Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Coordinated Care Clinical Policy Manual apply to Coordinated Care members. Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a “Centene” heading.  Coordinated Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Coordinated Care clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Coordinated Care. In addition, Coordinated Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Coordinated Care.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Ambetter Clinical Policies Listing

 

Ambetter Pharmacy Policies Listing

 

 

 

Medicaid Clinical Policies Listing

Medicaid Pharmacy Policies Listing

 

 

 

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Coordinated Care Payment Policy Manual apply with respect to Coordinated Care members. Policies in the Coordinated Care Payment Policy Manual may have either a Coordinated Care or a “Centene” heading.  In addition, Coordinated Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Coordinated Care.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Ambetter Payment Policies

Medicaid Payment Policies

Policy Revision Summary (Clinical)

Policy Number Policy Title Revision Notes
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

No revisions this month.

Policy Number Policy Title Revision Notes
CP.MP.107 Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines Annual 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 Number Policy Title Revision Notes
WA.CP.MP.525 Catheter Ablation for Supraventricular Tachyarrhythmia Annual 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.500 Mandibular Advancement Devices Annual review. Reference reviewed
CP.MP.38 Ultrasound in Pregnancy Updated 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.70 Proton and Neutron Beam Therapies Annual 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.142 Urinary Incontinence Devices and Treatments Annual 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.151 Transcatheter Closure of Patent Foramen Ovale Annual review. Minor rewording in Background section with no impact on criteria. References reviewed and updated. 
CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea Annual 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.181 Polymerase Chain Reaction Respiratory Viral Panel Testing Updated 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.206 Skilled Nursing Facility Leveling Retire
CP.MP.247 Transplant Service Documentation Requirements Annual 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.

Policy Number Policy Title Revision Notes
CP.BH.124 ADHD Assessment and Treatment Annual Review. Changed reference number for the policy from “CP.MP.124” to “CP.BH.124”. Added the following statement to section I and II: “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. In criteria point II. A. 1. replaced “Actometer” with “Actigraphy”. In criteria point I.A. 2. added “Acoustic reflex testing”.  In criteria point I.A.12: removed Magnetic resonance imaging, brain functional MRI as it is already captured in I.A.16: under MRI. Removed I.A.14. “Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping”.  In criteria point I.A.16. added “brain mapping” to the brain imaging section. In Criteria point I.A. 24 removed “Triiodothyronine T3 levels in the blood” and reworded as “Measures of thyroid hormones”. Removed II.A.18 “neuropsychological testing from the insufficient evidence list”, with corresponding codes also removed.  In criteria point II. B.2., added “Application of modality (e.g. hot or cold packs, traction, mechanical, electrical stimulation (unattended), vasopneumatic devices, paraffin bath, whirlpool, diathermy (eg, microwave), infrared, ultraviolet, electrical stimulation (manual), iontophoresis, contrast baths, ultrasound, hubbard tank)”. Removed education interventions from criteria point II.B.19. and added policy statement III. “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that interventions that are strictly educational in nature (e.g., classroom environmental manipulation, academic skills training training) are not medically necessary as they are not considered medical interventions”. Added criteria point II.B.19.  “EndeavorRx®”. Replaced instances of dashes (-) with the word “to” within the CPT description code list. Coding reviewed. Added the following codes and related indications as not medically necessary when billed with a sole diagnosis of ADHD: 70496, 70554, 70555, 78610, 84436, 84437, 84439, 84442, 84443, 84445, 84478, 84479, 84481, 92568, 92569, 92570, 95954, 96020, 96902, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036. References reviewed and updated. Policy reviewed by internal specialist. Policy reviewed by an external specialist.
CP.MP.108 Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia Annual review. Added note at end of Description regarding criteria related to Zynteglo. Criterion I.C.3. removed related to lack of adequate support system. Expanded Criteria II.A. and Criteria II.B. to specify not in the context of gene therapy. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal and external specialist.
CP.MP.31 Cosmetic and Reconstructive Procedures Annual review. Minor edits to I.A.4.b with no clinical significance. Updated pharmacy policies for Serostim (somatropin) in note. Removed CPT code 11310. References reviewed and updated. Reviewed by internal specialist.
CP.MP.101 Donor lymphocyte infusion Annual review. Minor rewording in Description with no impact on criteria. Criteria II.B. updated to state grade 2 or higher acute graft versus host disease (GvHD). Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. Updated policy description. Updated all criteria in statements I. and II. 
CP.MP.209 GI Pathogen Nucleic Acid Detection Panel Testing Annual review completed. Replaced previous criteria with current in sections I. and II. and removed section III. Background updated with no impact to criteria. Reworded some extraneous language with no clinical significance. Moved code 87506 from Table 1 to Table 2. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 to include ICD-10 diagnosis codes which support medical necessity. References reviewed and updated.
CP.MP.250 Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy New policy
CP.MP.123 Laser Therapy for Skin Conditions Annual review. Added medically necessary indications I.C. atopic dermatitis and I.D. cutaneous T-cell lymphoma. Removed II.B. atopic dermatitis from insufficient evidence section. Added codes L20.81, L20.82, L20.89, C84.00 through C84.09, and C84.10 through C84.19 to table of ICD-10-CM diagnosis codes that support coverage criteria. References reviewed and updated.
CP.MP.57 Lung Transplantation Revised adult and pediatric criteria to align with ISHLT 2021 consensus document. References reviewed and updated. 
CP.MP.202 Orthognathic Surgery Annual review. Added CPT codes 21248 and 21249. References reviewed and updated.
CP.MP.109 Panniculectomy Annual Review. Combined criteria I.D. and E. into criteria I.D.1. and 2. Removed CPT code 00802 from policy. References reviewed and updated. Reviewed by external specialist.
CP.MP.138 Pediatric Heart Transplant Annual review. Added additional criteria I.A.1.b.vi.a., pulmonary hypertension and a potential risk of developing fixed, irreversible elevation of pulmonary vascular resistance that could preclude orthotopic heart transplantation in the future. Updated I.D.1. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2. Expanded I.D.2. with qualifying criteria for members who are HIV positive. Updated I.D.21. to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background reviewed and updated. References reviewed and updated. Reviewed by external specialist.
CP.MP.246 Pediatric Kidney Transplant Annual review. Description updated to include source information for policy criteria. Updated Criteria I.A.1. from glomerular filtration rate (GFR) ≤ 15 mL/min/1.73m2 to GFR < 15 mL/min/1.73m2 to align with Kidney Disease: Improving Global Outcomes (KDIGO) guidance and Organ Procurement Transplant Network (OPTN) guidance. Updated Criteria I.A.2. to include members/enrollees with CKD stage 4 with GFR < 30 mL/min/1.73m2 who are expected to reach end stage renal disease (ESRD) to align with KDIGO guidance and OPTN guidance. Updated contraindications in I.B. consistent with KDIGO guidelines. References reviewed and updated.
CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia Annual review. Reworded criteria I.C. for inclusive language. References reviewed and updated.
CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing Annual review. Replaced prior criteria in sections I. and II. with current criteria. Removed policy statement III. Background updated with no impact on criteria. Updated verbiage in Table 2 description to include new diagnosis code requirements. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 which include ICD-10 diagnosis codes. References reviewed and updated.
CP.MP.98 Urodynamic Testing Annual review. Added criteria I.D.5. for 4.5. Prostate nodule, asymmetry or other suspicion of prostate cancer. Moved N40.3 from ICD-10 Table 2 to ICD-10 Table 1. References reviewed and updated.
WA.CP.MP.527 Vitamin D Testing Annual review. Updated references.

