Donor Lymphocyte Infusion:

(CP.MP.101)

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

Policy updates include:

• Contraindications removed from policy language in Section I
• Removed total host chimerism from Section II for medically not necessary indications

Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy

(CP.MP.250)

Ambetter

New policy overview:

• Medical necessity and criteria
• Description of diabetes management
• FDA approval and description of Lantidra
• Conclusions of two studies evaluating Lantidra
• Coding information
• HCPCS code and description

Reduction Mammoplasty and Gynecomastia Surgery

(CP.MP.51)

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

Policy updates include:

• Updated criteria I.A.1. for criteria for members/enrollees ≥ 18 years of age and members/enrollees < 18 years of age
• Updated criteria I.A.2. 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
• Updated criteria I.A.3.b. to include pain in arm
• Updated criteria II.A.1. to align with ASPS guidance regarding length of time gynecomastia persists in adolescents < 18 years
• Updated criteria II.B.3. 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
• ICD-10 codes removed

Sacroiliac Joint Interventions for Pain Management

(CP.MP.166)

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

Policy updates include:

• Added [thrust tests may not be recommended in pregnant members/enrollees or those with connective tissue disorders] to I.A.1.c. for clarity
• Updated the time requirements in I.A.1.d.i. and iii. to reflect 4 weeks
• ICD-10 Diagnosis Code table removed