist reviewed.
CP.MP.244	Liposuction of Lipedema	New Policy
CP.MP.170	Nerve Blocks for Pain Management	Annual review completed. Added “as effectiveness has not been established” to I. C. Background updated. Reworded some extraneous language with no clinical significance. References reviewed and updated.
CP.MP.206	Skilled Nursing Facility Leveling	Annual review completed. Added “in the community” and “moderate/maximum/total” to Section I.A.4. and II.A.4. Updated II.C.4. from 3 hours of skilled therapy per day to “at least” 3 hours of skilled therapy per day. Additional minor rewording with no clinical significance. References reviewed and updated. Specialist reviewed.
CP.BH.100	Substance Use Treatment and Services	New Policy
CP.BH.200	Transcranial Magnetic Stimulation for Treatment Resistant Major Depression	Annual Review. Revisions made to Policy/Criteria Section I. E to reflect the elimination of point 1 completely. The former point 2 and 3, will now be combined as the new point 1. The original point 4 has now changed to become the new point 2. Replaced terminology in Policy/Criteria I: H.5, II: B.5, III: V.5 from “Substance abuse at time of treatment” to “a minimum of 3 month substantiated early remission from substance use disorder”
CP.MP.169	Trigger Point Injections for Pain Management	Annual review. References reviewed, updated, and reformatted. Updated criteria in I.B. from 2 additional injections to 4. In I.B.1 added pain relief with functional improvement, in I.B.2. added “≥” 6 weeks, and in I.B.4 added “from initial injection” and changed maximum of 4 total sessions to 6. Specialist review.
CP.MP.12	Vagus Nerve Stimulation	Adopted CP.MP.12 to replace WA.CP.MP.12.
WA.CP.MP.12	Vagus Nerve Stimulation	Retire