Policy Number Policy Title Revision Notes
CP.MP.129 Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Annual review. Criteria I.F.3. updated to include confirmation on fetal MRI. Added clarifying language to Criteria I.F.4. Background updated with no impact on criteria. Added CPT code 59072. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist.

 

WA.CP.MP.50 Drugs of Abuse: Definitive Testing

Annual Review. Added an example of synthetic cannabinoids to I.A.1., drugs for which presumptive testing is not reliable. Coding reviewed.  Replaced all instances of  dashes (-) with the word “to” within the CPT and HCPCS codes.  Added 0082U to the CPT codes that do not support coverage criteria list. Removed table of ICD-10 CM codes. Updated background information to include information regarding American Society of Addiction Medicine (ASAM). Other minor  wording changes made to background with no clinical significance. References reviewed and updated. Policy reviewed by an internal specialist.

Removed deleted codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U from table of CPT codes that do not support coverage criteria.

Policy Number Policy Title Revision Notes
WA.CP.MP.519 Administrative Days

Changed “denial” to “discharge” in Note.

 

CP.MP.100 Allergy Testing and Therapy Annual review. Updated description and background with no clinical significance. References reviewed and updated. Coding reviewed. Reviewed by external specialist.
WA.CP.MP.37 Bariatric Surgery Modified section II.B. to allow family practice in addition to internal medicine physicians conduct pre-operative assessments.
CP.MP.156 Cardiac Biomarker Testing Annual review. Background updated with no impact on criteria. Coding reviewed. References reviewed and updated. Reviewed by external specialist.
CP.MP.105 Digital EEG Spike Analysis Annual review. Minor rewording in Criteria I. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist
CP.MP.155 EEG in the Evaluation of Headache Annual review. Edits to policy name in header. Background updated with no clinical significance. References reviewed and updated.
CP.MP.134 Evoked Potential Testing Annual review. References reviewed and updated. Reviewed by external specialist.
CP.MP.153 Helicobacter Pylori Serology Testing Annual review. References reviewed and updated. Reviewed by external specialist.
CP.MP.113 Holter Monitors Annual review. Criteria I. updated to specify a Food and Drug Administration (FDA) approved Holter monitor device, and age in Criteria I. changed from > 18 years old to ≥ 18 years old. Criteria I.D. updated to include arrhythmogenic right ventricular cardiomyopathy (ARVC), hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy, or a first degree relative with HCM. Added Criteria I.O. for baseline or periodic screening for those with adult congenital heart disease. Criteria II. updated to specify an FDA approved Holter monitor device, and age in Criteria II. changed from ≤ 18 years old to < 18 years old. Minor rewording in background with no impact on criteria. References reviewed and updated. Reviewed by internal specialist.
CP.MP.102 Pancreas Transplantation Added note to policy to see CP.MP.250 Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy for criteria related to Lantidra.
CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing Removed note after the policy description referring to CP.CPC.03 Preventive Health and Clinical Practice Guidelines for PCR testing for COVID-19. Added 0202U, 0223U and 0225U to CPT table 2.
CP.MP.154 Thyroid Hormones and Insulin Testing in Pediatrics Annual review. Edits to title in header. References reviewed and updated. Reviewed by external specialist.
CP.MP.38 Ultrasound in Pregnancy Annual review. Minor rewording in Description, in Table 1 under Criteria IV., and in Criteria V. Verbiage added to indicate list is not all inclusive under Classifications of fetal ultrasounds Section I. and Section II. Background updated with no impact on criteria. Updated Table 4 Coding description. The following retired code ranges were removed: O35.0XX0 through O35.0XX9 and O35.1XX0 through O35.1XX9. The following code ranges were added: O35.00X0 through O35.00X9, O35.01X0 through O35.01X9, O35.02X0 through O35.02X9, O35.03X0 through O35.03X9, O35.04X0 through O35.04X9, O35.05X0 through O35.05X9, O35.06X0 through O35.06X9, O35.07X0 through O35.07X9, O35.08X0 through O35.08X9, O35.09X0 through O35.09X9, O35.10X0 through O35.10X9, O35.11X0 through O35.11X9, O35.12X0 through O35.12X9, O35.13X0 through O35.13X9, O35.14X0 through O35.14X9, O35.15X0 through O35.15X9, O35.19X0 through O35.19X9, O35.AXX0 through O35.AXX9, O35.BXX0 through O35.BXX9, O35.CXX0 through O35.CXX9, O35.DXX0 through O35.DXX9, O35.EXX0 through O35.EXX9, O35.FXX0 through O35.FXX9, O35.GXX0 through O35.GXX9, O35.HXX0 through O35.HXX9. References reviewed and updated.  

