Bariatric Surgery

(CP.MP.37)

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

Policy updates include:

• To the diabetes criteria in II.B: removed criteria options of Fasting blood glucose level of ≤ 110 mg/dL and 2-hour postprandial blood glucose concentration of ≤ 140 mg/dL

Bone-Anchored Hearing Aid

(CP.MP.93)

Ambetter

Policy updates include:

• Revised I.E from “threshold of 20dB” to “threshold of < 20dB”
• In I.F.4., added idiopathic causes to the list of causes of unilateral deafness
• Revised description of HCPCS L8691 and added L8694

Fetal surgery in utero

(CP.MP.129)

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

Policy updates include:

• Added, “D. Placement of a thoraco-amniotic shunt for pleural effusion with or without secondary fetal hydrops,” to criteria set I
• Added criteria set, “II. It is the policy of health plans affiliated with Centene Corporation that all repeat utero fetal surgery procedures require secondary review”

Neonatal Sepsis Management

(CP.MP.85)

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

Policy updates include:

• Removed “or level 1 nursery (rev code 171),” from II.D: “Asymptomatic infants with a positive blood culture and no other indications are appropriate for transitional care or level 1 nursery (rev code 171)”
• Added sentence to note under criteria point II.D. to say, “It is difficult to administer intravenous antibiotics in the home with home health care due to the challenge of keeping very small catheters in place and patent