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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

For Ambetter information, please visit our Ambetter from Coordinated Care website.

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

For Ambetter information, please visit our Ambetter website.

Medicaid Payment Policies

Policy Revision Summary (Clinical)

Policy Number

Policy Title

Revision Notes

CP.MP.132Heart-Lung TransplantationAnnual review. Changed criteria I.A.1. from “age >
18” to “age ≥ 18” to align with guidelines and other transplant policies.
Specified “severe” heart failure in criteria I.A.1.a. Updated verbiage in
I.A.1.b. from “nonspecific” severe pulmonary fibrosis to “idiopathic” severe
pulmonary fibrosis. Specified COPD with “severe” heart failure in criteria
I.A.1.a. Removed “non-complex” and updated and expanded congenital heart
disease indications in criteria A.1.h. to align with guidelines. Changed
criteria I.A.2. from “age ≤ 18” to “age < 18” to align with guidelines and
other transplant policies. Updated I.A.2.d. to include “pulmonary” alveolar
proteinosis. Updated and expanded congenital heart disease indications in
criteria I.A.2.h. to align with guidelines. Updated age guidelines in I.B1.a.
and b. to align with age updates In I.A.1 and I.B.2. Added “for at least 3
months before transplantation” to CD4 cell count > 200 cells/mm3 in criteria
I.C.1.a. and added criteria I.C.1.d. regarding contraindication for chronic
wasting or severe malnutrition. Updated history of substance use
contraindication in I.C.16.a. to include alcohol or illicit drugs. Background
reviewed and updated. Coding verified. Internal and external specialist
reviewed.
WA.CP.MP.69Intensity-Modulated RadiotherapyAnnual review. Updated logo and added “Coordinated
Care Corporation”. Added criteria 1.C. to mirror HCA Billing Guideline. Added
codes 77332-77334 and 77370. Updated references.
CP.MP.57Lung TransplantationAnnual review. Updated glomerular filtration rate from
< 30 to < 40 mL/min/1.73m2 in Criteria I.C.2. Updated Criteria I.C.9.a.
to include at least three months prior to transplantation. Removed additional
information regarding heart transplant waiting list in Criteria I.C.9.b. Minor
grammatical update in Criteria I.C.9.c. Added Criteria I.C.9.d. regarding
chronic wasting or severe malnutrition. Expanded Criteria I.C.13. regarding
active substance use or dependence and added Criteria I.C.14. regarding
documentation of abstinence from substance use. Minor grammatical changes to
Criteria I.D.1.b.ii.b)5), Criteria I.D.1.c.i., Criteria I.D.2., Criteria I.D.2.a.ii.b)5),
and Criteria I.D.2.d.i. with no clinical significance. Added Criteria I.D.2.h.,
Criteria I.D.2.i, and Criteria I.D.2.j. regarding alveolar capillary dysplasia,
pulmonary vein stenosis refractory to intervention, and pulmonary
veno-occlusive disease. Background updated with no impact to criteria.
References reviewed and updated. Reviewed by internal specialist and external
specialist.
WA.CP.MP.517Testosterone TestingAnnual review. Updated logo and added “Coordinated
Care Corporation”. Updated criteria to mirror HCA Billing Guideline Updated
references.
WA.CP.MP.520Tympanostomy TubesAnnual review. Updated logo and added “Coordinated
Care Corporation”. Removed reference to HCA Billing Guideline.

Policy Number

Policy Title

Revision Notes

CP.BH.104Applied Behavior AnalysisAnnual review. Policy reorganized to remove redundant
information and clarity. In criteria I.B. removed the “Krug Aspergers Disorder
Index (KADI)”, added the following new screening tools: EarliPoint, The Survey
of Well-Being of Young Children (SWYC): Parent's Observations of Social
Interactions (POSI), Rapid Interactive Screening Test for Autism in Toddlers
(RITA-T) and Communication and Symbolic Behavior Scales Developmental Profile –
Infant/Toddler Checklist (CSBS-ITC)”.  In
I.C: removed specific titles for specialist and added broader verbiage to allow
for a variation of state allowances “ABA is recommended by a qualified licensed
health care provider working within their scope of practice and who is
qualified to diagnose ASD and recommend ABA.” Removed former I.E. “The
member/enrollee is medically stable and does not require 24 hour
medical/nursing monitoring or procedures provided in a hospital level of care”.
Removed I.F. “The member/enrollee exhibits behavior that presents as a
clinically significant threat to self or others, such as but not limited to,
one of the following: self-injury, aggression toward others, destruction of
property, elopement, severe disruptive behavior, significant interference with
daily living.”  In I.D. added the
statement “as specified according to state-defined ABA criteria” to allow for a
variation of state requirements for a comprehensive diagnosis evaluation. In
I.E added the behavior assessment under requested service. In I.E.,2. b, added
that the behavior assessment must be completed by a “Board Certified Behavior
Analyst (BCBA), or other duly certified, licensed or registered equivalent
provider (as defined by state law)”. In I.E.,2. b. iv added direct observation
and measurement to include “continuous and discontinuous procedures”. In
I.E.,2. b.v. b)., added the following additional skills acquisition
assessments: “Essentials for Living (EFL), Socially Savvy, and other valid
forms of evidence-based skills assessment tools to be reviewed on a
case-by-case basis” In I.E.,2. c. iv and v. reworded criteria statements
regarding treatment setting and number of treatment hours for clarity. Removed
the examples of coordination of care responsibilities (speech therapy,
occupational therapy, psychiatric evaluation, psychotherapy, case management,
family therapy, feeding therapy); In I.E.,2. c. viii added “Transition planning
and discharge considerations made with input from the entire care team and
involving a gradual step-down in services”. In I.E.,3. a., added,
“Member/enrollee’s behavior concerns are not exacerbated by treatment”. In
I.E.,3. b added “Member/enrollee has the cognitive ability to retain and
generalize advancement in treatment goals”. In I.E.,3. d added “Documented
coordination of care and communication regarding additional provider
responsibilities (i.e., school, prescribers, and physical, occupational and/or
speech therapists)”; In I E.3.e.iii added transition planning criteria. Added
statement I.E.,3. f “There is reasonable expectation that the member/enrollee will
benefit from the continuation of ABA services due to one of the following”.
Updated background. References reviewed and updated.
CP.BH.105Applied Behavioral Analysis Documentation RequirementsAnnual review. Policy restructured and reformatted to
remove redundant information and clarity in documentation requirements
throughout. Added inclusive language to allow for a variation of state
allowances throughout the policy. Removed comprehensive assessment report
criteria and replaced it with I.C. “Comprehensive diagnostic evaluation,
consistent with state defined ABA criteria. Defined service documentation
requirements, which are note listed as I.D.1., Behavior assessment, I.D.2.,
Initial treatment record requirements and I.D. 3. Continuation treatment
records. Summarized treatment plan criteria and listed under the initial
treatment records in I. D.2. Service activity note requirements are listed
under I.E. Added Policy statement II to document discharge summary requirements
if member/enrollee no longer meets medical necessity criteria. Background
section reviewed and updated. References reviewed and updated. In the important
reminder section, changed “ medical necessity” to “documentation” in the statement
“The purpose of this clinical policy is to provide a guide…” because this is
not a medical necessity policy.
WA.CP.MP.515Fecal Microbiota TransplantationAnnual review. Updated logo and added “Coordinated
Care Corporation” Removed reference to FDA regulations. Updated references.
Added J1440 and 0780T and removed 44799. Added reference to Pharmacy policy.
CP.MP.121Homocysteine Testing

