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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

Effective Date

Policy Number

Policy Title

Revision Notes

4/1/21

CP.MP.49

Physical, Occupational and Speech Therapy Services

Added criteria to section IV. for a formal reevaluation, requiring that there must be documentation of new clinical findings or a significant change in condition, or a failure to respond to therapeutic interventions outlined in the POC.  Replaced "member" with "member/enrollee." 

Effective Date

Policy Number

Policy Title

Revision Notes

3/1/21

WA.CP.MP.524

Whole Exome Sequencing

New policy

3/1/21

CP.MP.100

Allergy Testing and Therapy

Added “(scratch, puncture, prick)” to description in I.C.1.  Updated IIIB.  adding several not medically necessary tests. Updated background, adding section on sublingual immunotherapy.  CPT codes added to not medically necessary CPT Table 2:  86160, 86161, 86162, 86332, 86343, 86485, 86628, 0165U, 0178U.  Revised description of ICD-10 codes Z88.0-Z88.9 in ICD-10 Tables 4 & 5.  References reviewed and updated.  Replaced member with member/enrollee in all instances.

Effective Date

Policy Number

Policy Title

Revision Notes

2/1/21

CP.MP.139

Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy

Renamed policy to Low Frequency Ultrasound Therapy and Noncontact Normothermic Wound Therapy for Wound Management. Added criteria and background for noncontact normothermic wound therapy. References reviewed and updated. Replaced “members’ with “members/enrollees” in all instances.

Effective Date

Policy Number

Policy Title

Revision Notes

1/1/21

WA.CP.MP.177

Video Electroencephalography (V-EEG)

New Policy

1/1/21

WA.UM.23

Video Electroencephalography (V-EEG)

Policy is archived and replaced with WA.CP.MP.177

1/1/21

CP.MP.169

Trigger Point Injections for Pain Management

I.B.4: Changed maximum of 6 injections/year to 4.  Added ICD-10 code M79.18 and changed M79.1 to M79.12.  References reviewed and updated.

1/1/21

CP.MP.181

Polymerase Chain Reaction Respiratory Viral Panel Testing

New Policy

Effective Date

Policy Number

Policy Title

Revision Notes

 

 

 

 

Effective Date

Policy Number

Policy Title

Revision Notes

11/1/20

CP.MP.189

Thymus Transplantation

New Policy

11/1/20

WA.CP.MP.38

Ultrasound in Pregnancy

Policy is archived and replaced with CP.MP.38

11/1/20

CP.MP.38

Ultrasound in Pregnancy

New Policy

Effective Date

Policy Number

Policy Title

Revision Notes

10/1/20

CP.MP.124

ADHD Assessment & Treatment

Policy reviewed. References reviewed and updated. Updated Section I.A. to include “collection of collateral information” and “toxicology screen.” Updated Section I.B. to include “ongoing assessment and application of standardized scales to assess treatment benefit.” Updated Section II. “investigational or unproven” assessments and treatments with the following: pharmacogenetic tools; Cannabidiol oil; cognitive training; external trigeminal nerve stimulation (eTNS); mindfulness; and supportive counseling, to reflect the 2019 version of American Academy of Pediatrics (AAP) Clinical Practice Guidelines. Edited Section II.A.19. to read “Neuro Biofeedback/EEG Biofeedback.” Updated AAP recommended treatment modalities. Added information regarding The Society for Developmental and Behavioral Pediatrics (SDBP) Clinical Practice Guidelines and Process of Care Algorithms for Assessment and Treatment of Children and Adolescents with Complex ADHD. Updated Background section to include most recent prevalent statistics and the necessity of treatment by Primary Care Providers.

CPT Code Updates: Removed 78607, 95827, 97127. Added 78803, 81171, 81172, 92547, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726, 96121, 97129, 97130.

HCPCS Code Updates: Added G0176.  (All code changes relate to non-covered services)

10/1/20

CP.MP.186

Burn Surgery

New policy

10/1/20

CP.MP.184

Home Ventilators

New policy

10/1/20

CP.MP.121

Homocysteine Testing

References reviewed and updated. Revised I.A from “Borderline vitamin B12 deficiency” to “Borderline low or inconclusive Vitamin B12 deficiency, or discordant with the clinical picture.”

