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.244	Liposuction of Lipedema	New Policy

Policy Number	Policy Title	Revision Notes
CP.MP.243	Implantable Loop Recorder (Implantable Cardiac Monitor)	New Policy

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.

Policy Number	Policy Title	Revision Notes
CP.MP.179	Antithrombin III (Atryn, Thomate)	Annual review. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” “Not medically necessary” verbiage replaced in policy statement with “current evidence does not support” verbiage.
CP.MP.156	Cardiac Biomarker Testing for Acute MI	Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." References reviewed, and updated. Reviewed by specialist.
WA.CP.MP.84	Cell-Free Fetal DNA Testing	Removed deleted CPT 0168U. Moved code 0060U from the coding table supporting medical necessity to the table of codes that do not support medical necessity.
CP.MP.105	Digital EEG Spike Analysis	Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated and reformatted. Reviewed by specialist.
CP.MP.125	DNA Analysis of Stool	Policy retired.
CP.MP.101	Donor Lymphocyte Infusion	Annual review. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” “Experimental/investigational” verbiage replaced with policy statement verbiage that “current evidence does not support” the use of DLI for the stated indications. Replaced “hematological” with “hematologic” throughout the policy.
CP.MP.155	EEG in Evaluation of Headache	Annual review complete. Coding reviewed. References reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Reviewed by specialist.
CP.MP.131	Essure Removal	Annual review. References reviewed and updated. Reviewed by Specialist. Changed "Last Review Date" in the header to "Date of Last Review" and "Date" in revision log to "Revision Date."
CP.MP.150	Home Phototherapy for Neonatal Hyperbilirubinemia	Annual review. References reviewed and updated. Background updated, no clinical significance. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date."
CP.MP.153	H. Pylori Testing	Annual review. References reviewed and updated. Reviewed by specialist. Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date”.
CP.MP.87	Inhaled Nitric Oxide	Added indications for case by case review of iNO initiation for preterm infants <34 weeks at birth to section II. Split continuation criteria into section III, and not medically necessary indications are now section IV. Minor rewording of background. Added reference 35. Changed “Review Date” in policy header to “Date of Last Revision,” and “Date” in the revision log table header to “Revision Date.”
CP.MP.70	Nerve Blocks for Pain Management	Edited note in section VI to state: If administered as part of a surgery or other procedure, coding for peripheral/ganglion nerve blocks should follow proper coding practices and would not be subject to prior authorization or payment separately from the procedure.
CP.MP.154	Thyroid Hormones and Insulin Testing in Pediatrics	Annual review. References reviewed and updated. Specialist review. Changed "Last Review Date" in the header to "Date of Last Review" and "Date" in revision log to "Revision Date."

Policy Number	Policy Title	Revision Notes
CP.MP.100	Allergy Testing and Therapy	Annual review. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Criteria and coding reviewed by specialist.
WA.CP.MP.119	Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis	Policy retired.
CP.MP.164	Caudal or Interlaminar Epidural Steroid Injections for Pain Management	In policy statement, changed “with or without radiographic guidance” to “with imaging, except in rare instances.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed and updated. Replaced “member” with “member/enrollee” in all instances. Specialist review.
WA.CP.MP.84	Cell-free Fetal DNA Testing	Annual review. Added “Effective Date”. Added codes 0168U and 0060U. Separated code tables.
CP.MP.107	Durable Medical Equipment and Orthotics and Prosthetics Guidelines	Removed requirement for replacement requests not due to physiological changes to meet existing criteria and reformatted criteria. Contents table renumbered.
CP.MP.40	Gastric Electrical Stimulation	Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date."
CP.MP.136	Home Birth	Annual review. Added to I.A.2.b an option for family practice physicians who have completed an OB fellowship to attend a home birth without a supervising OB. Removed WHO background information on home birth, and supporting reference. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." References reviewed, reformatted, and updated.
WA.CP.MP.27	Hyperbaric Oxygen Therapy	Policy updated to reflect HCA Billing Guideline. “Members” updated to “Members/Enrollees”. References updated.
CP.MP.57	Lung Transplantation	8/21: Replaced contraindications of “severely limited functional status with poor rehabilitation potential” and those regarding past or current nonadherence to medical therapy, and psychological condition associated with the inability to comply with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “review date” in header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” 9/21: Annual review. References reviewed and updated. Reviewed by specialist.
CP.MP.86	Neonatal abstinence syndrome guidelines	Annual review. References reviewed, updated and reformatted. Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date.” Website for Modified Finnegan scoring added to the background under B.1.Clarifying edits added to I.A.1 regarding “duration of observation for symptoms.” Clarifying edits added to Note in I.B regarding “medications to treat withdrawal symptoms.”
CP.MP.51	Reduction Mammoplasty and Gynecomastia Surgery	In I.A.2., changed “No change in cup size for at least 6 months” to “For adolescents, no breast growth equivalent to a change in cup size for at least 6 months.” Updated background regarding gigantomastia of pregnancy with no impact on criteria.
WA.CP.MP.523	Sleep Apnea Diagnosis and Treatment	Moved section III on CPAP titration to be section II and expanded this section. Added qualifying statements to I.A., I.H. and I.I. Added language for sleep-related hypoventilation. Made minor changes to Description. Updated references. Replaced “members” with “members/enrollees”.
WA.CP.MP.177	Video Electroencephalography (V-EEG)	Annual review. Updated verbiage for outpatient video encephalography (EEG) monitoring in the home to indicate no or unclear support for its use. Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date”. Reviewed by specialist. References reviewed and updated. Replaced “members” with “members/enrollees’ in all instances.