Annual review. Expanded
criteria to include I.a. First-degree relative with homocystinuria; I.b.
Markedly elevated serum and urine homocysteine; I.c. Characteristic physical
findings including one of the following: I.c.i. Developmental delay; I.c.ii.
Marfanoid appearance; I.c.iii. Osteoporosis; I.c.iv. Ocular abnormalities
(ectopia lentis); I.c.v. Thromboembolic disease; I.c.vi. Severe premature
atherosclerosis. Added dementia as a not medically necessary indication.
Updated background with no impact to criteria. Removed table of Medically
Necessary ICD10 codes and replaced with a table of Not Medically Necessary
ICD-10 codes. References reviewed and updated. Reviewed by external specialist.


In ICD-10 coding table, removed Z01.8 and replaced with Z01.810, Z01.811, Z01.812,
and Z01.819.

CP.MP.82 NICU Apnea Bradycardia GuidelinesAnnual review. Replaced “Guidelines” section title
with “Policy/Criteria” title and added verbiage regarding health plans
affiliated with Centene Corporation®. Updated Criteria I.A.1. to include
desaturation as a clinically significant cardiorespiratory event and updated
criteria verbiage for clarity. Removed notation in Criteria I.A.1.b. regarding
consideration of using heart rate decrease > 33.3% below baseline for older,
more mature infants or those with a lower baseline heart rate. Updated Criteria
I.A.1.d. from bradycardia to isolated bradycardia and updated from < 70
beats per minute to < 80 beats per minute. Minor rewording for clarity in
Criteria I.B. and Criteria I.D. Updated Note at end of criteria section to
state caffeine levels may be therapeutic in preterm infants for as long as ten
days after discontinuation. Removed statement in Note section regarding
“caffeine countdown.” Added car bed and added clarifying language to Note
section regarding assessment of cardiorespiratory stability in a car seat.
Background updated with no impact on criteria. References reviewed and updated.
Reviewed by internal specialists.  
CP.MP.81NICU Discharge GuidelinesAnnual review. Updated Authorization protocol A.5.
Apnea or bradycardia monitoring with last dose of caffeine seven days prior to
discharge. Updated NICU DC recommended practices B.4. An assessment of
cardiorespiratory stability in a car seat or car bed is recommended prior to
discharge for infants born at < 37 weeks gestation or for infants with other
risk factors for cardiorespiratory compromise (e.g. neuromuscular, orthopedic
problems). Reference reviewed and updated. External specialist review.
WA.CP.MP.526Stem Cell Therapy for Musculoskeletal ConditionsAnnual review. Updated logo and added reference to
Coordinated Care Corporation. References updated. Added 0489T and 0490T.
Removed S2015 and allogeneic procedures.
CP.MP.162Tandem TransplantAnnual review. Updated I.A.3.b., c. and d. to reflect
months of age instead of days. Replaced all previous contraindications, I.B.1.
through 15. with new contraindication list, I.B.1. through 6. Background
updated with no impact on criteria. References reviewed and updated. Reviewed
by external specialist.
WA.CP.MP.510Tinnitus TreatmentAnnual review. Updated logo and added “Coordinated
Care Corporation”. Updated section II.A. to mirror HCA Billing Guideline.
CP.MP.163Total Parenteral Nutrition and Intradialytic
Parenteral Nutrition		Annual review. 
Updated criteria I.A.1.a. regarding low body weight to include details
by age group and expanded to I.A.1.a. through c. Removed previous criteria
I.A.1.b. and c. regarding total protein and serum albumin. Removed previous
criteria I.A.4.d. CNS disorders from list of conditions that make oral or tube
feedings inappropriate. Updated criteria I.A.1.2.h. to include children with
paralytic ileus and added I.A.4.m and n. to list conditions that make oral or
tube feedings inappropriate. References reviewed and updated.