Policy Number	Policy Title	Revision Notes
WA.CP.MP.37	Bariatric Surgery	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. Updated references.
CP.MP.14	Cochlear Implant Replacements	Annual review completed. Removed “or” in I.A. and I.B. Background updated with no impact to criteria. References reviewed and updated.
WA.CP.MP.514	Extra-Corporeal Membrane Oxygenation	Annual review. References updated.
CP.MP.137	Fecal Incontinence Treatments	Annual review completed. In Section I.B. changed “member” to “member/enrollee”. Added “sacral neuromodulation” to Section I.C. Background updated with minor verbiage changes with no clinical significance. Updated description for CPT codes 46760, 46761, 64581, 64590 and HCPCS Code L8683. References reviewed and updated. Specialist reviewed.
CP.MP.129	Fetal Surgery in Utero for Prenatally Diagnoses Malformations	Annual review. Description updated with no impact on criteria. Background updated with no impact on criteria. References reviewed and updated.
CP.MP.243	Implantable Loop Recorder (Implantable Cardiac Monitor)	New Policy
CP.MP.85	Neonatal Sepsis Management	Annual review. Description updated. Background updated: Minor rewording for clarity in II.C; added verbiage about procalcitonin in II.G; in III.B, changed 48 hours to 36-48 hours. References reviewed and updated. Reviewed by specialist.
CP.MP.128	Optic Nerve Decompression Surgery	Annual review. References reviewed and updated. Specialist review. Background updated with no clinical significance.
CP.MP.51	Reduction Mammoplasty and Gynecomastia Surgery	Annual review completed. Changed “women” to “members/enrollees” in I.A.5.c. Added I.B.5. to gigantomastia of pregnancy criteria. Language references in the criteria, description and background sections changed from “male” and/or “female” to “those with a male reproductive system” and/or “those with a female reproductive system.” References reviewed and updated.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.37	Bariatric Surgery	Annual review. Moved note about G9012 into section I. Description updated with no impact on criteria. Criteria I.A. procedures listed with abbreviations with no impact on criteria. Background updated with no impact on criteria. Corrected ICD10 code I10.0 to I10. References reviewed and updated.
CP.MP.93	Bone-anchored Hearing Aid	Annual Review. Description updated with no impact on criteria. Criteria I. updated to include abbreviation of BAHA. Criteria III.C. wording updated for clarity. Background updated with no impact on criteria. References reviewed and updated. Removed deleted codes 69715 and 69718. Added new codes 69716, 69719, 69726, and 69727.
CP.MP.94	Clinical Trials	Annual review. Criteria I.,II.,III.,IV. updated to remove “and” after semi-colons. Criteria IV.B. “et al” changed to “etc.” Criteria IV.E. #7 abbreviation updated for Department of Energy (DoE). References reviewed and updated.
CP.MP.115	Discography	Annual review completed. Description and background updated with no impact to criteria. References reviewed and updated. Specialist reviewed.
CP.MP.107	Durable Medical Equipment (DME), Orthotics and Prosthetics Guidelines	Removed cardiac event monitor (E0616) criteria from cardiac equipment section of policy and moved to CP.MP.243 Implantable Loop Recorders. Removed invasive home ventilator criteria (E0465) and moved to CP.MP.184 Home Ventilators. Added statement that current evidence does not support the effectiveness of intrapulmonary percussive ventilation (E1399).
CP.MP.184	Home Ventilators	Annual review. Changed policy title from “Noninvasive Home Ventilators” to “Home Ventilators”. Removed (-) before 60 in I.A.1.b. Changed ≥ 45 to > 45 in I.A.1.a.i. Added pediatric criteria in I.A.1.a.ii. Changed I.A.1.b.i to apply to those over age 18 and added “1.A.1.b.ii. “For those < 18 years of age, documentation of Type 1 (hypoxemic) and/or Type 2 (hypercapneic) respiratory failure or inability to maintain airflow”. Replaced “tachypnea (respirations >24)” with “including tachypnea, increased work of breathing, hypoxemia, hypercapnia and/or respiratory acidosis (e.g., pH <7.35)” in I.A.2.c.; I.B.3.c.; I.C.3.c.; and I.D.1.c. Added “Baseline” to all “FIO2 requirement > 0.40”. Moved invasive ventilator criteria from CP.MP.107 DME and placed in criteria IV. Combined invasive and nonivasive backup or second home ventilator into section V. Added HCPCS code E0465. Description and background updated to include information re: invasive ventilators. Reworded some extraneous language 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.” References reviewed and updated. Specialist reviewed.
CP.MP.82	NICU Apnea Bradycardia Guidelines	Annual review completed. Expanded criteria I.A.3.c. into two criteria points by adding criteria I.A.3.d. Changed “child’s” to “infant’s” in criteria I.B. Removed conditional caffeine criteria I.D. Reworded criteria former criteria I.E, now I.D., for clarity. Moved criteria I.E. and I.F. to notes section. Minor rewording in description, original notes, and background with no clinical significance. References reviewed and updated. Specialist reviewed.
CP.MP.81	NICU Discharge Guidelines	Annual Review. Description updated with no impact on criteria. Criteria II.A. updated to include normal axillary and rectal temperature ranges and to include range for normal ambient environment temperature. References reviewed and updated.
CP.MP.49	Physical, Occupational and Speech Therapy Services	Annual review completed. References reviewed and updated. Specialist reviewed.

Policy Number	Policy Title	Revision Notes
CP.MP.100	Allergy Testing and Therapy	Added the following ICD-10 codes as medically necessary in ICD-10 code table 1: L20.0, L20.81-L20.83 (within code range L20-L20.9), L24.9, L30.2.
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
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.132	Heart-Lung Transplant	Added specific congenital heart disease criteria to 2.i. Removed contraindication regarding specific congenital heart disease lesion.
CP.MP.58	Intestinal and Multivisceral Transplant	Annual review. References reviewed, updated, and reformatted. Specialist reviewed.
CP.MP.116	Lysis of Epidural Lesions	Annual review. References reviewed, updated, and reformatted. Background updated with no clinical significance. Specialist reviewed.
WA.CP.MP.518	Negative Pressure Wound Therapy for Home Use	Annual review. References updated. Added emphasis that coverage is for a maximum of four months of treatment.
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
CP.MP.188	Pediatric Oral Function Therapy	Annual review completed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Expanded criteria I.D. to I.D.1.-3. and included parenteral nutrition and/or gastrostomy feedings as options for nutritional support. Background updated with no impact to criteria. References reviewed and updated. Specialist reviewed.
CP.MP.210	Repair of Nasal Valve Compromise	Annual Review. Updated Criteria I.B. to include nasal dilators such as Max-Air Nose Cones® and Sinus Cones®. Background updated with no impact on criteria. References reviewed and updated. Changed “Last Review Date” in policy header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.”
WA.CP.MP.509	Upper GI Endoscopy for GERD	Annual review. Detailed Alarm Symptoms. Updated reference.
WA.CP.MP.524	Whole Exome Sequencing	Policy retired