Policy Number	Policy Title	Revision Notes
CP.MP.93	Bone-Anchored Hearing Aid	Annual review. Reworded I.B. with no clinical significance. Revised I.E from “threshold of 20dB” to “threshold of < 20dB.” In I.F.4., added idiopathic causes to the list of causes of unilateral deafness. Revised description of HCPCS L8691 and added L8694. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Replaced “member” with “member/enrollee.” References reviewed, updated and reformatted. Reviewed by specialist.
WA.CP.MP.516	Carotid Artery Stenting	Annual review. References updated. Added additional criteria for “high risk” from HCA Billing Guideline. Changed statement regarding intracranial stents from not covered to not medically necessary. Removed 37217, 37218, 0075T and 0076T from code list.
CP.MP.107	Durable Medical Equipment and Orthotics and Prosthetics Guidelines	Reorganized Standing Frame criteria and required that replacement requests also meet existing criteria for the initial request. For initial request under 18, added "and one of the following: Developmental delay in ambulation and ≥ 18 months of age; Documented neurological or neuromuscular impairments and ≥ 1 year of age.” Required that documentation supports meeting height and weight requirements, alert and responsive to stimuli, no contraindications to standing program, and caregiver trained, available, and able to safely assist. Removed requirement for “able to tolerate upright position.” Added informational note.
CP.MP.134	Evoked Potential Testing	Annual review completed. Minor typo corrections. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated, and reformatted. Coding reviewed and updated. Removed intraoperative CPT codes 95940, 95941, and HCPCS code G0453.
CP.MP.132	Heart-Lung Transplant	In B.2., removed “adequate functional status with the ability for rehabilitation.” Replaced contraindications of “history of history of psychological, behavioral, or cognitive disorders, poor family support structures, or documented noncompliance with previous therapies that could interfere with successful performance of care regimens after transplantation” and “current non-adherence to medical therapy…” with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “Review Date” in policy header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.”
CP.MP.58	Intestinal and Multivisceral Transplant	Replaced contraindications of “severely limited functional status with poor rehabilitation potential” and those regarding past or current nonadherence to medical therapy, and psychological condition associated with the inability to comply with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “review date” in header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.”
CP.MP.167	Intradiscal Steroid Injections for Pain Management	Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, reformatted and updated. Replaced “member” with “member/enrollee” in all instances. Specialist review.
CP.MP.128	Optic Nerve Decompression Surgery	Revised language in II from “investigational” to “insufficient evidence to support…” References reviewed, updated and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Replaced member with member/enrollee.
CP.MP.102	Pancreas Transplantation	Removed contraindication of “severely limited functional status with poor rehabilitation potential.” Replaced “Psychiatric or psychological condition associated with the inability to cooperate or comply with medical therapy” and the contraindication regarding non-compliance with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “Review Date” in header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.”
CP.MP.138	Pediatric Heart Transplants	In I.C., replaced “adequate functional status with ability for rehabilitation” and contraindications regarding past or current nonadherence to medical therapy, and psychological condition associated with the inability to comply with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “review date” in header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.”
CP.MP.120	Pediatric Liver Transplant	Replaced contraindications regarding psychological condition preventing compliance with medical therapy and “current non-adherence to medical therapy” with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “Review Date” in header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.”
CP.MP.181	Polymerase Chain Reaction Respiratory Viral Panel Testing	Removed criteria specific to Covid 19 testing in I.A.
CP.MP.210	Repair of Nasal Valve Compromise	New policy.
CP.MP.166	Sacroiliac Joint Interventions for Pain Management	Annual review completed. References reviewed, updated, and reformatted.
CP.MP.88	Sickle Cell Disease Observation	Policy retired in favor of InterQual criteria.
CP.MP.206	Skilled Nursing Facility Leveling	Annual review. In I.B.1 and II.B.I, corrected list of appropriate oversight to include doctors. References reviewed and updated. Reviewed by specialist.
CP.MP.162	Tandem Transplant	Replaced contraindications regarding past or current nonadherence to medical therapy, and psychological condition associated with the inability to comply with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.”
CP.MP.169	Trigger Point Injections for Pain Management	Annual review. Referenced reviewed and updated. Updated criteria II. to replace “not medically necessary” with “current evidence does not support.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Replaced member with member/enrollee. Reviewed by specialist.
CP.MP.12	Vagus Nerve Stimulation	Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Background updated with additional study on nVNS for migraine headaches. References reviewed and updated. Reviewed by specialist.
WA.CP.MP.522	Varicose Vein Treatment	Clarified in III to cyanoacrylate is used in endovenous ablation and not sclerotherapy. Updated background accordingly. Changed “review date” in policy header to “date of last revision,” and “date” in the revision log header to “revision date.” Updated references.