Policy Number

Policy Title

Revision Notes

WA.CP.MP.37Bariatric SurgeryAnnual review. 
Updated Criteria III.B. to include other names of procedure for
clarification. Minor rewording in Criteria III.K. Removed one-anastomosis
gastric bypass in Criteria III.L. since duplicative. Updated Background with no
impact on criteria. References reviewed and updated. Formatting changes to
section 2 and 3 to more closely mirror HCA Billing Guideline.
WA.CP.BH.521Behavioral Health Wraparound Support (BHWS)Annual review. References updated.
CP.MP.101Donor Lymphocyte InfusionAnnual review. Added clarifying verbiage regarding
non-Medicare health plans in Criteria I. with no impact to criteria. Added
clarifying language to Criteria II. References reviewed and updated. Reviewed
by internal specialist.
CP.MP.107Durable Medical Equipment (DME) and Orthotics and Prosthetics GuidelinesAnnual review. Minor rewording to description with no
clinical significance. Replaced codes K1032 and K1033 with E0678 and E0679
under non-pneumatic compression devices. Added additional note to enclosed bed
section. Removed halo procedure and equipment criteria due to no prior auth.
Removed lumbar sacral orthotics criteria, defer to IQ. Updated verbiage and
coding in spinal orthotics section. Updated criteria under hip orthotics. Added
section and code L2006 for microprocessor-controlled knee-ankle-foot orthoses
(KAFO). Removed code L4130 under shoulder, elbow, wrist, hand, finger
orthotics. Updated code E2300 to E2298 under power seat elevator on power
wheelchair. Updated wheelchair repairs section to include wheelchair and other
DME repairs. References reviewed and updated.
WA.CP.BH.528HRSN - Intensive Behavioral Supportive SupervisionAnnual review. Updated description: added “services
likely to be avoided”, added “Qualifying Population”, clarified duration of
authorization. Updated references.
CP.MP.62Hyperhidrosis TreatmentsAnnual review. Updated criteria I.E.3. by removing
(hyperhidrosis often improves pregnancy). Removed previous Criteria I.E.5.
regarding cracked skin near the treatment area. Added epilepsy to Criteria
I.E.5. Minor grammatical update in Criteria II. Updated Criteria II.A. to
include through Criteria I.E. Minor grammatical update in Criteria III. Updated
Criteria III.A. to include through Criteria I.E. Updated verbiage in Criteria
III.B., Criteria III.F., Criteria III.G., Criteria III.H., and Criteria III.I. with
no impact to criteria. Updated verbiage in Note section at the end of Criteria
III. with no impact to criteria. Minor verbiage update in Criteria IV.
Background updated with no impact to criteria. Added diathermy to notation at
end of coding section regarding insufficient evidence in the peer-reviewed
literature. References reviewed and updated.
CP.MP.170Nerve Blocks for Pain ManagementAnnual review. Added note in Description to refer to
CP.MP.171 Facet Joint Interventions for facet joint injections and
radiofrequency neurotomy and added note for Medicare plans to refer to
MC.CP.MP.170 Peripheral Nerve Blocks and Ablation of Peripheral Nerves for Pain
Management. Added clarifying verbiage regarding non-Medicare health plans in
Policy/Criteria with no impact to criteria. Added clarifying language to
Criteria I.A.2. Updated Criteria II.A.1.c. to include application of lidocaine
and minor grammatical change made. Grammatical update made in Criteria II.B.1.
for clarity. Grammatical update made in Criteria VI.B.2.b. for clarity.
References reviewed and updated. Reviewed by internal specialist and external
specialist.
CP.MP.246Pediatric Kidney TransplantAnnual review. 
Background updated with no clinical significance.  References reviewed and updated.  Reviewed by internal specialist.
CP.MP.182Short Inpatient Hospital StayAnnual review. Updated criteria I.A. from CMS 2024
inpatient only to 2025 and updated the link. References reviewed and updated.
V1.2025CG Aortopathies and Connective Tissue DisordersSee policy posted on Website
V1.2025CG Cardiac DisordersSee policy posted on Website
V1.2025CG Dermatologic ConditionsSee policy posted on Website
V1.2025CG Epilepsy Neurodegenerative and Neuromuscular ConditionsSee policy posted on Website
WA.CP.MP.219CG Exome and Genome Sequencing for the Diagnosis of Genetic DisordersReactivated policy. Updated to reflect latest HTA regarding Whole Genome Sequencing and latest Concert Genetics policy guidelines.
V1.2025CG Eye DisordersSee policy posted on Website
V1.2025CG Gastro-enterologic Disorders Non-cancerousSee policy posted on Website
V1.2025CG General Approach to Genetic TestingSee policy posted on Website
V1.2025CG Hearing LossSee policy posted on Website
V1.2025CG Hematologic Conditions Non-cancerousSee policy posted on Website
V1.2025CG Hereditary Cancer SusceptibilitySee policy posted on Website
V1.2025CG Immune Autoimmune and Rheumatoid DisordersSee policy posted on Website
V1.2025CG Kidney DisordersSee policy posted on Website
V1.2025CG Lung DisordersSee policy posted on Website
V1.2025CG Metabolic Endocrine Mitochondrial DisordersSee policy posted on Website
WA.CP.MP.230CG Multisystem Inherited Disorders, Intellectual Disability and Developmental DelaySee policy posted on Website
WA.CP.MP.231CG Prenatal Cell-Free DNA TestingSee policy posted on Website
WA.CP.MP.237CG Oncology Algorithmic TestingPolicy developed using Concert Genetic Testing Oncology Algorithmic Testing v1.2025 and Washington State Health Technology Assessment “Gene Expression Profile Testing of Cancer Tissue”.
V1.2025CG Oncology Cancer ScreeningSee policy posted on Website
V1.2025CG Oncology Circulating Tumor DNA Tumor Cells Liquid BiopsySee policy posted on Website
V1.2025CG Oncology Cytogenetic TestingSee policy posted on Website
V1.2025CG Oncology Molecular Analysis Solid Tumors & Hematolgic MalignanciesSee policy posted on Website
WA.CP.MP.232CG Pharmacogenetics (Version A)See policy posted on Website
V1.2025CG Preimplantation Genetic TestingSee policy posted on Website
V1.2025CG Prenatal and Preconception Carrier ScreeningSee policy posted on Website
V1.2025CG Prenatal Diagnosis Pregnancy LossSee policy posted on Website
V1.2025CG Skeletal Dysplasia Rare Bone DisordersSee policy posted on Website

Policy Number

Policy Title

Revision NotesWA.CP.MP.36

WA.CP.MP.36Experimental TechnologiesAnnual review. In Note section after Criteria I.B.2.,
added example of Hayes as an evaluation body. References reviewed and updated.
Reviewed by internal specialist.

