CP.MP.37

Bariatric Surgery

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS)

Policy updates include:

• Added Coronary Artery Disease as a comorbidity under Section I.A.1.b.ii.
• Edits made to ICD-10 codes:
  • M54-M54.9 now M54.00-M54.9;
  • T81.1X+-T81.9X now T81.10X+ -T81.9XX+;
  • T85.59 – T85.59 now T85.590+ -T85.598+.

CP.MP.50

Outpatient Testing for Drugs of Abuse

• Added criteria for presumptive testing:
  • In II.B, added that “Tests are only for the specific drug(s) or number of drug classes for which the presumptive test is expected to be positive.”
• Added the following not medically necessary indications:
  • Blanket orders;
  • Reflex definitive testing when presumptive testing is performed at point of care;
  • Physician standing orders for all patients;
  • Billing codes for individual drugs which are included in a billed panel;
  • Presumptive immunoassay testing in a lab when presumptive POC testing has been performed;
  • Presumptive screening before definitive testing if presumptive testing not ordered;
  • IA testing used to confirm a presumptive test result obtained by cups, dipsticks, cards, cassettes or other CLIA-waived methods.
• Removed request requirements section:
  • “A clinical laboratory may not bill for a service unless it has received a written request to perform that specific service from an authorized prescriber who is treating the member and will use the test for the purpose of diagnosis, treatment, or an otherwise medically necessary reason as defined in this policy. Any claim for a service for which a prior-authorization has not been provided may be subject to denial. Any clinical laboratory billing for a service must maintain such request in its records, and make such records available upon request.”
• Added additional CPT codes to support coverage criteria: 80184, 80305, 80306, 80307, 80320, 80321, 80322, 80323, 80327, 80328, 80332, 80333, 80334, 80335, 80336, 80337, 80338, 80339, 80340, 80341, 80342, 80343, 80344, 80366, 80374, 80375, 80376, 80377.
• Added the following CPT codes as not medically necessary: 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U.
• Added HCPCS codes 0011U and G0659 as medically necessary.
• Added a list of ICD-10-CM codes as supporting coverage criteria.

CP.MP.185

Skin Substitutes for Chronic Wounds

Ambetter

• Added criteria of age ≥ 18 years, or type 1 diabetic.
• Added the following to the requirement for documentation of effort to cease nicotine use:
  • “This does not include nicotine replacement therapy.”
• Added to Section II that all indications that are not noted in Section I are not medically necessary.
• Added CPT codes: 15271-15278.
• Updated list of HCPCS codes of current products available, although not inclusive or a guarantee of coverage.

TX.CP.MP.520

Private Duty Nursing

• In Section I, added B. PDN Services may be authorized on a provider or member ratio other than 1:1.
• Added the following under Section I, C. Requested care, one of the following:
  • Initial requests must be submitted within three business days of the start of care (SOC) date.
  • Requests for revisions must be submitted within three business days of the revised SOC date;
• In Section I, added G. PDN services require prior authorization within three business of the SOC for initial request of services. Added the following under Section I, G:
  • During the authorization process, providers are required to deliver the requested services from the SOC date.
  • The SOC dates is the date agreed upon by the physician, the PDN provider, and the member, parent, or guardian and is indicated on the submitted POC as the SOC date.
  • The PDN provider requesting the authorization for PDN services must submit all of the following documentation:
    • A completed THSteps-CCP Prior Authorization Request form signed and dated by the primary physician within 30 calendar days prior to the SOC date.
    • A completed POC form, signed and dated by the primary physician within 30 calendar days prior to the SOC date.
    • A completed Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form signed and dated by the primary physician, RN completing the assessment.
  • Recertifications may be prior authorized for up to a maximum of six months.
    • The following criteria must be met before a member receives a recertification:  
      • The member must have received PDN services for at least three months.
      • No significant changes in the member’s condition for at least three months.
      • No significant changes in the member’s condition are anticipated.
      • The member’s parent or guardian, physician, and provider agree the recertification is appropriate.
      • STAR Kids will require the CCP Prior Authorization Private Duty Nursing 6-Month Authorization form when requesting prior authorization for six months.
• In Section III, added D. Special Circumstances: PDN services provided in a school or day care facility, at the request of the family, may be authorized provided the member requires the requested amount of PDN services if in the home. PDN services may be provided in a hospital, SN facility or intermediate care facility for the individuals with intellectual disabilities, or special care facility with documentation from the facility showing it is unable to meet the SN needs of the member, and the services are medically necessary. These facilities are required by licensure to meet all the medical needs of the member.