Changed borderline B12 deficiency and idiopathic VTE/thromboembolism indications from medically necessary to investigational. Added supporting background information and references. Removed from the list of ICD-10 codes supporting coverage criteria: D51.0-D51.9, E53.8, I26.01-I26.99, I81, I82.0-I82.91, Z86.711, Z86.718.

10/1/20

WA.PP.800

Observation Status

Archived policy

10/1/20

CP.MP.188

Pediatric Oral Function Therapy

New policy

10/1/20

CP.MP.182

Short Inpatient Hospital Stay

Renumbered from WA.PP.800 and renamed.

Observation status will be approved for stays of 48 hours or less, unless one of the policy exceptions is noted.

Intermediate/step down level of care is now part of the observation exclusion list.

Effective Date

Policy Number

Policy Title

Revision Notes

9/1/20

WA.CP.BH.104

ABA Therapy

Annual Review.  Renumbered policy, was WA.CP.MP.104.  Moved to standard corporate policy, with state-specific requirements for Center of Excellence, DSM Checklist and use of HCPCS H2020.

9/1/20

CP.MP.96

Ambulatory EEG

Annual review completed.  References reviewed and updated.  Added the following ICD-10 codes:  R40.4, R55  

9/1/20

CP.MP.107

Durable Medical Equipment

Code E0780 added to criteria for ambulatory infusion pump. Moved ambulatory and implantable infusion pump criteria into pumps section. Updated table of contents.

9/1/20

CP.MP.137

Fecal Incontinence Treatment

Additional criteria added for sacral nerve stimulators from local coverage article (A53017). Clarified definition of chronic fecal incontinence as greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth. Added additional criteria requiring a successful percutaneous test stimulation, condition not be related to anorectal malformation and/or chronic inflammatory bowel disease, incontinence not be related to another neurologic condition and contraindications for device. Added sacral nerve stimulation for the treatment of chronic constipation or chronic pelvic pain to the not medically necessary section II.

9/1/20

CP.MP.85

Neonatal Sepsis Management Guidelines

Under section III. Discharge criteria, added E. Follow-up planned with provider within 48 hours of discharge. In background section I.G., changed ≥ 10^5 CFU to ≤ 10^5 CFU. References reviewed and updated.

9/1/20

WA.CP.MP.523

Obstructive Sleep Apnea Diagnosis and Treatment

Clarified Attended Sleep Study criteria. Updated references.

9/1/20

WA.CP.MP.50

Outpatient Testing for Drugs of Abuse

In II.B, added that “Tests are only for the specific drug(s) or number of drug classes for which the presumptive test is expected to be positive.” Added CPT 80366. Reinstated notes regarding PA not being required for children < 6 years of age, and a 10 day post-test window for PA.

9/1/20

CP.MP.51

Reduction Mammoplasty and Gynecomastia Surgery

Added note to reference CP.MP.95 for breast surgeries pertaining to gender affirming procedures. Added criteria for breast reduction for females that cup size has not changed in 6 months. Added criteria for adolescent males requiring that adult testicular size has been attained. References reviewed and updated. 

9/1/20

CP.MP.162

Tandem Transplant

Changed contraindication of significant systemic or multisystem disease to “significant, uncorrectable, life-limiting medical condition. Removed substance abuse or dependence contraindication. Background updated with no impact on criteria.  References reviewed and updated.

9/1/20

CP.BH.200

Transcranial Magnetic Stimulation

Renumbered policy, was WA.CP.MP.172.  Policy/Criteria section updated to clarify that Section I. refers to initial approval of TMS sessions. Updated item I.B. to reflect “Oversight of treatment is provided by a licensed psychiatrist.” Updated I.C. to include “Other standardized scale indicating moderately severe to severe depression.” Added Section I.I., “The initial request can be reviewed for up to 20 TMS sessions.” Added Section II. to include criteria for authorization of additional TMS sessions.

9/1/20

CP.MP.183

2019 Novel Coronavirus Testing

Modified criteria to reflect CDC testing guidelines as of 7/20/20. Added criteria for neonatal testing. Added criteria for discontinuation of transmission-based precautions, home isolation, and for return to work for healthcare providers. Changed antibody/serology testing medical necessity statement to medically necessary for those presenting late in illness, in conjunction with viral testing, and when post-acute infection syndrome is suspected. Removed background statement about antibody testing not being appropriate for diagnosis of acute infection. Added antibody testing code 86328 to the table supporting medical necessity, as well as codes 0202U, 0223U, 0224U. References updated.