CP.MP.248

Facility Based Sleep Studies for Obstructive Sleep ApneaAnnual review. Description updated with no impact on
criteria. Minor rewording in Criteria I., I.A., and I.B.3. with no impact to
criteria. Updated wording in Criteria I.B.8.a.v. and added addition of
disorders that interfere with HSAT. Removed “moderate to-to-high-risk” verbiage
in Criteria I.B.8.b. and updated outline of this criteria. Removed Epworth
Sleepiness Scale criteria from I.B.8.b.i. 
Added Criteria I.B.8.b.ii.c) which states, “Diagnosis of hypertension.”
Minor rewording in Criteria II. with no impact to criteria. References reviewed
and updated. Reviewed by internal specialist. 
WA.CP.MP.130Fertility PreservationPolicy archived.
CP.MP.40 Gastric Electrical StimulationAnnual review. Updated description and background with
no clinical significance. Changed I.C. to “Chronic intractable (drug
refractory) nausea and vomiting”. Revised verbiage in note at the end of
policy/criteria. Added L8685, L8686, and L8687 and their respective
descriptions to HCPCS code table. 
References reviewed and updated. External specialist reviewed.
CP.MP.209Gastrointestinal Pathogen Nucleic Acid Panel TestingPolicy archived
CP.MP.113Holter MonitorsAnnual review. Removed criteria II. regarding efficacy
not established for all other indications. New codes added to existing ranges
including I24.81 and I24.89. References and codes reviewed and updated.
CP.MP.136Home BirthsPolicy archived.
CP.MP.86 Neonatal Abstinence Syndrome GuidelinesAnnual review. Updated background with information on
marijuana with no clinical criteria significance. References reviewed and
updated.
CP.MP.85 Neonatal Sepsis Management GuidelinesAnnual Review. References reviewed and updated.
CP.MP.141Non-Myeloablative Allogenic Stem Cell TransplantsAnnual review. Updated verbiage for macrophage
disorders in Criteria I.A.12. for clarity. References reviewed and updated.
Reviewed by internal specialist.
CP.MP.102Pancreas TransplantationAnnual review. In I.B.3. changed "myocardial
infarction within 30 days" to "myocardial (within 6 months)" and
reworded the information about "stroke or acute coronary syndrome".
Added I.C.1.a.ii "Recurring severe hypoglycemic attacks". Background
updated. Added CPT code 50328. References reviewed and updated.
CP.MP.150Phototherapy for Neonatal HyperbilirubinemiaPolicy archived
CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel TestingPolicy archived
CP.MP.97Testing for Select Genitourinary Conditions / Diagnosis of VaginitisPolicy archived

Policy Number

Policy Title

Revision Notes

CP.MP.186Burn SurgeryAnnual review. References reviewed and updated.
Reviewed by external specialist.
WA.CP.MP.525Catheter Ablation for SVTAAnnual review. References updated
WA.CP.MP.54Hospice ServicesAnnual review. References reviewed and updated.
Background updated per corporate policy. Initial Request Section II. B. and
Subsequent Requests Section II. A. verbiage updated to align with HCA billing
guidelines. Subsequent Requests section I. verbiage updated to reflect the
length election periods per HCA billing guidelines. Subsequent Requests section
III. removed length of certification period. Section III. Not Medically
Necessary services, added reference to WAC for concurrent care < age 21. Levels
of Care Definitions and Certification Periods sections removed. Covered
Services section I. verbiage updated and section O. added to align with HCA
billing guidelines. Non-covered Services section updated to list services not
included in the hospice daily rate per HCA billing guidelines. Removed G0299
from coding table.
CP.MP.173Implantable Intrathecal or Epidural Pain PumpPolicy archived
WA.CP.MP.173Implantable Intrathecal or Epidural Pain PumpPolicy developed
CP.MP.243Implantable Loop Recorder (Implantable Cardiac Monitor)Annual review. Background updated with no impact to
criteria. References reviewed and updated.
WA.CP.MP.117Peripheral and Percutaneous Electrical Nerve
Stimulation		Annual review. Added section III and IV. Coding
reviewed and descriptions updated as needed. Added codes 64596, 64597, 64598.
References reviewed and updated.
WA.CP.MP.70Proton and Neutron Beam TherapiesAnnual review. Background updated with no impact on
criteria. References reviewed and updated.
CP.MP.51Reduction Mammoplasty and Gynecomastia SurgeryAnnual review. Verbiage updated in criteria I.A.4.b.
Removed criteria I.A.4.c. and d. Criteria updated to include mammogram
requirement for members/enrollees < 40 years of age with symptoms of breast
cancer or high-risk factors for breast cancer in what is now I.A.4.c.i.through
iii. Clarifying language added to Criteria II.A.2. Criteria II.B.3. updated to
include clarifying language and to include gynecomastia that persists for more
than three months after unsuccessful medical treatment for pathological gynecomastia.
Criteria II.B.4. updated to include clarifying language. References reviewed
and updated.
CP.MP.87Therapeutic Utilization of Inhaled Nitric OxideUpdated criteria IV. from “adult respiratory distress”
to “acute respiratory distress”.
CP.MP.142Urinary Incontinence Devices and TreatmentsAnnual review. Added language to Criteria I. regarding
a United Sates Food and Drug Administration (FDA) approved device. Minor
rewording in Criteria I.B. with no impact to criteria. Added language to
Criteria II. to include an FDA approved device. Updated verbiage in Criteria
II.B. to state “at least” a 50% reduction in incontinence. Minor rewording in
Criteria III. with no impact on criteria. Reworded Criteria III.B. for flow and
changed Kegel exercises to pelvic floor therapy. Changed “patient” to “Member/enrollee”
in Criteria III.C. References reviewed and updated.
WA.CP.MP.46Ventricular Assist DevicesAnnual review. Added code Q0508 to HCPCS coding table.
References reviewed and updated.

Policy Number

Policy Title

Revision Notes

CP.MP.100Allergy Testing and TherapyAnnual review. Added Criteria I.C.8. to include
ingestion (oral) challenge testing. Grammatical updates added to Criteria
II.A.1., II.A.2., II.A.3., II.A.4., and II.A.5. Grammatical updates added under
Limitations and under Documentation Requirements with no impact on criteria.
Reviewed, reformatted and updated coding tables and descriptions. Removed CPT
code 95070 from policy. References reviewed and updated. 
CP.MP.156Cardiac Biomarker Testing for Acute MIAnnual review. References reviewed and updated. 
CP.MP.105Digital EEG Spike Analysis

In the coding description for 95957, added a note that
was previously removed in error stating that it is performed in conjunction
with any of the CPT codes below it.

Annual review. Background updated with no impact on criteria. References
reviewed and updated. 