Policy Number	Policy Title	Revision Notes
WA.CP.MP.519	Administrative Days	Criteria for Physical Health (Section I.) re-ordered and discharge planning criteria restated. Section II on non-approval removed. Criteria for Behavioral Health, previously Section III, renumbered and re-ordered. References reviewed and updated. All occurrences of “member” replaced with “member/enrollee”.
WA.CP.MP.504	Elective Delivery Prior to 39 Weeks	Annual review. Changed “Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” Updated diagnosis code list.
CP.MP.106	Endometrial ablation	Changed criteria I.D. from “no structural anomalies, such as fibroids or polyps that require transmural surgery or represent a contraindication to an ablation procedure” to “no structural anomalies, such as fibroids or polyps that require transmural surgery or represent a contraindication to an ablation procedure.” Added contraindication criteria I.F.6. “Previous classical cesarean or other transmural surgery.”
WA.CP.MP.207	Home Prothrombin Time Monitoring	Policy retired.
WA.CP.MP.27	Hyperbaric Oxygen Therapy	Policy reviewed and verified variances from InterQual justify maintenance. References reviewed and updated. Changed “date” in the revision log header to “revision date”.
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."
CP.MP.87	Inhaled nitric oxide	Annual Review. Spelled out “partial pressure of oxygen” in I.B.1.e. and “inhaled nitric oxide” in IV. Updated description and background with no impact on criteria. References reviewed and updated. Specialist reviewed.
CP.MP.24	Multiple Sleep Latency Testing	Annual review. Added criteria for repeat MSLT in section II. Updated additional background information with no further impact to criteria. 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.
WA.CP.MP.507	Oral Enteral Nutrition	Annual Review. Changed “Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” Replaced "members" with "members/enrollees".
WA.CP.MP.506	Psychological Testing	Annual review. Policy updated to more closely mirror HCA Billing Guidelines.
WA.CP.MP.185	Skin Substitutes	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.” Reworded some extraneous language with no clinical significance. Added to I.F.2. “unless Integra® is used per FDA guidelines”. Removed I.J.3. “Concurrent treatment with hyperbaric oxygen therapy”. Background section updated with no additional impact to criteria. Update code listing of covered and non-covered codes to mirror HCA Billing Guidelines. Added reference CMS A56696. Specialist reviewed.
CP.MP.163	Total Parenteral Nutrition and Intradialytic Parenteral Nutrition	Annual review. References reviewed and updated to AMA format. Spelling correction in criteria I.A.2.c. 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 impact to criteria. Specialist reviewed.
CP.BH.200	Transcranial Magnetic Stimulation for Treatment Resistant Major Depression	Revised Policy/Criteria Section I.B. to reflect that oversight of treatment is provided by a licensed psychiatrist except where state scope of practice acts allow otherwise.
WA.CP.MP.522	Varicose Vein Treatment	Annual review. Added I.C, that if cyanoacrylate adhesive (VenaSeal) is requested, it is for the smaller saphenous vein only. Removed section III stating that cyanoacrylate adhesive is not medically necessary. References reviewed and updated. Background updated with no impact on criteria. Specialist reviewed. Moved codes 36482 and 36483.
WA.CP.MP.527	Vitamin D Testing	Annual review. Added reference to coding guidelines. References updated.

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.

Clinical & Payment Policies

Clinical Policies

Ambetter Clinical Policies Listing

A - G

Genetic Testing

H - Q

R - Z

Ambetter Pharmacy Policies Listing

A - G

H - Q

R - Z

Medicaid Clinical Policies Listing

A - G

Genetic Testing

H - Q

R - Z

Medicaid Pharmacy Policies Listing

A - G

H - Q

R - Z

Payment Policies

Ambetter Payment Policies

A - H

I - Q

R - Z

Medicaid Payment Policies

A - H

I - Q

R - Z

Policy Revision Summary

April 2023

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February 2023

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December 2022

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