Effective Date

Policy Number

Policy Title

Revision Notes

8/1/20

WA.CP.MP.185

Skin Substitutes for Chronic Wounds

New Policy

Effective Date

Policy Number

Policy Title

Revision Notes

7/1/20

WA.CP.MP.50

Outpatient Testing for Drugs of Abuse

Revised policy to state that HCPCS codes G0482 & G0483 are not medically necessary. Updated references.

Effective Date

Policy Number

Policy Title

Revision Notes

6/1/20

WA.CP.MP.519

Administrative Days

Removed exclusion for custodial care days.

6/1/20

CP.MP.96

Ambulatory Electroencephalography

Removed CPT codes 95950, 95953-codes deleted 1/1/2020.  Added the following 2020 CPT codes:  95700, 95705, 95708, 95717, 95719, 95721, 95723, and 95725. Removed CPT codes from criteria note specifying which CPT codes should precede which ambulatory EEG codes.

6/1/20

CP.MP.183

2019 Novel Coronavirus Testing

Added CPT codes 86328 and 86769.

6/1/20

CP.MP.155

EEG in the Evaluation of Headache

Revised CPT 95813 description

6/1/20

WA.CP.MP.504

Elective Delivery Prior to 39 Weeks

Annual review.  Added WAC reference to background. Updated references. Added ICD-10 codes K83.5 and O26.

6/1/20

CP.MP.140

EpiFix

Archive policy

6/1/20

CP.MP.113

Holter Monitors

Annual review completed.  References and codes reviewed/updated.  ICD-10 codes I42.3-7 were added; R06.00-R06.09 description changes to Dyspnea

6/1/20

WA.CP.MP.54

Hospice Services

Annual review, references updated. Inclusion of transportation services added. Associated revenue code added to HCPCS table.

6/1/20

WA.CP.MP.505

Microprocessor-Controlled Lower Limb Prosthetics

Annual review.  Added L2006.

6/1/20

WA.CP.MP.517

Testosterone Testing

Annual review. Reference updated. Grammatical changes.  84410 added.

6/1/20

CP.MP.169

Trigger Point Injections for Pain Management

CPT 20560 and 20561 added as not supporting coverage criteria.

6/1/20

CP.MP.56

Ventriculectomy and Cardiomyoplasty

CPT codes added: 33426, 33542, and 33548.

Effective Date

Policy Number

Policy Title

Revision Notes

5/1/20

CP.MP.31

Cosmetic and Reconstructive Surgery

Removed “significant” in I.A.4.a. In II. N.changed “hair replacement” to “hair transplantation.”  Added additional not medically necessary indications i.e.,(mastopexy except for breast reconstruction post-mastectomy or lumpectomy resulting in significant asymmetry, correction of inverted nipples, and repair of diastasis recti. Specialist reviewed.  References reviewed and updated. 

5/1/20

CP.MP.89

Genetic Testing

Added general criteria for pharmacogenetic testing. Updated background on pharmacogenetic testing.  References reviewed and updated. 

5/1/20

CP.MP.109

Panniculectomy

ICD -10 codes added.  References reviewed and updated. Specialist reviewed.

5/1/20

CP.MP.142

Urinary Incontinence Devices and Treatments

References reviewed and updated.  Added ICD-10: R35.0.

5/1/20

CP.MP.183

Novel Coronavirus Testing

Modified medical necessity statement to state that testing following CDC guidelines is medically necessary. Changed criteria to reflect CDC guidelines as of 3/4/20

Effective Date

Policy Number

Policy Title

Revision Notes

4/1/20

 

CP.MP.103

Fractional Exhaled Nitric Oxide

Added that testing FeNO is investigational for all other conditions, in addition to asthma, with supporting sources.