WA.CP.MP.50Drugs of Abuse: 
Definitive Testing		Annual review. Removed reference to Medication
Assisted Treatment (MAT). Updated background with no clinical significance.
Removed lists of codes not covered by the HCA. References reviewed and updated.
Internal specialist review. 
CP.MP.155EEG in Evaluation of HeadacheAnnual review. Background updated with no impact to
criteria. References reviewed and updated. Reviewed by external specialist.
CP.MP.106Endometrial ablationAnnual review. Updated criteria under I.A.1. by
removing “at least three months of”. Expanded criteria under I.D. to include
fibroids greater than 3cm in diameter. Added additional contraindications under
I.G.5.-I.G.8. to include active pelvic infection or recent uterine infection,
endometrial hyperplasia or uterine cancer, recent pregnancy, and
post-menopausal. Updated wording in Table 1 under Background with no impact to
criteria. References reviewed and updated. Reviewed by external specialist.
Removed “greater than 3 cm in diameter” from Criteria I.D. Background updated
with no impact on criteria. References reviewed and updated.
CP.MP.134Evoked Potential TestingAnnual review. Added CPT codes 32701 and 77370. Struck
"and not covered" from section 4. Updated references.
CP.MP.153H. Pylori TestingPolicy archived

CP.MP.123

Laser Therapy for Skin Conditions
Annual review. Background updated with no impact on
criteria. References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.500Mandibular Advancement DevicesAnnual review. Reference updated.
CP.MP.242Pulmonary Function TestingAnnual review. Updated description and background with
no clinical significance. Coding reviewed. References reviewed and updated.
Reviewed by external specialist.
WA.CP.MP.22Stereotactic Body Radiation TherapyAnnual review. Added CPT codes 32701 and 77370. Struck
"and not covered" from section 4. Updated references.
CP.MP.154Thyroid Hormones and Insulin Testing in PediatricsAnnual review. Added “routine” verbiage to Criteria I.
and to Criteria II. for clarification on testing. Background updated with no
impact on criteria. References reviewed and updated. 
CP.MP.151Transcatheter Closure of Patent Foramen OvalePolicy archived
CP.MP.247Transplant Service Documentation RequirementsAnnual review. Background updated with no impact on
criteria. References reviewed and updated. Reviewed by internal specialist and
external specialist. 
CP.MP.38Ultrasound in PregnancyAnnual review. Updated description and background with
no clinical significance. Coding reviewed. References reviewed and updated.
CP.MP.98Urodynamic TestingAnnual review. References reviewed and update.  Reviewed by external specialist.

Policy Number

Policy Title

Revision Notes

CP.MP.93

Bone-anchored Hearing AidAnnual review. Updated criteria in I.C. to specify “is
consistent with the FDA indications for the requested device”. Added “(provided
that the nerve is functional)” to I.F.1. Minor updates made to I.F4. and the
policy statements in II. and III. Reference reviewed and updated. 
WA.CP.MP.532Chronic Migraine and Tension-Type HeadachesNew policy
CP.MP.129Fetal Surgery in Utero for Prenatally Diagnosed MalformationsAnnual review. Description updated with no impact to
criteria. Under I.A. added “with treatment including”. Added criteria to
I.A.1.-I.A.2. to include: Correction via a minimally invasive approach; SCT
resection when meeting all of the following: Fetuses with high-risk SCT and
hydrops developing at a gestational age earlier than appropriate for delivery
and neonatal care (eg. 28-32 weeks gestation); Does not have the following
contraindications: Type III or IV Altman-type tumors; Severe placentomegaly;
Maternal cervical shortening. Removed indication I.F.5. Normal fetal karyotype.
Quantified criteria I.F.5.c. to include (≥30 degrees). Added criteria I.G.
Fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia
(CDH) when all of the following criteria are met: Severe left-sided CDH; Severe
pulmonary hypoplasia defined as a quotient of the observed-to-expected
lung-to-head ratios of less than 25%; Gestational age ≤ 30 weeks. Removed
III.A. Open or endoscopic fetal surgery for congenital diaphragmatic hernia
(CDH), including temporary tracheal occlusion. References reviewed and updated.
Reviewed by external specialist.
WA.CP.MP.531Imaging for Breast Cancer ScreeningNew policy
WA.CP.BH.522Nonpharmacological Treatments for DepressionNew policy
CP.MP.182Short Inpatient Hospital StayUpdated to policy description. Changed policy
statement I. to “an inpatient level of care for hospital stays of less than
three midnights is medically necessary…”. Added “in use by the applicable plan”
to criteria I.B. Added “inpatient” criteria I.F. Updated policy statement
II.  to “inpatient hospital stays lasting
three midnights and beyond…”.
WA.CP.MP.534Upright Positional MRINew policy
WA.CP.MP.12Vagus Nerve StimulationConsolidated Section II and III to more closely mirror
the corporate policy. Corrected criteria II.J. to read "essential
tremor".
WA.CP.MP.527Vitamin D TestingAnnual review. References verified.