Policy Number Policy Title Revision Notes
CP.BH.500 Behavioral Health Treatment Documentation Requirements Annual Review. No changes made to criteria. References reviewed and updated.
WA.CP.MP.516 Carotid Artery Stending Annual review. References updated. Removed InterQual guidelines and edited section I. to reflect current HTA criteria.
CP.MP.203 Diaphragmatic/Phrenic Nerve Stimulation Annual review. Product name updates in criteria II. and in background with no clinical significance. References reviewed and updated.
CP.MP.248 Facility Based Sleep Studies for Obstructive Sleep Apnea Corrected I.B.8.a.i. to require either continuous, chronic nocturnal oxygen use or moderate to severe pulmonary function impairment instead of both.
WA.CP.MP.69 Intensity Modulated Radiation Therapy Annual review. References updated.
CP.MP.167 Intradiscal Steroid Injections for Pain Management Annual review. References reviewed and updated.
CP.MP.170 Nerve Blocks for Pain Management Annual review completed. Examples added to I.B.1. and III.B.2. Minor rewording with no clinical significance. Background updated. Added CPT codes 64628. ICD-10 Diagnosis code table removed. References reviewed and updated. External specialist reviewed.
WA.CP.MP.507 Oral Enteral Nutrition Added Exception to the Rule comment for adults requesting PKU formula
CP.MP.194 Osteogenic Stimulation Annual review completed. Background and references reviewed and updated.
CP.MP.51 Reduction Mammoplasty and Gynecomastia Surgery Annual review. Criteria I.A.1. updated for criteria for members/enrollees ≥ 18 years of age and members/enrollees < 18 years of age. Criteria I.A.2. updated to include note regarding medical director review on case-by-case basis when weight of tissue to be resected is less than the 22nd percentile minimum based on the Schnur Sliding Scale. Criteria I.A.3.b. updated to include pain in arm. Criteria II.A.1. updated to align with ASPS guidance regarding length of time gynecomastia persists in adolescents < 18 years. Criteria II.B.3. updated to align with ASPS guidance for length of time gynecomastia persists in adults ≥ 18 years. Removed Criteria II.B.6. regarding malignancy being ruled out. Minor rewording in background with no impact on criteria. ICD-10 codes removed. References reviewed and updated. Reviewed by internal specialist and external specialist.
CP.MP.182 Short Inpatient Hospital Stay Annual review completed. Updated hyperlink to CMS inpatient only list in Criteria I.A. Added option in I.A. for procedure to be listed as an inpatient-only procedure in InterQual for those under 18 years of age, and noted that the CMS inpatient only list applies to those 18 years of age and older. Minor rewording with no clinical significance. References reviewed and updated. Internal specialist reviewed.
CP.BH.100 Substance Use Disorder Treatment and Services Policy Retired
WA.CP.BH.200 Transcranial Magnetic Stimulation for Treatment Resistant Major Depression Typos corrected
CP.MP.169 Trigger Point Injections for Pain Management Annual review completed. Minor rewording with no clinical significance. Background updated. ICD-10 Diagnosis code table removed. References reviewed and updated.
CP.MP.12 Vagus Nerve Stimulation Annual review completed. Removed II.B. “Obesity”. Additional minor rewording with no clinical significance. Background updated; moved “Removal of implant” section to background. ICD-10 Diagnosis code table removed. References reviewed and updated. External specialist reviewed.