4/1/20

CP.MP.107

DME

Under Ambulatory Assist Products: Added criteria for standers under codes E0637, E0638, E0639, E0641, and E0642; Under Heat, Cold & Light Therapy Equipment: Changed coverage recommendation for Cold Pad Pump to “Not medically necessary” based on current research; Under Orthopedic Care Equipment: Added criteria for traction equipment for codes E0849 and E0855 that target Temporomandibular Joint Dysfunction; Moved Fracture Frames with codes E0974 and E0984 to the section with Halo Procedure Equipment as criteria and indications are the same; Changed male vacuum erection devices from not medically necessary to medically necessary; Added hip labral tears as an indication for a Hip Orthotic; Added clarification to prosthetics an additions section to avoid inappropriate application; Under Other Equipment: Added criteria for E1399, K0108 and K0739 when they are used for wheelchair repairs; Added criteria for E2300 Seat Elevators; Under Stimulator Equipment: Added E0770 when the diagnosis is spinal cord injury to the coverage criteria detailed under Neuromuscular stimulator

Effective Date

Policy Number

Policy Title

Revision Notes

3/1/20

CP.MP.27

Hyperbaric Oxygen Therapy

Policy archived

3/1/20

CP.MP.91

OB Home Health Program

Pre-eclampsia program: I.H changed dipstick reading from 1+ to 2+.  Updated background with ACOG’s statement on administration of Hydroxyprogesterone Caproate.  Specialist review.

3/1/20

CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

Removed restriction of TFESI to lumbar region. Added the statement to all TFESI indications that for cervical TFESI, non-particulate steroid must be used and the procedure must be conducted with real-time imaging, such as fluoroscopy. Revised the not medically necessary statement regarding TFESI for all other indications and locations to only note all other indications.

3/1/20

WA.CP.MP.171

Facet Joint Interventions

Revised wording of section I.A. to match corporate policy. No change to criteria. Updated reference.

Effective Date

Policy Number

Policy Title

Revision Notes

2/1/20

 CP.MP.179

Antithrombin III (Atryn, Thromate)

New policy

2/1/20

CP.MP.180

Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

New policy

Effective Date

Policy Number

Policy Title

Revision Notes

1/1/20

CP.MP.106

Endometrial Ablation

Added codes F64.0, F64.8 and F64.9 for transgender indication. Expanded the menorrhagia indication to instead say “abnormal uterine bleeding” and added the following corresponding codes: N92.5, N92.6, N93.8, N93.9.

1/1/20

CP.MP.134

Evoked Potentials

Removed age limit in I.B.6 and replaced with “infants and preverbal children or children with developmental delay or intellectual disability.” References reviewed and updated.  ICD-10 codes deleted in 2019: H81.41, H81.42, H81.43, H81.49.  Specialist review.

1/1/20

CP.MP.137

Fecal Incontinence Treatments

Added recommendation from ACOG to background.   References reviewed and updated.  CPT code 46762 deleted.  Added CPT code 64566 and HPCPS code L8605 as codes that do not support medical necessity. Revised description of CPT codes 95970, 95971 and 95972. Reviewed by specialist.

1/1/20

CP.MP.85

Neonatal Sepsis Management Guidelines

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

1/1/20

CP.MP.170

Nerve Blocks

Peripheral/Ganglion Nerve Blocks: Section A indication added for peripheral nerve blocks for malignant pain; section B.1. and 2. added indication for diagnosis or treatment of post-herniorrhaphy pain and therapeutic post-herniorrhapy pain; section C added peripheral nerve blocks for prevention or treatment of headaches, including migraines, refractory migraines in pregnancy, and short-lasting unilateral neuralgiform headaches as not medically necessary.  Background and references updated accordingly.

1/1/20

WA.PP.800

Observation Stay

New Policy

1/1/20

CP.MP.49

PT, OT, ST Services

New Policy

1/1/20

CP.MP.146

Sclerotherapy for Varicose Veins

Added perforating veins under a current or healed ulcer as an indication; Edited previous criteria for saphenous veins to apply to saphenous veins or perforating veins.

1/1/20

CP.MP.151

Transcatheter Closure of Patent Foramen Ovale

Annual review. Added Gore Cardioform as an FDA-approved device appropriate for medically necessary closure of PFO. Reviewed by specialist.

1/1/20

CP.MP.142

Urinary Incontinence Devices and Treatment

Separated out criteria for trial and placement of SNM, with trial criteria being the same as permanent placement, excluding the permanent placement requirement for a positive response to the trial.

1/1/20

CP.MP.98

Urodynamic Testing

Added ICD-10-CM code R39.14 to support medical necessity of all procedure codes. Added ICD-10-CM code R35.1 to support medical necessity for CPT 51798.

Effective Date

Policy Number

Policy Title

Revision Notes

12/1/19

WA.CP.MP.12

Vagus Nerve Stimulation

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