Policy Number

Policy Title

Revision Notes

CP.MP.108

Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-ThalassemiaAnnual review. Added note at end of Description
regarding criteria related to Casgevy. Reformatted all notes in policy
description. Reformatted Criteria I.A. to specify one of the following. Minor
format changes in Criteria I. with no impact to criteria. References reviewed
and updated.
WA.CP.MP.530Bone Morphogenic Proteins for Use in Spinal FusionNew policy
WA.CP.MP.516Carotid Artery StentingAnnual review. References updated. CPT codes updated
to include 37217, 37246, and 37247 per billing guidelines. Section I. C.
removed as criteria and changed to informational note defining “high risk” per
HTA criteria. Section II verbiage updated to align with HCA Billing Guideline
requirement for accredited facility.
CP.MP.31Cosmetic and Reconstructive ProceduresAnnual review. Added note to see MC.CP.MP.31 for
Medicare health plans. Updated criteria numbering so that I.A.2.a. is now
I.A.3. Added criteria to I.A.2. to include in an area that affects eyesight.
Under I.A.3. replaced “standard” with “conservative. Moved notes about health
plan-adopted nationally recognized decision support criteria and gender
dysphoria to Description. Removed note regarding prophylactic mastectomy with
BRCA mutation. Minor rewording in Background with no impact to criteria.
References reviewed and updated. Reviewed by external specialist.
CP.MP.203Diaphragmatic/Phrenic Nerve StimulationAnnual review. Criteria I. updated to include the
Spirit Diaphragm Pacing Transmitter. Background updated to include information
regarding full FDA approval of the Spirit Diaphragm Pacing Transmitter.
References reviewed and updated. Reviewed by external specialist.
CP.MP.107Durable Medical Equipment (DME) and Orthotics and Prosthetics GuidelinesUpdated verbiage in Newborn Care Equipment, Breast
Pumps for inclusivity. Added new criteria section titled Lumbar-Sacral
Orthotics (LSO) and included codes L0450, L0452, L0454, L0455, L0456, L0457,
L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480,
L0482, L0484, L0486, L0488,  L0490,
L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629,
L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640,
L0643, L0648, L0649, L0650, L0651, L0700, L0710, L0999, L1000, L1001, L1005.
Renamed original “Spinal Orthotics” criteria “Other Spinal Orthotics”. Updated
manual wheelchair initial request criteria A., A.2. and 4., B.1. and 2., and
removed C. Reformatted and updated manual wheelchair replacement request
criteria. Deleted codes E1091 and K0009. Reviewed by internal specialist.
CP.MP.184Home VentilatorsAnnual review. Added note for corresponding Medicare
policy. Updated all policy statements to indicate "non-Medicare"
health plans. In I.A.1 changed "both" to "one" of the
following and added "taken while member/enrollee was stable (not in acute
respiratory failure)". Removed criteria for BiPAP failure and
contraindications in sections I and II, and replaced with criteria requiring
documentation that "member/enrollee could not be appropriately treated
with a RAD" and "non-invasive home ventilator will not be used to
provide RAD or CPAP therapy...". Removed criteria in I.A.1.a. and b. for
members/enrollees < 18 years. In 1.A.1a. updated PaCO2 > to greater than
or equal to. In I.C.1 updated BMI > than 30 to greater than or equal to 30.
In 1.C.2 added "at baseline". Added criteria I.C.3.
"Hypoventilation has been documented by polysomnography and other
conditions are not considered the primary cause of hypoventilation..."
Removed medical necessity criteria I.D. for home ventilators for treatment
failure of BiPAP. In II.B. replaced "medical records document
improvement..." with II.B.1. and 2. "Documentation supports: Ongoing
benefits... and "non-invasive home ventilator will not be used to provide
RAD or CPAP therapy...". Minor rewording throughout policy with no
clinical significance. References reviewed and updated. External specialist
review.
CP.MP.180Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep ApneaPolicy being archived due to lack of benefit.
CP.MP.250Lantidra (donislecel): Allogeneic pancreatic islet cellular therapyAnnual review. References reviewed and updated.
Reviewed by external specialist.
CG.CP.MP.01ID Respiratory Lab TestingNew policy
CG.CP.MP.02ID Multisystem Lab TestingNew policy
CG.CP.MP.03ID Dermatologic Lab TestingNew policy
CG.CP.MP.04ID Gastroenterologic Lab TestingNew policy
CG.CP.MP.05ID Primary Care Preventive Lab TestingNew policy
CG.CP.MP.06ID Vector-Borne and Tropical Diseases Lab TestingNew policy
CG.CP.MP.07ID Genitourinary Lab TestingNew policy
WA.CP.MP.69Intensity-Modulated RadiotherapyRemoved section I. A. (Age <= 18 years) and section
I. C. Added section I. B. documentation of critical structure and re-worded
section I. A. to align with HCA Billing Guidelines. References reviewed and
updated.
CP.MP.167Intradiscal Steroid Injections for Pain ManagementAnnual review. References reviewed and updated. Reviewed
by external specialist.
WA.CP.MP.507Oral Enteral NutritionAnnual review. References updated.
CP.MP.202Orthognathic SurgeryAnnual review. Updated Criteria I.A.1.b. from greater
than 4 mm to 4 mm or greater. Updated Criteria I.A.2.c. to include irritation
of buccal or lingual soft tissues of the opposing arch. Added clarifying
language to Criteria I.A.3.b. References reviewed and updated. Reviewed by
internal specialist and external specialist.
WA.CP.MP.194Osteogenic StimulationNew policy
CP.MP.109PanniculectomyAnnual review. References reviewed and updated.
CP.MP.138Pediatric Heart TransplantAnnual review. Updated description and background with
no clinical significance. References reviewed and updated.
CP.MP.150Phototherapy for Neonatal HyperbilirubinemiaAnnual review. Rearranged verbiage regarding infants ≥
38 weeks gestation in Criteria I. and I.A. Removed “Term” verbiage in Criteria
I.B. References reviewed and updated. Reviewed by external specialist.
CP.MP.87Therapeutic Utilization of Inhaled Nitric OxideCorrected May revision log entry to include, removed
criteria I.A.“iNO will be administered via endotracheal tube or tracheostomy,”
and, updated oxygen index from ≥ 25 to > 20 in criteria I.A.6. Added
additional indication I.B.1.a.3) right ventricular failure.
WA.CP.BH.200Transcranial Magnetic Stimulation (TMS) for TRMDAdded contraindications
CP.MP.169Trigger Point Injections for Pain ManagementAnnual review. Removed “with or without radiographic
guidance” language in Criteria I.A. Criteria I.A.1.a. updated to state
“myofascial pain.” Removed Criteria II.C. regarding location of trigger point
injection in the neck, shoulder, and/or back. Background updated with no impact
to criteria. References reviewed and updated. Reviewed by internal specialist
and external specialist.
WA.CP.MP.12Vagus Nerve StimulationPolicy reimplemented
WA.CP.MP.522Varicose Vein TreatmentAnnual review. References reviewed and updated.
Background updated with no impact on criteria. Section I. A. a. reflux
measurement removed to align with billing guidelines. Section I. C. removed
criteria and added note for reviewer to utilize CP.MP.146 for procedures 36482,
36483. Section II. removed. Codes 36482, 36483 and 0524T removed from coding
table. Code 37799 removed from note regarding ligation/stripping procedures.

Policy Number

Policy Title

Revision Notes

CP.BH.500Behavioral Health Treatment Documentation RequirementsAnnual Review. No changes to criteria. Background
updated. References reviewed and updated
CP.MP.14Cochlear Implant ReplacementsAnnual review. Updated description and background with
no clinical significance. Coding reviewed, updated description for L8623.
References reviewed and updated.
CP.MP.94Clinical TrialsAnnual review. Updated policy statement in I. to
include “Centene Advanced Behavioral Health”. References reviewed and updated.
WA.CP.MP.514Extracorporeal Membrane Oxygenation TherapyAnnual review. References updated.
CP.MP.137Fecal Incontinence TreatmentsAnnual review. Minor rewording in Description and in
Background with no impact on criteria. References reviewed and updated.