Policy Number Policy Title Revision Notes
CP.MP.14 Cochlear Implant Replacements Annual review completed. Changed verbiage in I.C. from “A sound processor replacement if the current processor is at least five years old” to “C. The existing component has reached the limit of its reasonable useful life. The reasonable useful life of a sound processor is not less than five years”. Minor rewording with no clinical significance. Background updated with no impact to criteria. ICD-10-CM Diagnosis Code table removed. References reviewed and updated. External specialist reviewed.
WA.CP.MP.514 Extra-Corporeal Membrane Oxygenation Therapy (ECMO) Annual review. References updated.
CP.MP.137 Fecal Incontinence Treatments Annual review. Removed “≥ 4 years age” criteria and added “in a member/enrollee that has previously achieved bowel control” to I.A. Also removed “more than twelve months after vaginal childbirth” from definition of severe, chronic fecal incontinence in I.A. Description and background section updated with no clinical significance. References reviewed and updated. External specialist reviewed.
WA.CP.MP.54 Hospice Services References updated. Background information updated. Removed statement regarding previous investigational treatment from Initial Request paragraph. Updated Initial Request Section I. language to correspond to HCA billing guidelines. Updated Initial and Subsequent Request sections II. Continuous Homecare and General Inpatient descriptions to correspond to HCA billing guidelines.  Removed debility and failure to thrive exclusion from section III. Updated section III. D. language re: hospice discharge per HCA billing guidelines. Covered and non-covered services sections updated to correspond to HCA billing guidelines.
CP.MP.127 Total Artificial Heart Annual review. Removed criteria III. Updated background with no clinical significance. Removed ICD-10 code table. References reviewed and updated.
WA.CP.BH.200 Transcranial Magnetic Stimulation for Treatment Resistant Major Depression New policy.
WA.CP.MP.522 Varicose Vein Treatment Annual review. References reviewed and updated. Section I. medical necessity criteria revised to align with HTA/HCA billing guidelines. Removed ligation/stripping procedures from policy description and criteria. Added note below section II. regarding use of InterQual criteria for review of ligation/stripping procedures. Removed ligation procedure codes 37780 and 37785 from CPT code table. Updated section B. contraindications to correspond to HTA/billing guidelines and current corporate sclerotherapy/EVLA policy CP.MP.146. Updated section C. Venaseal requirements per CP.MP.146. Background updated with no impact on criteria. . Removed table of codes that do not support medical necessity.
V2.2023 CG Aortopathies and Connective Tissue Disorders Annual review. Policy number change from CP.MP.215
V2.2023 CG Cardiac Disorders Annual review. Policy number change from CP.MP.216
V2.2023 CG Dermatologic Conditions Annual review. Policy number change from CP.MP.217
V2.2023 CG Epilepsy Neurodegenerative and Neuromuscular Conditions Annual review. Policy number change from CP.MP.218
V2.2023 CG Exome and Genome Sequencing for DX of Genetic Disorders Annual review. Policy number change from CP.MP.219
V2.2023 CG Eye Disorders Annual review. Policy number change from CP.MP.220
V2.2023 CG Gastroenterologic Disorders Non-cancerous Annual review. Policy number change from CP.MP.221
V2.2023 CG General Approach to Genetic Testing Annual review. Policy number change from CP.MP.222
V2.2023 CG Hearing Loss Annual review. Policy number change from CP.MP.223
V2.2023 CG Hematologic Conditions Non-cancerous Annual review. Policy number change from CP.MP.224
V2.2023 CG Hereditary Cancer Susceptibility Annual review. Policy number change from CP.MP.225
V2.2023 CG Immune Autoimmune and Rheumatoid Disorders Annual review. Policy number change from CP.MP.226
V2.2023 CG Kidney Disorders Annual review. Policy number change from CC.MP.227
V2.2023 CG Lung Disorders Annual review. Policy number change from CC.MP.228
V2.2023 CG Metabolic Endocrine Mitochondrial Disorders Annual review. Policy number change from CP.MP.229
WA.CP.MP.230 CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay Annual review.
WA.CP.MP.231 CG Non-Invasive Prenatal Screening Annual review.
V2.2023 CG Oncology Algorithmic Testing Annual review. Policy number change from CP.MP.237
V2.2023 CG Oncology Cancer Screening Annual review. Policy number change from CP.MP.238
V2.2023 CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy Annual review. Policy number change from CP.MP.239
V2.2023 CG Oncology Cytogenetic Testing Annual review. Policy number change from CP.MP.240
V2.2023 CG Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies Annual review. Policy number change from CP.MP.241
V2.2023 CG Pharmacogenetics Annual review. Policy number change from CP.MP.232
V2.2023 CG Preimplantation Genetic Testing Annual review. Policy number change from CP.MP.233
V2.2023 CG Prenatal and Preconception Carrier Screening Annual review. Policy number change from CP.MP.234
V2.2023 CG Prenatal Diagnosis Pregnancy Loss Annual review. Policy number change from CP.MP.235
V2.2023 CG Skeletal Dysplasia Rare Bone Disorders Annual review. Policy number change from CP.MP.236

Policy Number Policy Title Revision Notes
CP.MP.93 Bone-anchored Hearing Aid Annual review. Removed Criteria II. stating "BAHAs for any other indication are considered not medically necessary." Updated background with no clinical significance. Added new CPT codes 69728, 69729, and 69730 and removed ICD-10 codes from policy. References reviewed and updated. Reviewed by external specialist.
CP.MP.94 Clinical Trials Annual review completed; policy reformatted. Minor rewording with no clinical significance. References reviewed and updated.
CP.MP.115 Discography Annual review. Background updated with no impact on criteria. References reviewed and updated.
CP.MP.248 Facility-Based Sleep Studies for Obstructive Sleep Apnea Revised criteria III.B. by removing requirement to meet criteria for facility-based sleep study and rewording failed APAP trial statement.
CP.MP.184 Home Ventilators Annual review completed. Minor rewording with no clinical significance. Background updated with no clinical significance. References reviewed and updated.
CP.MP.249 Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy New Policy
CP.MP.49 Physical, Occupational and Speech Therapy Services Annual review. Minor rewording throughout Criteria section with no impact on policy criteria. Removed Criteria I.F.6.a. and added as a notation. Added Criteria I.F.8. that member/enrollee agrees to participation and plan of care. Added Criteria I.H. and Criteria II.B. regarding treatment to be performed in the home. Removed Criteria V. and Criteria VI. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist.   
CP.MP.142 Urinary Incontinence Devices and Treatments Removed continence support pessaries from criteria I.D.1. Revised order in which conservative therapies are listed in I.D.2.