Policy Number	Policy Title	Revision Notes
CP.MP.96	Ambulatory EEG	Annual review completed. References reviewed, updated, and reformatted. Replaced all instances of member with member/enrollee. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Background updated with no clinical significance. Specialist reviewed.
WA.CP.BH.104	Applied Behavior Analysis	Annual review. Reference list reviewed and updated. Changed “Review Date” in the header to “date of last revision” and “date” in the revision log header to “Revision date.” Corrected typo
CP.MP.14	Cochlear Implant Replacements	Annual review. References reviewed and updated. Coding reviewed, added codes L8621 and L8622. Replaced all instance of “member” with “member/enrollee.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Sent for specialist review.
WA.CP.MP.208	Drugs of Abuse: Presumptive Testing	Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Removed diagnosis code listing. Removed reference to WA.CP.MP.50, Drugs of Abuse, Definitive Testing.
CP.MP.107	Durable Medical Equipment (DME)	Added criteria for enclosed beds to “Other Equipment” section of policy. Added references and codes E0316, E1399 and E0328 or E0329 (when combined with E0316 or E1399) for enclosed beds. Replaced “investigational” with “not proven safe and effective” in the following sections: Pneumatic compression devices, neuromuscular stimulator, and peroneal nerve stimulators. Updated policy to remove neuromuscular stimulator, functional neuromuscular stimulator, and peroneal nerve stimulator, which was transferred to CP.MP.48 Neuromuscular Electrical Stimulation (NMES). Replaced existing Standing Frames criteria with new initial request and replacement request criteria. Revised section on pneumatic compression devices to state that they are not proven safe and effective for lymphedema of the abdomen, trunk, chest, genitals, or neck; and for arterial insufficiency. Added criteria for Wheelchair-mounted Assistive Robotic Arm (JACO). Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Removed archived Hayes references.
CP.MP.106	Endometrial ablation	Annual review completed. References reviewed and updated and reformatted for AMA style. Changed “members” to “members/enrollees.” Removed “experimental and investigation” from II, changing to “insufficient evidence.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Specialty review completed. Added ThermaChoice to Table 1 per UpToDate reference “3”.
WA.CP.MP.514	Extra-Corporeal Membrane Oxygenation (ECMO) Therapy	Annual review. References updated. “Members” replaced with “Members/Enrollees”
CP.MP.211	Electromyography and Nerve Conduction Studies	New policy.
WA.CP.MP.171	Facet Joint Interventions for Pain Management	Clarified that radiographic guidance is required for the injections. Noted maximum of 3 injections. Removed requirements for injection that were in the neurotomy criteria. Clarified clinically significant improvement for second neurotomy. Indicated neurotomy of the thoracic region is not medically necessary rather than not covered. Updated references.
CP.MP.137	Fecal Incontinence Treatments	Annual review completed. References reviewed, updated, and reformatted. “Experimental/investigational” verbiage replaced in policy statement with “have not been proven effective for the treatment of fecal incontinence, although they continue to be evaluated in clinical studies”. Replaced all instances of “member” with “member/enrollee”. "Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Minor verbiage changes to background with no clinical significance.
CP.MP.137	Fetal Surgery in Utero for Prenatally Diagnosed Malformations	Annual review. References reviewed and updated. Coding reviewed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Replaced all instance of “member” with “member/enrollee.” Added, “D. Placement of a thoraco-amniotic shunt for pleural effusion with or without secondary fetal hydrops,” to criteria set I. Added criteria set, “II. It is the policy of health plans affiliated with Centene Corporation that all repeat utero fetal surgery procedures require secondary review.” Reviewed by specialist.
WA.CP.MP.511	Gene Expression Profile Testing	Annual review. Expanded Description. References updated. Replaced “members” with “members/enrollees”. Added codes 81522, 81542, 81552, 0045U, 0089U, 0090U, 0153U. Multiple myeloma and colon cancer testing changed from not covered to not medically necessary.
WA.CP.MP.512	Genomic Microarray Testing	Annual review. References updated. Removed reference to Whole Exome Sequencing in Description. Replaced statement about non-coverage with “not medically necessary”. Replaced “members” with “members/enrollees”.
CP.MP.85	Neonatal Sepsis Management	Annual Review. Removed “or level 1 nursery (rev code 171),” from II.D: “Asymptomatic infants with a positive blood culture and no other indications are appropriate for transitional care or level 1 nursery (rev code 171).” Added sentence to note under criteria point II.D. to say, “It is difficult to administer intravenous antibiotics in the home with home health care due to the challenge of keeping very small catheters in place and patent.” References reviewed and updated. Replaced all instances of “member” with “member/enrollee”. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Sent for specialist review.
CP.MP.51	Reduction Mammoplasty and Gynecomastia Surgery	Annual review. Deleted “for non-cosmetic reasons” from the policy statement in I, as it is redundant given the symptom criteria required. Replaced "and/or" with "or" in I.A.1. Reworded paragraph under Medical Record Documentation Requirements for both reduction mammoplasty and gynecomastia, and changed requirement of photographic documentation to “photographic documentation may be requested to support written documentation.” References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Specialist reviewed.
CP.MP.162	Tandem Transplant	Annual review. References updated. Minor wording changes with no clinical significance. Coding reviewed. Replaced all instance of “member” with “member/enrollee.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Sent for specialist review.
CP.MP.98	Urodynamic testing	Annual review completed. Codes checked. References updated and reformatted for AMA style. Changed “Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” Specialty review completed.