CP.MP.40

Gastric Electrical Stimulation

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

CP.MP.132

Heart-Lung Transplant

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

CP.MP.141

Non-Myeloablative Allogenic Stem Cell Transplants

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

CP.MP.249Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapyAnnual review. Added note to policy to refer to
MC.CP.MP.249 for Medicare criteria. Added “non-Medicare” to health plans in
Policy/Criteria I. Background updated with no impact on criteria. References
reviewed and updated. Reviewed by external specialist.
CP.MP.49Physical, Occupational and Speech Therapy ServicesAnnual review. Minor rewording in Criteria I.G.1.,
Criteria I.G.2., Criteria II.A., and Criteria II.A.10. Updated formatting in
Criteria III.A.2. with no impact on criteria. Minor rewording in Background
with no impact on criteria. Reviewed by external specialist.

WA.CP.MP.185

Skin and Soft Tissue Substitutes for Chronic Wounds

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

CP.MP.127Total Artificial HeartAnnual review. References reviewed and updated.
Reviewed by external specialist.

Policy Number

Policy Title

Revision Notes

CP.MP.114

Disc Decompression Procedures

Annual review. Removed “unilateral” for radiculopathy in Criteria I.C.1. Updated muscle strength score in Criteria I.C.1.a. from < 3 to ≤ 3. Updated muscle strength score in Criteria I.C.1.b. from 3 or 4 to 4. Added “within the last year” for conservative therapy in Criteria I.C.1.b.ii. Updated physical therapy from ≥ six weeks to ≥ four weeks in Criteria I.C.1.b.ii.a). Updated activity modification from ≥ six weeks to ≥ four weeks in Criteria I.C.1.b.ii.b). Updated Criteria I.C.1.b.ii.c) to specify one of the following: 1) NSAID or acetaminophen ≥ 3 weeks unless contraindicated or not tolerated 2) Epidural steroid injection. Removed “unilateral” for radiculopathy in Criteria I.C.2. Updated physical therapy from ≥ six weeks to ≥ four weeks in Criteria I.C.2.a. Updated activity modification from ≥ six weeks to ≥ four weeks in Criteria I.C.2.b. Updated Criteria I.C.2.c. to specify one of the following: i. NSAID or acetaminophen ≥ 3 weeks unless contraindicated or not tolerated ii. Epidural steroid injection. References reviewed and updated. Reviewed by external specialist. 

CP.MP.115

Discography

Annual review. Background updated with no impact on criteria. References reviewed and updated.

CP.MP.58

Intestinal and Multivisceral Transplant

Annual review. Expanded criteria under II.A.4. to include (e.g. opioid dependency, or pseudo-obstruction). Updated contraindication under II.B.3. Glomerular filtration rate < 40 mL/min/1.73m2 to <30mL/min/1.73m2. Expanded contraindication under II.B.4.a-II.B.4.c. to include CD4 cell count >200 cells/mm3; Absence of active AIDS-defining opportunistic infection (unless treated efficaciously or prevented, can be included on the heart transplant waiting list) or malignancy; Member/enrollee is currently on effective ART (antiretroviral therapy). References reviewed and updated. Reviewed by external specialist.

CP.MP.244

Liposuction of Lipedema

Annual review. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.

CP.MP.116

Lysis of Epidural Lesions

Annual review. Updated description and background with no clinical significance. References reviewed and updated. Reviewed by external specialist.

CP.MP.24

Multiple Sleep Latency Testing

Annual review. References reviewed and updated. Reviewed by external specialist.

WA.CP.MP.518

Negative Pressure Wound Therapy for Home Use

Annual review. References reviewed and updated. Section I. A. i. and ii. diagnoses of seroma and wound dehiscence removed.

CP.MP.120

Pediatric Liver Transplant

Annual review. Added HIV points a. - c., under I.C.2. Minor edits to Background with no effect on criteria. References reviewed and updated.

CP.MP.188

Pediatric Oral Function Therapy

Annual review. References reviewed and updated. Reviewed by external specialist.

CP.MP.210

Repair of Nasal Valve Compromise

Annual review. Background updated with no impact to criteria. References reviewed and updated.

CP.MP.87

Therapeutic Utilization of Inhaled Nitric Oxide

Annual review. Condensed criteria statement II. to, "while the medical literature predominantly does not support the use of inhaled nitric oxide (iNO) in premature infants < 34 weeks gestational age at birth, requests for initiation of iNO therapy in these infants may be reviewed on a case-by-case basis with consideration of the criteria for premature newborns ≥ 34 weeks gestational age at birth in section I.” References reviewed and updated. Reviewed by external specialist.

WA.CP.MP.509

Upper GI Endoscopy for GERD

Annual review. References reviewed and updated. CPT codes 43237, 43238 and 43242 added per billing guidelines. Description and section I. updated to reflect diagnostic endoscopy per billing guidelines. Removed section II. header and use of InterQual guidelines; converted policy to billing guidelines/HTA only.

August 2024 – Genetic Testing

Policy Number

Policy Title

Revision Notes

V2.2024

CG Aortopathies and Connective Tissue Disorders

See policy posted on Website

V2.2024

CG Cardiac Disorders

See policy posted on Website

V2.2024

CG Dermatologic Conditions

See policy posted on Website

V2.2024

CG Epilepsy Neurodegenerative and Neuromuscular Conditions

See policy posted on Website

V2.2024

CG Exome and Genome Sequencing for DX of Genetic Disorders

See policy posted on Website

V2.2024

CG Eye Disorders

See policy posted on Website

V2.2024

CG Gastroenterologic Disorders Non-cancerous

See policy posted on Website

V2.2024

CG General Approach to Genetic Testing

See policy posted on Website

V2.2024

CG Hearing Loss

See policy posted on Website

V2.2024

CG Hematologic Conditions Non-cancerous

See policy posted on Website

V2.2024

CG Hereditary Cancer Susceptibility

See policy posted on Website

V2.2024

CG Immune Autoimmune and Rheumatoid Disorders

See policy posted on Website

V2.2024

CG Kidney Disorders

See policy posted on Website

V2.2024

CG Lung Disorders

See policy posted on Website

V2.2024

CG Metabolic Endocrine Mitochondrial Disorders

See policy posted on Website

V2.2024

CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay

See policy posted on Website

WA.CP.MP.230

Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay

See policy posted on Website

V2.2024

CG Non-Invasive Prenatal Screening

See policy posted on Website

WA.CP.MP.231

Genetic Testing Non-Invasive Prenatal Screening (NIPS)