Policy Number Policy Title Revision Notes
CP.MP.108 Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia Added contraindication criteria I.C.1. through 4. Removed ICD-10 code table from policy. 
WA.CP.MP.37 Bariatric Surgery Revised policy sections I and II to mirror WAC 182-531-1600 requirements. Added note to section II indicating extensions may be granted to 6-month time period. Removed section III. Contraindications for surgical weight loss procedures, as this is a standard part of bariatric COE pre-operative evaluations.
CP.MP.101 Donor lymphocyte infusion Added contraindication criteria I.C.1. through 4. 
WA.CP.MP.36 Experimental Technologies Annual review. Clarifying changes made to description and notes. Policy statement updated to require both of the following, A. and B. Criteria describing technology for experimental or investigational, originally under A-C, is now I.A.1 and 2.  Statement “It does not have final clearance…and credible evaluation.” was removed. Medical necessity for technology has been restructured and indicated under I.B.1 through 10. Removed “the technology should be used…. life-threatening condition.” Added criteria points B.8.-10. Added note regarding severity of condition being considered as part of request. References reviewed and updated. Internal specialist review completed.  
WA.CP.MP.130 Fertility Preservation Annual review. Reference updated.
CP.MP.40 Gastric Electrical Stimulation Annual review. “Dietary modifications” added to I.C. and “FDA specifications” added as I.E. Updated verbiage in note at the end of criteria I. and added additional note about humanitarian device exemptions. ICD-10 code table removed. References reviewed and updated. External specialist reviewed.  
CP.MP.132 Heart-Lung Transplant Annual review completed. Removed pediatric indication of  Alpha- 1 antitrypsin deficiency. Added “Lung transplantation alone will restore right ventricular function” to I.C. Updated I.C.10. to include “unless being considered for multi-organ transplant”. Criteria I.C.16. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. ICD-10 diagnosis code table removed. Minor rewording with no clinical significance. References reviewed and updated. External specialists reviewed. 
CP.MP.58 Intestinal and Multivisceral Transplant Annual review. Updated verbiage in II.B.13. to “Active substance use or dependence including current tobacco use, vaping, marijuana use (unless prescribed by a licensed practitioner), or IV drug use without convincing evidence of risk reduction behaviors (unless urgent transplant timelines are present, in which case a commitment to reducing behaviors is acceptable).” References reviewed and updated.
CP.MP.244 Liposuction of Lipedema Annual review. Removed Criteria I.H. Added clarifying language to Criteria I.J. Minor rewording to Background with no impact on criteria. Removed ICD-10 codes. References reviewed and updated.
CP.MP.116 Lysis of Epidural Lesions Annual review. Background updated with no impact on Policy Criteria section. ICD-10 codes removed. 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.
WA.CP.MP.518 Negative Pressure Wound Therapy for Home Use Annual review. References reviewed and updated. Addition of codes to policy note following section III.  
CP.MP.86 Neonatal Abstinence Syndrome Guidelines Annual review. Minor rewording in description and criteria. Updated criteria I.C.7. to include family medicine provider. Added criteria I.C.8. regarding follow up appointment with the primary care pediatrician or family medicine provider scheduled prior to discharge. Background updated with no impact on criteria. References reviewed and updated. 
CP.MP.128 Optic Nerve Decompression Surgery Policy retired.
CP.MP.102 Pancreas Transplantation Annual review. Removed criterion I.A. stating that medical treatment does not exist or has failed. Removed C-peptide values and BMI requirements from Criteria I.B.1 and I.B.2. Noted in I.B.1. that member/enrollees with requirements for insulin over one unit/kg should be closely evaluated as they may be less likely to benefit from pancreas transplant compared to those with lower insulin doses Added indication in I.B.2 for exocrine pancreatic insufficiency. Added indication I.B.3. for requirement for the procurement or transplantation of a pancreas as part of a multiple organ transplant for technical reasons; Changed “chronic” to “active” in infection contraindication in I.C.7. Removed acute renal failure contraindication. Criteria I.C.12. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Added chronic, non-healing wounds as contraindication in Criteria I.C.13. Added contraindication of significant comorbidities in Criteria I.C.14. Clarified in I.C.1.b that problems with insulin could be clinical or clinical and emotional. Added in I.C.2.c. that the GFR does not have to be the most recent value. Added Criteria I.D.1.c. requirement for being medically managed by an endocrinologist for at least 12 months for pancreas transplant alone. Added requirements for SPK and PAK that PTA criteria also needs to be met for those procedures. ICD-10 codes removed. Background updated with no impact on criteria. References reviewed and updated. 
CP.MP.120 Pediatric Liver Transplant Annual review. Criteria I.B.1.a.ii. updated to remove “beyond 3 months from procedure” and added a) Total bilirubin > 6 mg/dL beyond three months from hepatoportoenterostomy b) Total bilirubin remains between 2 to 6 mg/dL. Updated Criteria I.B.1.b. to add “if partial external biliary diversion or ileal exclusion failed or could not be performed.” Removed “acute liver failure associated with encephalopathy” in Criteria I.B.3.a. and added I.B.3.a.i. and ii. Added Criteria I.B.3.c. Budd-Chiari Syndrome. Added, “At the time of diagnosis…” to I.B.4.a.ii. Updated Criteria I.B.4.d. to infantile hemangioma as well as verbiage in I.B.4.d.i. and ii. Removed “that is not responsive to medical therapy” in criteria I.B.5.h. and added I.B.5.h.i. through iv. Criteria I.B.5.m.ii. changed from “hyper-ammonia” to “hyperammonemia.” Criteria I.B.7.b. updated to Factor VII and updated to state, “with complications from or failure of medical management.” Removed “that has failed medical therapy” from Criteria I.B.7.c. and added sub criteria i. and ii. Removed “Budd-Chiari Syndrome” from I.B.7.d. Added Hepatopulmonary syndrome (HPS) as I.B.7.d. and added sub criteria i. and ii. Criteria I.C.1. updated from “chronic” to “active” infection. Criteria I.C.3. updated and added note for exclusion of malignancies that transplant could sufficiently address. Criteria I.C.8. updated to remove age requirement. Criteria I.C.18. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background updated with no impact on criteria. ICD-10 codes removed. References reviewed and updated. Reviewed by internal specialist and external specialist. 
CP.MP.188 Pediatric Oral Function Therapy Annual review. Updated Criteria I.A. to include anatomic conditions and removed “severe” and “complex” verbiage. Minor rewording in Criteria section with no impact on criteria. Listed disorders and impairments in Criteria I.B. for clarity. Added Criteria I.H. to include complex medical conditions with concern for feeding difficulty. Background updated with no impact on criteria. References reviewed and updated.
CP.MP.210 Repair of Nasal Valve Compromise Annual review completed. Updated Criteria I.C.3. to include nonallergic rhinitis with examples. Background updated with no impact to clinical criteria. Dashes removed from ranges. CPT Code 30469 added to Codes That Do Not Support Coverage table. ICD-10 diagnosis code table removed. References reviewed and updated. External specialist reviewed.
CP.MP.162 Tandem Transplant Updated verbiage I.3.b.ii., I.3.c.i. through iii., and I.A.3.d. Added substance use contraindication I.B.15. Removed criteria IV. stating, current evidence does not support tandem transplants for any other indication than what is listed above.
WA.CP.MP.509 Upper GI Endoscopy for GERD Annual review. References reviewed and updated. Section II. A. language updated to mirror billing guidelines.