WA.CP.MP.528	Whole Exome Sequencing	New policy.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.37	Bariatric Surgery	Section I: Added BMI criteria for Asian ethnicity to I.B.1 and I.B.3. Section II: Removed criteria for ECG during cardiac clearance except for high risk, corrected typos; in II.B, added note about medical director review if A1C ≥8 and removed blood glucose requirements; in II.C., Pulmonary Evaluation removed requirement of chest x-ray and specific criteria for PSG, noting that PSG is warranted if OSA screening is positive in; In II.D, added examples of nutritional tests to be conducted, and that malabsorptive procedures may require further testing; Removed requirement of 1 year abstinence of drug & alcohol use and urine drug screen if history of abuse in II.F; added “current drug and alcohol abuse” to list of contraindications; added II.I, clinically significant GI symptoms should be evaluated & treated prior to surgery. In III.A.2.e, removed option for non-compliance with post-operative regimen if completing a multidisciplinary bariatric program. In III.A.2.f., removed option for non-compliance. Reworded V, replacing “investigational” with “current medical literature is inadequate to determine the safety, efficacy and long-term outcomes” and added one-anastomosis gastric bypass; endoscopic sleeve gastroplasty; transoral endoscopic surgery; vagus nerve blocking (e.g., Maestro) and gastric balloon (e.g., ReShape Duo, Orbera intagastic balloon, Obalon Balloon) to this list. Updated background. Added the following CPT codes as not supporting medical necessity: 43648, 43882, 64595, 0312T, 0313T, 0314T, 0315T, 0316T and 0317T. References reviewed, updated and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”
CP.MP.83	Carrier Screening in Pregnancy	Policy retired.
CP.MP.94	Clinical Trials	References reviewed, updated and reformatted. Replaced all instances of “member” with “member/enrollee.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”
CP.MP.115	Discography	Replaced WA.CP.MP.115
WA.CP.MP.115	Discography	Archived and replaced with CP.MP.115
CP.MP.209	GI Pathogen Nucleic Acid Detection Panel Testing	New policy.
WA.CP.MP.207	Home Prothrombin Time Monitoring	New policy.
CP.MP.123	Laser Therapy for Skin Conditions	Annual review. “Experimental/investigational” verbiage replaced in policy statement with “evidence is insufficient to draw conclusions.” Replaced all instances of “member” with “member/enrollee.” Coding reviewed. References reviewed and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”
CP.MP.170	Nerve Blocks for Pain Management	Added the following note to VI. Peripheral/ganglion nerve blocks: Peripheral/ganglion nerve blocks may be approved without prior authorization when used during another medically necessary procedure (i.e. as anesthesia during surgery).
CP.MP.82	NICU Apnea Bradycardia Guidelines	In I.A.1 and I.3.B., changed requirement for no clinically significant events before discharge from “5” to “5-7” days. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”
CP.MP.81	NICU Discharge Guidelines	Added I.A.3 regarding weight lost in preterm infants less than a week old. Added a note regarding gastrostomy tube placement recovery/education to I.B.2.d.ii. Updated II.A with temperature range and in note changed 1600 grams to1800 grams. Added “Chronic Lung Disease/” to “Bronchopulmonary dysplasia” for condition in III.B.3.a. Added note under III.B.3.b.i explaining stability on home ventilator in hospital prior to discharge. Removed V.A and B, updating the “free of infection” criteria statement. Added new section VI regarding caregiver competency. In section VII: clarified in A “should be approved for any of….”; added A.5 regarding caffeine for apnea; added B regarding parent/caregiver refusal to sign; added C.1 and 2 regarding nondenial of care; updated the note under describing rooming-in. In Discharge Recommended Practices: Added “immunoglobulin” to C.2 ;updated C.3 with influenza injection; added “hospital developed education program” under D; added E.1-4 regarding car seats. Replaced all instances of “members” with “members/enrollees.” References reviewed and updated to AMA format. Reviewed by neonatologist. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”
CP.MP.49	Physical, Occupational and Speech Therapy Services	In I.B, noted that treatment order can come from “other qualified health professional” as well as a physician; added “other qualified healthcare professional to II.A.9, and the background. References reviewed, updated, and reformatted. Revised wording with no clinical significance. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”
WA.CP.MP.503	Private Duty Nursing	Annual review. Reference updated. Minor changes to section I. Removed T1030 from HCPCS table. Updates “Members” to “Members/Enrollees” in Important Reminder.
CP.MP.166	Sacroiliac Join Interventions for Pain Management	Updated I.A. to specify that the criteria applies to therapeutic injections as well as diagnostic. Updated I.B. to state “A second diagnostic or confirmatory sacroiliac joint injection when pain was improved by at least 75% after the first diagnostic SIJ injection”, rather than that pain did not improve. I.C. was updated to specify “therapeutic” SIJ injection. II was changed from 50% to 75%. Replaced member with member/enrollee in all instances. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”
CP.MP.206	Skilled Nursing Facility Leveling	Updated therapy requirement verbiage for SNF Level 1 from “skilled therapy for up to 2 hours per day” to “skilled therapy 1-2 hours per day.” For SNF Levels 1 and 2, changed requirement from skilled nursing hours and therapy hours to skilled nursing hours or therapy hours. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”
CP.MP.189	Thymus Transplantation	Annual review complete. References reviewed, updated and reformatted. Replaced all instances of member with member/enrollee. Specialty review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.”
CP.MP.38	Ultrasound in Pregnancy	Section IV.Table 1, revised note * Increase frequency to weekly in women with TVU cervical length of 25 to 29 mm, to 26 to 29mm and changed “If < 25 mm before 24 weeks…” to < = 25mm; edited maximum # TVU to 11 for prior preterm birth at 14-27 weeks, and 9 for prior preterm birth at 28 to 36 weeks. Changed total number of allowed TVUS per pregnancy to 13. Removed “experimental” from section V. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed and updated.