See policy posted on Website

V2.2024

CG Oncology Algorithmic Testing

See policy posted on Website

V2.2024

CG Oncology Cancer Screening

See policy posted on Website

V2.2024

CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy

See policy posted on Website

V2.2024

CG Oncology Cytogenetic Testing

See policy posted on Website

V2.2024

CG Oncology Molecular Analysis Solid Tumors & Hematologic Malignancies

See policy posted on Website

V2.2024

CG Pharmacogenetics

See policy posted on Website

WA.CP.MP.232

Genetic Testing Pharmacogenetics

New policy

V2.2024

CG Preimplantation Genetic Testing

See policy posted on Website

V2.2024

CG Prenatal and Preconception Carrier Screening

See policy posted on Website

V2.2024

CG Prenatal Diagnosis Pregnancy Loss

See policy posted on Website

V2.2024

CG Skeletal Dysplasia Rare Bone Disorders

See policy posted on Website

Policy Number

Policy Title

Revision Notes

WA.CP.MP.519Administrative DaysReferences reviewed and updated. Removed note
requiring providers to request administrative days. Section I. subsections D.
and E. and section IV. subsections E. and F. facility requirements for
discharge planning removed to align with WAC. Billing section updated to
include other service categories that may be billed per revenue codes in the
billing guidelines. Section II. E. added to reflect additional newborn
administrative day services per the billing guidelines. Added references for
acute PM&R. Description updated to clarify the process for social
admissions per WAC 182-550-4550. WAC reference removed from description and
replaced with Washington State Health Care Authority. Section I. approval
requirements changed from “all” to “A. and B. or C.” per the HCA billing
guidelines. Section IV. D. removed.

WA.CP.BH.521

Behavioral Health Wraparound Support (BHWS)

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

WA.CP.MP.513

Cardiac Stents

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

WA.CP.BH.529Community Behavioral Health Support - Supportive Supervision (CBHS)New policy.
CP.MP.101Donor lymphocyte infusionAnnual review. Minor rewording in Description with no
impact on Criteria. Background updated with no impact on criteria. References
reviewed and updated. Reviewed by external specialist.

WA.CP.MP.504

Elective Deliveries Before 39 Weeks

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

CP.MP.248

Facility Based Sleep Studies for Obstructive Sleep Apnea

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

CP.MP.62

Hyperhidrosis treatments

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

WA.CP.MP.27

Hyperbaric Oxygen Therapy

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

CP.MP.173

Implantable Intrathecal or Epidural Pain Pump

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

CP.MP.243

Implantable Loop Recorder (Implantable Cardiac Monitor)

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

WA.CP.BH.528Intensive Behavioral Supportive Supervision (IBSS)Added Tiering Guidelines. Changed “IBSS Modifier” to
“ILOS Modifier”
CP.MP.57Lung TransplantationAnnual review. Updated I.C.2. from GFR < 40
mL/min/1.73m2 to GFR < 30 mL/min/1.73m2. Expanded I.C.9. with qualifying
criteria for members who are HIV positive. Updated I.D.2.a.1. from FEV1<25%
to FEV1<30%. Background updated with no impact to criteria. References
reviewed and updated.
CP.MP.170Nerve Blocks and Neurolysis for Pain ManagementAnnual review completed. Minor rewording with no
clinical significance. References reviewed and updated.

CP.MP.82

NICU Apnea Bradycardia Guidelines

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

CP.MP.246Pediatric Kidney TransplantAnnual review. Updated contraindication I.B.2, adding
a. through c. References reviewed and updated. Reviewed by external specialist.
CP.MP.182Short Inpatient Hospital StayAnnual review. Updated criteria I.A. from 2023
inpatient only link to 2024 link. Updated description and background with no
clinical significance. References reviewed and updated.
WA.CP.MP.22Stereotactic Body Radiation TherapyNew policy

CP.MP.22

Stereotactic Body Radiation Therapy

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

Policy Number

Policy Title

Revision Notes

WA.CP.MP.501

Continuous Glucose Monitor

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

WA.CP.MP.50

Drugs of Abuse:  Definitive Testing

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

WA.CP.MP.36

Experimental Technologies

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

CP.MP.62

Hyperhidrosis Treatments

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

CP.MP.250

Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy

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

WA.CP.MP.505

Microprocessor-Controlled Lower Limb Prosthetics

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

CP.MP.102

Pancreas Transplantation

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

WA.CP.MP.503

Private Duty Nursing

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

CP.MP.162

Tandem Transplant

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

WA.CP.MP.517

Testosterone Testing

Annual review. References updated.

CP.MP.163

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

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

WA.CP.MP.520

Tympanostomy Tubes

Annual review. References updated.

WA.CP.MP.46

Ventricular Assist Devices

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

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

WA.CP.MP.200

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression

Revised to reflect updated Billing Guideline and revised HTA

CP.MP.186

Psychological Testing

Archived

Policy Number

Policy Title

Revision Notes

CP.BH.104

Applied Behavioral Analysis

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

CP.BH.105

Applied Behavioral Analysis Documentation Requirements

 New Policy

CP.MP.186

Burn Surgery

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

CP.MP.105

Digital EEG Analysis

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

WA.CP.MP.515

​Fecal Microbiota Transplantation

Annual review. References updated.

WA.CP.MP.130

Fertility Preservation

Annual review. Reference updated.

CP.MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

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

CP.MP.136

Home Birth

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

CP.MP.81

NICU Discharge Guidelines

Annual review. References reviewed and updated.

CP.MP.86

Neonatal Abstinence Syndrome Guidelines

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

CP.MP.85

Neonatal Sepsis Management

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

WA.CP.MP.117

Percutaneous Electrical and Peripheral Nerve Stimulation

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

WA.CP.MP.526

​Stem Cell Therapy for Musculoskeletal Conditions

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

WA.CP.MP.510

Tinnitus Treatment

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

V1.2024

All Genetic Testing Policies

Twice-per-year review

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

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