Policy Number Policy Title Revision Notes
CP.BH.104 Applied Behavior Analysis New Policy
WA.CP.BH.104 Applied Behavior Analysis Policy archived
CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections for Pain Management Policy archived
NIA_CG_300 Epidural Spine Injections New Policy on NIA site
NIA_CG_301 Facet Joint Injections New Policy on NIA site
NIA_CG_302 Facet Joint Denervation New Policy on NIA site
WA.CP.MP.171 Facet Joint Interventions for Pain Management Policy archived
WA.CP.BH.506 Psychological Testing  Annual review. Renumbered policy from WA.CP.MP.506 to WA.CP.BH.506. Replaced “member” with “member/enrollee’ in all instances. References updated.
CP.MP.166 Sacroiliac Joint Interventions for Pain Management Policy archived
NIA_CG_305 Sacroiliac Joint Injection New Policy on NIA site
CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management Policy archived
WA.CP.MP.248 Sleep Apnea Diagnosis and Treatment Policy archived
CP.BH.200 Transcranial Magnetic Stimulation for Treatment Resistant Major Depression Ad hoc Review. Policy restructured. Added additional information to the description section with no impact to the policy.  Replaced all instances of the statement “It is the policy of health plans affiliated with Centene Corporation®” with “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. Deleted criteria point I.D as the information was redundant to I.B. In criteria subsection I.I. (5), clarified that three months or less of remission constitutes a contraindication. Added the statement “requests for 6 tapered final sessions of TMS (over a 3-week period)” to the revised criteria point II. Added criteria point II.A to indicate that “all initial criteria must be met prior to request for additional sessions”. Deleted what was criteria III as the information was redundant to criteria II. In criteria section III, replaced “maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it” with “It is the policy of health plans affiliated with Centene Corporation that maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it”. Added criteria point IV.A to indicate that “criteria for initial TMS treatment guidelines continues to be met”. Added semicolons throughout the criteria section.  References reformatted. Replaced all instances of “dashes (-) in page numbers to the word “to”.  

Policy Number Policy Title Revision Notes
WA.CP.MP.37 Bariatric Surgery Annual review. Updated policy format. Updated policy statement in I, I.A.1, and I.A.1.a. In I.A.1.a.i updated policy statement and BMI threshold to ≥ 35 or ≥ 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults. In I.A.1.a.ii BMI threshold was updated to "BMI ≥ 30 and < 35 kg/m², or < 27.5 kg/m2 and < 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults and policy statements in I.A.1.a.ii, I.A.1.a.ii.a), and c). Moved Type 2 diabetes mellitus (DM) to I.A.1.a.ii.b) as an absolute co-morbidity. Added "pseudotumor cerebri" and "disqualification from other surgeries..." to I.A.1.a.ii.c). Updated policy statement in I.A.1.b.ii. Updated I.B.2 to "Glycemic control evaluation to include A1c and fasting blood glucose". Removed criteria I.B.5.c. requiring prescribed exercise program as part of nutritional counseling. Moved IV. Contraindications to I.C and added "severe cardiac disease with prohibitive anesthetic risks," "uncontrolled and untreated eating disorders (eg, bulimia)," "inability on the part of the patient or parent/guardian to comprehend the risks and benefits of the surgical procedure," and "a medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens or impairs decisional capacity." Background updated with no clinical impact. Removed deleted CPT codes 0312T- 0317T and added CPT codes 43290, 43291, and 43632 to not medically necessary table. Removed ICD-10 codes and table. References reviewed and updated. Reviewed by internal and external specialists. Section III: updated abbreviations in III.3 with no clinical significance; added indication for SG to RYGB or BPD-DS DS as a bridging procedure for BMI ≥ 50 kg/m² in III.4.
CP.MP.107 Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines Annual review. Updated policy statement in I. and added general criteria I.A.1. and I.A.2. Removed ambulatory assist products and updated I.B. policy table. Retired gait trainers and standing frame criteria, defer to standard IQ criteria. Updated pneumatic compression device criteria and added non-pneumatic compression device criteria. Added "one month’s rental for a standard manual wheelchair is considered medically necessary if a member/enrollee owned wheelchair is being repaired" to wheelchair repair. Added foot orthotics, custom criteria and codes. Removed "male" from male vacuum erection device. Added criteria section for walkers. Minor verbiage and formatting updates with no impact on criteria. References reviewed, updated, and reformatted. Internal specialist review.
CP.MP.106 Endometrial ablation Annual review completed. Added requirement in I.F. that thyroid disorders have been treated or ruled out. Removed contraindication “previous classic cesarean or other transmural surgery” from I.G. Background and Table 1 updated. Minor rewording with no clinical significance. References reviewed and updated. Internal specialist reviewed. 
CP.MP.121 Homocysteine Testing Annual review. References reviewed and updated. 
WA.CP.MP.505 Microprocessor Controlled Lower Limb Prosthetics Annual review. References updated. Removed HCPCS L2006 and L5973 as these services are not covered by HCA.
CP.MP.242 Pulmonary Function Testing Annual review. Updated Criteria I.B.1. to include type and degree of pulmonary dysfunction. Minor rewording to Criteria I.B.2. and I.B.4. without clinical significance. Minor rewording to Criteria C. Background updated with no impact on criteria. References reviewed and updated.
WA.CP.MP.517 Testosterone Testing Annual review. Reference updated. Grammatical changes to mirror billing guideline.
CP.MP.247 Transplant Service Documentation Requirements New policy
WA.CP.MP.520 Tympanostomy Tubes in Children Annual review. References updated. Criteria updated to mirror billing guideline.