Policy Number	Policy Title	Revision Notes
CP.MP.124	ADHD Assessment and Treatment	Revised language in I.A.5.d. to specify ECG can be performed only if clinically indicated. Added applicable CPT codes 93000, 93005 and 93010 to not medically necessary table when billed with a sole diagnosis of ADHD. Added assessment of serum lipid profiles to II.A, as well as applicable codes 80061, 83718, 83719, 82721, 83722 and 84475 to not medically necessary table when billed with a sole diagnosis of ADHD. Removed CPT-92585, 92586- codes deleted in 2021. Replaced with 92650, 92651, 92652 and 92653. Revised description of CPT- 95930. Replaced all instances of “member” with “member/enrollee.”
CP.MP.186	Burn Surgery	Removed ICD-10 codes from policy. References reviewed and updated. Replaced “member” with “member/enrollee.”
CP.MP.121	Homocysteine Testing	In the policy statement in section II, replaced “investigational” with the statement that homocysteine testing has not been proven to improve outcomes compared to other technologies. References and coding reviewed and updated. Replaced all instances of “member” with “member/enrollee.”
CP.MP.58	Intestinal and Multivisceral Transplant	References reviewed and updated. All instances of “member” changed to “member/enrollee.”
CP.MP.116	Lysis of Epidural Lesions	Revised policy statement to state, “current medical literature does not support the efficacy of lysis of epidural lesions,” and removed “investigational.” References review and updated.
WA.CP.MP.518	Negative Presure Wound Therapy for Home Use	References reviewed and updated. Added A7000 and note about benefit limit. Replaced all instances of “member” with “member/enrollee”.
CP.MP.82	NICU Apnea Bradycardia Guidelines	References reviewed and updated.
CP.MP.184	Non-Invasive Home Ventilator	References reviewed and updated. ICD-10 codes removed.
CP.MP.188	Pediatric Oral Function Therapy	Updated background. References reviewed and updated. Replaced all instances of member with member/enrollee. Removed ICD-10 codes.
WA.CP.MP.509	Upper GI Endoscopy for GERD	Annual review. Removed reference to gastro-intestinal symptoms in the Description and Section II to mirror Billing Guideline. References updated. Replaced all instances of “member” with “member/enrollee”.
WA.CP.MP.527	Vitamin D Testing	New policy. (Replaces CP.MP.152 and CP.MP.157)

