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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.

Clinical Policies Listing

Ambetter Pharmacy Policies Listing

Medicaid Pharmacy Policies Listing

Allwell Specialty 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

Allwell Payment Policies

Policy Revision Summary

Policy Date

Policy Number

Policy Title

Revision Notes

9/1/19

CP.MP.26

Articular Cartilage Defect Repairs

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.114

Disc Decompression Procedures

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.106

Endometrial Ablation

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

9/1/19

WA.CP.MP.171

Facet Joint Interventions

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

9/1/19

CP.MP.89

Genetic Testing

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

9/1/19

CP.MP.173

Implantable Intrathecal Pain Pump

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.85

Neonatal Sepsis Management

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

9/1/19

CP.MP.148

Radial Head Implant

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.174

Selective Dorsal Rhizotomy

Archived policy. Replaced with TurningPoint policy

9/1/19

CP.MP.117

Spinal Cord Stimulation

Archived policy. Replaced with TurningPoint policy

Policy Date

Policy Number

Policy Title

Revision Notes

8/1/19

 

CP.MP.100

Allergy Testing and Therapy

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

8/1/19

WA.CP.MP.37

Bariatric Surgery

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

8/1/19

CP.MP.14

Cochlear Implant Replacements

Removed CPT 69717and 69718 and replaced with CPT 69949

8/1/19

WA.CP.MP.115

Discography

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

8/1/19

CP.MP.107

DME

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

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

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

8/1/19

WA.CP.MP.36

Experimental Technologies

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

8/1/19

WA.CP.MP.54

Hospice Services

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

8/1/19

WA.CP.MP.503

Private Duty Nurse

New Policy

8/1/19

WA.CP.MP.38

Ultrasound in Pregnancy

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

8/1/19

WA.CP.MP.46

Ventricular Assist Devices

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

8/1/19

CP.PHAR.225

Dalteparin (Fragmin)

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

8/1/19

CP.PHAR.310

Daratumumab (Darzalex)

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

Policy Date

Policy Number

Policy Title

Revision Notes

7/1/19

CP.MP.87

Inhaled Nitric Oxide

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

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

7/1/19

CP.MP.83

Carrier Screening in Pregnancy

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

7/1/19

CP.MP.84

Cell-free Fetal DNA Testing

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

7/1/19

CP.MP.89

Genetic Testing

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

7/1/19

CP.MP.82

NICU Apnea Bradycardia Guidelines

Restructured guidelines and specified that these are “guidelines.” In discharge criteria for significant events and on home respiratory monitoring, added that the infant has no other conditions requiring inpatient care. Reworded sections headings and organized information accordingly.  Changed all instances of “parents” to “parents or caregivers.” Combined caffeine criteria section into the“discharge for significant cardiorespiratory events” section.

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

7/1/19

CP.MP.148

Radial Head Implant

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

7/1/19

CP.MP.174

Selective Dorsal Rhizotomy for Spasticity in CP

New Policy

 

Policy Date

Policy Number

Policy Title

Revision Notes

6/1/19

CP.MP.124

ADHD Assessment and Treatment

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

6/1/19

 

CP.MP.108

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

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

6/1/19

CP.MP.31

Cosmetic and Reconstructive Surgery

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

6/1/19

CP.MP.132

Heart-Lung Transplant

Added contraindication of “Active peptic ulcer disease”.

6/1/19

CP.MP.34

Hyperemesis gravidarum treatment

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

6/1/19

CP.MP.62

Hyperhidrosis treatments

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

6/1/19

CP.MP.69

Intensity-Modulated Radiotherapy

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

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

6/1/19

CP.MP.141

Non-Myeloablative Allogeneic Stem Cell Transplants

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

6/1/19

CP.MP.91

Obstetrical Home Health Care Programs

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

6/1/19

CP.MP.102

Pancreas transplant

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

6/1/19

CP.MP.120

Pediatric Liver Transplant

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

6/1/19

CP.MP.70

Proton and Neutron Beam Therapy

Removed inactive CPT 77422

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

6/1/19

CP.MP.146

Sclerotherapy for Varicose Veins

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

6/1/19

CP.MP.22

Stereotactic Body Radiation Therapy

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

6/1/19

CP.MP.172

Transcranial Magnetic Stimulation

Added contraindications to retreatment section III.

6/1/19

CP.MP.142

Urinary Incontinence Devices and Treatments

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

6/1/19

CP.MP.12

Vagus Nerve Stimulation

Updated background with additional information on non-implantable VNS