Policy Number Policy Title Revision Notes
WA.CP.MP.519 Administrative Days Added section III for Newborn Subsequent Days. References updated.
WA.CP.BH.521 Behavioral Health Personal Care Services Annual review. Changed policy number from WA.CP.MP.521 to WA.CP.BH.521. References updated.
WA.CP.MP.502 Cochlear Implants: Bilateral vs. Unilateral Annual review. references updated. Removed L8614.
WA.CP.MP.501 Continuous Glucose Monitoring Annual review. References updated. Updated all HCPCS
CP.MP.34 Hyperemesis Gravidarum Treatment Policy archived
CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea Annual review completed. I.C. Changed BMI to 35 kg/m2; I.E. Adjusted AHI to ≥15 to ≤ 65 events per hour; I.F.1. Adjusted 20 to 15. Added criteria I.I.5. and I.I.8. through 14. Background updated and minor rewording with no clinical significance. Added CPT codes 64582, 64583, and 64584. Removed CPT codes 0466T, 0467T, 0468T, 61886, 61888, 64568, 64569, 64570, and 64585.
CP.MP.57 Lung Transplantation Annual review. Criteria I.C.14. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Added pediatric indication for end-stage emphysema due to alpha-1 trypsin deficiency. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist
CP.MP.85 Neonatal Sepsis Management Annual review completed. Description and background updated. Minor rewording with no clinical significance. References reviewed and updated.
CP.MP.81 NICU Discharge Guidelines Annual review. Updated the note in section II. from "1800 grams” to “1600 to 1800 grams.” References reviewed and updated. Reviewed by external specialist.
CP.MP.141 Non-Myeloablative Allogenic Stem Cell Transplants Annual review completed. Criteria I.C.4. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background updated; minor rewording with no clinical significance. ICD-10 diagnosis code table removed. References reviewed and updated.
WA.CP.MP.503 Private Duty Nursing Services Annual review. Added HCA definition of Private Duty Nursting to the Description section. Added minimum hours to section I. Updated sections II.A and II.B to add clarity and examples. Reworded III.A. to add billing instructions for patient’s home in addition to the instructions for billing when in a group home. Clarified billing instructions in IV. Updated references.
CP.MP.187 Radiofrequency Ablation of Uterine Fibroids Policy archived
CP.MP.151 Transcatheter Closure of Patent Foramen Ovale Annual review. Updated description to include newest FDA-approved device: AmplatzerTM TalismanTM PFO Occluder. Clarfied in I.B. that age requirements are in years. Updated Criteria I.B. # 2 to state that cryptogenic stroke caused by a presumed paradoxical embolism, and a possible, probable, or definite likelihood that the stroke was causally related to PFO based on the PFO-associated stroke causal likelihood (PASCAL) classification system with a Risk of Paradoxical Embolism (RoPE) score > 6, and/or there is a large shunt or atrial septal aneurysm. Updated Criteria to include Criteria C. Device is FDA-approved for percutaneous transcatheter closure of PFO (eg AmplatzerTM PFO Occluder, AmplatzerTM TalismanTM PFO Occluder, and the Gore® Cardioform Septal Occluder). Background updated and includes information on PASCAL classification system and RoPE score. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist.
WA.CP.MP.46 Ventricular Assist Devices Annual review. Background and note updated with no clinical significance. Section III reworded. Removed ICD codes. References updated.