Policy Number	Policy Title	Revision Notes
CP.MP.100	Allergy Testing and Therapy	Added J30.0 to ICD-10-CM Code Table 1. Minor revision to description of CPT-95070. CPT-95071 deleted in 2021.
WA.CP.MP.508	Bone Growth Stimulator	Annual review. Typographical corrections. Replaced “member” with “member/enrollee’ in all instances. Updated references
WA.CP.MP.50	Drugs of Abuse: Definitive Testing	Added 2021 CPT- 82077 to list of codes that support coverage criteria
WA.CP.MP.208	Drugs of Abuse, Presumptive Testing	Added 2021 CPT-0227U to table of codes that do not support coverage criteria.
CP.MP.155	EEG in the Evaluation of Headache	Added code 95822 to Table 1, and G43.A0 and G43.A1 to Table 2. “Experimental/investigational” verbiage replaced in policy statement with descriptive language.
WA.CP.MP.504	Elective Deliveries Before 39 Weeks	Annual review. Replaced “member” with “member/enrollee’ in all instances. References updated.
CP.MP.134	Evoked Potentials	CPT code 92585 deleted 1/1/21. Added replacement CPT codes 92652 and 92653. “Experimental/investigational” verbiage replaced with descriptive language in in policy statement III.
WA.CP.MP.36	Experimental Technologies	Removed duplicative statement in Criteria A. regarding request for clinical trials. References reviewed and updated. Replaced all instances of member with “member/enrollee”.
CP.MP.89	Genetic and Pharmacogenetic Testing	Combined criteria notes into one notes section before criteria.
CP.MP.132	Heart-Lung Transplant	References reviewed and updated. Replaced all instances of “member” with “member/enrollee.”
CP.MP.113	Holter Monitors	Replaced all instances of “member” with “member/enrollee.” References reviewed and updated.
WA.CP.MP.54	Hospice Services	Replaced “member” with “member/enrollee’ in all instances.
CP.MP.87	Inhaled nitric oxide	References reviewed and updated.
CP.MP.24	Multiple Sleep Latency Testing	Replaced all instances of “member” with “member/enrollee.” References reviewed and updated.
WA.CP.MP.507	Oral & Enteral Nutrition	Updated reference. Removed criteria for tube feedings
WA.CP.MP.506	Psychological Testing	Annual review. Moved non-covered items to section IV and added reference in section I to sections III and IV. Replaced “member” with “member/enrollee’ in all instances. References updated.
CP.MP.51	Reduction Mammoplasty and Gynecomastia Surgery	Revised description of CPT-19318. Replaced all instances of “member” with “member/enrollee”
CP.MP.165	Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections	Minor revision to description of CPT 64479, 64480, 64483 and 64484. Replaced “member” with “members/enrollee” in the disclaimer.
WA.CP.MP.185	Skin Substitutes for Chronic Wounds	References reviewed and updated. All instances of “member” changed to “member/enrollee.” HCPCS code listing updated. Non-covered codes reported separately.
CP.MP.163	Total Parenteral Nutrition and Intradialytic Parenteral Nutrition	Added indications for radiation enteritis, liver failure in children, liver failure in adults, and acute necrotizing pancreatitis in adults, in I.A.2.j – I.A.2.m., along with relevant ICD-10 codes (i.e., K52.0, K72.00-K72.91, K85.01, K85.02, K85.11, K85.12, K85.31, K85.32, K85.81, K85.82, K85.91, K85.92 and Z76.82. In I.B.2, changed “end-stage renal disease” to “stage 5 chronic kidney disease.” References reviewed and updated and coding reviewed. Replaced member with member/enrollee in all instances. Replaced “experimental/ investigational” with “not proven safe and effective” in section II.
CP.BH.200	Transcranial Magnetic Stimulation	Changed medical necessity statements to require review by a medical director. Minor edits made for clarity of review process.
WA.CP.MP.12	Vagus Nerve Stimulation	Added new HCPCS code K1020 to a new table of codes that do not support coverage criteria. “Experimental/investigational” verbiage replaced with descriptive language. Removed duplicative reference to experimental and non-covered services. Replaced “member” with “member/enrollee”.
WA.CP.MP.522	Varicose Vein Treatment	“Experimental/investigational” verbiage replaced in policy statement with descriptive language. References reviewed and updated. Removed duplicate reference. Replaced all instances of member with member/enrollee.