CP.MP.89

Genetic and Pharmacogenetic Testing

Ambetter

Policy updates include:

• The title was changed to reflect pharmacogenetic criteria.
• The following general criteria for pharmacogenetic testing were added:
• Pharmacogenetic testing is medically necessary when all the following criteria are met:
  • Targeted drug therapy is reasonable and necessary for the treatment of the diagnosis.
  • Targeted drug therapy is associated with a specific gene biomarker or mutation.
  • Test results will be used to guide drug therapy decisions (e.g., drug choice, dose, evaluate adverse effects or non-responsiveness).
  • Previous pharmacogenetic testing has not been done for the gene biomarker or mutation, unless significant changes in testing technology or treatments indicate that test results or outcomes may change due to repeat testing.
  • Technical and clinical performance of the genetic test is supported by published peer-reviewed medical literature.

CP.MP.145

Electric Tumor Treating Fields (Optune)  

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) CHIP and Ambetter

• The age restriction of > 22 years was added.

CP.MP.132

Heart-Lung Transplant

Ambetter

• The following contraindications were removed from the policy:  Severe, irreversible, fixed elevation of pulmonary vascular resistance; and uncorrected atherosclerotic disease with suspected or confirmed end-organ ischemia or dysfunction and/or coronary artery disease not amenable to revascularization.
• The malignancy contraindication was edited to not specify within 2 years.
• Exceptions were added which include early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk.

CP.MP.144

Mechanical Stretching Devices for Joint Stiffness

• Medically necessary indications of knee, elbow, and wrist injuries for Low-Load Prolonged-Duration Stretch (LPSS) were added.
• The following criteria was specified in Section I:
  • Meets one of the following indications:
    • In addition to physical therapy in the subacute injury or post-operative period (≥3 weeks and ≤ 4 months after injury or operation) in members with signs and symptoms of persistent joint stiffness or contracture;
    • In the subacute injury or post-operative period (≥3 weeks and ≤ 4 months after injury or operation) and both of the following:
      • Limited range of motion poses a meaningful functional limitation as judged by the physician;
      • Has not responded to other therapy (including physical therapy);
    • In the acute post-operative period for members who have undergone additional surgery to improve the range of motion of the previously affected joint;
  • Request is for one of the following:
    • An initial four weeks;
    • A subsequent four week period, and improvement was noted upon reevaluation after the prior four week period.
• The indication of members unable to benefit from standard physical therapy modalities because of inability to exercise was removed.
• The not medically necessary statements changed to experimental/ investigational regarding LPSS for other indications, patient actuated serial stretch and static progressive stretch devices were changed.
• HCPCS codes as supporting coverage criteria were added.
• Existing ICD-10 codes were replaced.

CP.MP.146

Sclerotherapy for Varicose Veins

• The requirement for junctional reflux of greater saphenous veins was changed to 3 mm, from 2.5 mm.
• Varithena was added as an example of a foam irritant.