Policy Number Policy Title Revision Notes
CP.BH.500 Behavioral Health Treatment Document Requirements Edited policy statement I to apply to Centene Advanced Behavioral Health as well as plans affiliated with Centene.
NIA.CG.062 CT Coronary Angiography Added the following statement, "Low probability patients will be directed to exercise stress test over CCTA unless other criteria for imaging studies are met."
WA.CP.MP.515 Fecal Microbiota Transplantation Annual review. Updated references
CP.MP.136 Home Births Annual review completed. Removed criteria II. regarding all other indications not medically necessary. Minor rewording with no clinical significance. ICD-10 codes removed. References reviewed and updated. Internal and external specialist reviewed.
CP.MP.62 Hyperhidrosis Treatments Annual review. Updated Criteria II.B. to greater than 55 beats per minute. Removed “is relatively healthy” in criteria II.F. Background updated with no impact on criteria. ICD-10 codes removed. References reviewed and updated.
CP.MP.173 Implantable Intrathecal or Epidural Pain Pump Annual review.  References reviewed and updated.  ICD-10 code table removed. Minor rewording with no clinical significance. Reviewed by external specialist.
CP.MP.202 Orthognathic Surgery Annual review completed. Reformatted criteria II. and added II.B. as additional non-medically necessary indication. Additional minor rewording with no clinical significance. Background updated. CDT codes removed from policy. References revised and updated. Reviewed by external and internal specialists.
CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia Annual review. Changed title from “Home phototherapy…” to “Phototherapy…” Updated criteria I.D. from 24-48 hours to 12-24 hours. Updated criteria to include the following: I.E. ≥48 hours old; I.F. An LED-based phototherapy device will be available in the home without delay; I.G. No previous phototherapy; I.H. TSB will be measured daily. Criteria I.I. #1 updated to include example of positive direct antiglobulin test for isoimmune hemolytic disease and to include glucose-6-phosphate dehydrogenase (G6PD) and other hemolytic disease. Criteria I.I. #2 updated to include hypoxic ischemia encephalopathy (HIE). Significant lethargy removed from Criteria I.I. Criteria I.I. updated to include the following: #13 Significant clinical instability in the previous 24 hours; #14 Clinical history of a parent or sibling requiring phototherapy or exchange transfusion; #15 Exclusive breastfeeding with suboptimal intake (≥10% weight loss); #16 Down syndrome; #17 Macrosomic infant of a diabetic mother. Added note below Table 1 that explains the values are conservative TSB values based on lower age range thresholds in inpatient criteria. Added clarification to II that extenuating circumstances can include lack of expected compliance with therapy at home. Added note below policy statement II stating: that infants should be admitted for inpatient phototherapy if the TSB concentration is more than 1 mg/dL above the AAP guidelines phototherapy treatment threshold per the bili risk tool, and that table 1 is consistent with AAP guidelines allowing treatment at lower levels per provider discretion; and that clinical decision support tools provider further criteria for inpatient phototherapy treatment.  Updated background to include 2022 AAP clinical practice guidelines. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist.
WA.CP.MP.248 Sleep Apnea Diagnosis and Treatment Updated policy to reflect new Centene policy: significant changes to section I.B. and change in policy numbering from WA.CP.MP.523 to WA.CP.MP.248. Updated section II.A. to reflect consideration of titration studies. Added coverage statement about actigraphy. Added code 95803 to code list. Minor changes to company name. Updated references.
WA.CP.MP.526 Stem Cell Therapy for Musculoskeletal Conditions Annual review. Updated references. Added CPT codes 38230 and 38232 and HCPCS code S2150.
CP.MP.22 Stereotactic Body Radiation Therapy

Annual review completed. Added I.F. “Recurrent malignant disease requiring palliation and/or as palliative treatment for liver-related symptoms”. Added I.J. “Extracranial oligometastatic disease:

1.One to three metastatic lesions involving the lungs, liver or bone;

2.Primary tumor is breast, colorectal, melanoma, non-small cell lung, prostate, renal cell, or sarcoma;

3.Primary tumor is controlled

4.No prior history of metastatic disease”. Background updated and minor rewording with no clinical significance. ICD-10 Code table removed. References reviewed and updated. Reviewed by external specialist.

CP.BH.100 Substance Use Treatment and Services Ad-hoc review. Edited policy statement I. to note that it applies to health plans affiliated with Centene Corporation as well as CABH. Replaced all instances of “dashes (-)” in the CPT codes with the word “through”. Replaced all instances of “dashes (-) in page numbers to the word “to”.  
CP.MP.162 Tandem Transplant Annual review. References reviewed and updated. ICD-10 codes removed. Review completed by external specialist. Minor background edits with no change to criteria.
WA.CP.MP.510 Tinnitus Treatment Annual review. Replaced all instances of “members” with “members/enrollees”. Added “repetitive” to transcranial magnetic stimulation in 2.B. Updated references.

Policy Number Policy Title Revision Notes
WA.CP.MP.525 Catheter Ablation for Supraventricular Tachyarrhythmia Annual review. References updated. Removed CPT 93650
CP.MP.203 Diaphragmatic/Phrenic Nerve Stimulation Annual review. Criteria II.A.1.c. and Criteria II.A.2.b. updated to include “or by other radiographic techniques such as ultrasound” in addition to fluoroscopy. Background updated to include U.S. Food and Drug Administration premarket approval information regarding the Avery Spirit Diaphragm Pacing Transmitter. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.54 Hospice Services Annual review. References updated. Reworded description of Pediatric Palliative Care.
WA.CP.MP.69 Intensity-Modulated Radiotherapy Annual review. Updated references. Removed CPT 77370.
WA.CP.MP.500 Mandibular Advancement Devices Annual review. Reference updated.
CP.MP.138 Pediatric Heart Transplant Annual review. Appendix A tables updated to remove dashes. Removed ICD-10 codes. References reviewed and reformatted.
CP.MP.246 Pediatric Kidney Transplant New policy
WA.CP.MP.117 Percutaneous Electrical and Peripheral Nerve Stimulation Policy renumbered WA.CP.MP.117. References to spinal cord stimulation removed.
CP.MP.242 Pulmonary Function Testing New policy

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