Policy Number	Policy Title	Revision Notes
CP.MP.203	Diaphragmatic/Phrenic Nerve Stimulation	New policy.
WA.CP.MP.519	Administrative Days	Annual review. References updated.
WA.CP.MP.513	Cardiac Stents	Annual review. References updated. Minor grammatical change.
CP.MP.31	Cosmetic and Reconstructive Procedures	Annual review. Reviewed and updated references. CPT code description revised in 2021: 19318, 19325, 19328, 19340, 19342, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, and 19380. CPT 19324 and 19366 deleted in 2021.
CP.MP.89	Genetic and Pharmacogenetic Testing	References reviewed and updated. Removed section on authorization protocol. Replaced member with member/enrollee in all instances.
CP.MP.109	Panniculectomy	Annual review. Replaces all instances of member with member/enrollee. Expanded criteria for complications related to pannus to include non-healing ulceration under panniculus, chronic maceration or necrosis of overhanging skin folds, recurrent or persistent skin infection under panniculus, intertriginous dermatitis or cellulitis or panniculitis. Added the following ICD 10 codes: L03.319, L03.818, L98.499. Separated “D.” into separate criteria points, D. and E, adding that bariatric surgery weight loss must be stable for 6 months.
CP.MP.182	Short Inpatient Hospital Stay	References reviewed and updated. I.A. was updated to specify “2020” Inpatient Only List. Background updated to include heading for CMS and information related to the Inpatient Only List and CY 2021 OPPS/ASC Final Rule.
WA.CP.MP.517	Testosterone Testing	Annual review. Reference updated. Updates to criteria to mirror billing guideline
WA.CP.MP.520	Tympanostomy Tubes in Children	Annual review. Updates to mirror HCA Billing Guideline. References updated.
CP.MP.142	Urinary Incontinence Devices and Treatments	Annual review completed; references reviewed and updated, codes reviewed. Specialist reviewed. Replaced “member” with “members/enrollees” in all instances.

Clinical & Payment Policies

Clinical Policies

Ambetter Clinical Policies Listing

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Genetic Testing

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Ambetter Pharmacy Policies Listing

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H - Q

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Medicaid Clinical Policies Listing

A - G

Genetic Testing

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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

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Policy Revision Summary

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December 2021

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