CP.MP.185

Skin Substitutes

Ambetter

• The description information about identification of MD managing chronic conditions was removed.
• The requirement for MD review of all requests was removed.
• In Section I.D, the requirement for no nicotine use for at least 4 weeks was changed to documentation of effort to cease nicotine use, or no nicotine use for at least 4 weeks.
• In the diabetic foot ulcer criteria, removed requirement of neuropathy.
• In Section I.I., 1, changed contraindication of “active Charcot arthropathy of the ulcer extremity” to “active Charcot arthropathy of the ulcer surface.”
• In Section I. F., 1, removed documentation of assessment of physical activity, nutrition, physical exam, check of prosthetics, and history of diabetes management, including comorbidities.
• Changed requirement of HbA1c ≤7% to ≤8% or with documented improvement of blood glucose in last 4 weeks.
• Changed HbA1c contraindication to >8% or with no document improvement of blood glucose in last 4 weeks.
• Removed criteria stating that switching products during an episode of wound care is not allowed.
• Removed not medically necessary language about repeated billing of surgical preparation services.
• Revised name of the policy to Skin Substitutes for Chronic Wounds.

CP.MP.31        

Cosmetic and Reconstructive Procedures

Ambetter

• Criteria for dermal injections and autologous fat injections for HIV-associated FLS was added.
• The policy title and medical necessity statements were changed to state “cosmetic procedures” or “reconstructive procedures” instead of “cosmetic surgery” or “reconstructive surgery.”
• CPT and HCPCS codes for specified medically necessary indications were added.
• A note to refer to CP.MP.95 Gender Affirming procedures for procedures related to treatment of gender dysphoria was added.

CP.MP.57

Lung Transplantation

Policy updates include:

• The malignancy contraindication was edited to not specify within 2 years, and added exceptions of early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk.

CP.MP.58

Intestinal and Multivisceral Transplant

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) CHIP and Ambetter

• The malignancy contraindication was edited to not specify within 2 years, and added exceptions of early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk.

CP.MP.102

Pancreas Transplantation

• The malignancy contraindication was edited to not specify within 2 years, or low Gleason score, and added exceptions of early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk.
• The BMI maximum allowable value in I.B. 2 was clarified: (i.e., < 30 to 35 kg/m2, depending on transplant center).

CP.MP.114      

Disc Decompression Procedures

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) CHIP and Ambetter

Policy updates include:

• Interspinous/interlaminar process stabilization device (C1821) was added as investigational.
• The following codes were added as not covered: 22867, 22868, 22869, and 22870.

CP.MP.120      

Pediatric Liver Transplant

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) CHIP and Ambetter

Policy updates include:

• The malignancy contraindication was edited by adding exceptions: cancer that has been completely resected, or that has been treated and poses acceptable future risk.

CP.MP.138      

Pediatric Heart Transplant

Policy updates include:

• The malignancy contraindication was edited to not specify within 2 years, and added exceptions of cancer that has been completely resected, or that has been treated and poses acceptable future risk.
• Coronary artery disease not amenable to revascularization was removed from list of contraindications.

CP.MP.184      

Non-Invasive Home Ventilator

Policy updates include:

• The following criteria has been added for second/back up noninvasive ventilator from CP.MP.107 DME:
  • It is the policy of Health Plans affiliated with Centene Corporation that a second or back up non-invasive ventilator is considered medically necessary for the following indications:
    • A second ventilator to serve a different purpose from the first ventilator, based on the member’s medical needs. For example, two different types of ventilators are needed for each day, e.g., negative pressure ventilator with chest shell for one indication and a positive pressure ventilator with nasal mask the rest of the day;
    • A back-up ventilator for one of the following:
      • Member is confined to a wheelchair and requires a wheelchair mounted ventilator during the day and another ventilator of the same type for use while in bed (unable to position the wheelchair-mounted ventilator close enough to the bed for use while sleeping). Without both pieces of equipment, member may be prone to medical complications, unable to achieve appropriate medical outcomes, or may not be able to use the equipment effectively;
      • Residence in remote areas with poor emergency access.

CP.MP.189

Thymus Transplantation

New Policy Overview:

• “Complete DiGeorge anomaly is a disorder in which a person has no thymus function. Without thymus function, bone marrow stem cells do not develop into T cells, which results in immunodeficiency. Without successful treatment, patients usually die by 2 years of age. Thymus transplantation with and without immunosuppression has resulted in the development good T cell function in complete DiGeorge anomaly subjects.”