Policy
| Applicable Products
| Updated Policy Revisions
|
Allogeneic Hematopoietic Progenitor Cell Therapy
(CP.MP.249)
| Ambetter
| Policy updates include:
- Updated Criteria I. to include severe aplastic anemia as a medically necessary indication for Omisirge
|
Assisted Reproductive Technology
(CP.MP.55)
| Ambetter
| Policy updates include:
- Under I.A.1. removed “ART is performed by a physician board-certified or board eligible in reproductive endocrinology for those with a female reproductive system and by a board-certified or board eligible urologist or reproductive endocrinologist for those with a male reproductive system”
- Under I.A.5. removed “Evidence of such includes:
- In the case of vasectomy reversal – there must be two recent normal semen analyses within the past three months (sperm count > 20 million/ml; motility > 50% and normal morphology – > 14% normal forms by Krüger classification or > 30% normal forms by WHO criteria)
- In the case of previous tubal ligation with reanastamosis, documentation by hysterosalpingogram of unilateral or bilateral tubal patency
- Removed criteria I.A.6-I.A.7
- Under I.B.1. removed “all of”
- Under I.B.1.a.ii. added “(e.g.: stenosis, chronic cervicitis)”
- Added I.B.1.a.iii. “Ovulatory dysfunction treated with medications such as clomiphene”
- Under I.B.1.a.viii.2). added “or have a diagnosis of retrograde ejaculation and undergoing sperm washing”
- Under I.B.1.a.viii, updated criteria and removed reference to I.A.1 and updated reference to I.A.3 to I.A.2
- Under I.B.2. added “meets one of the following” and reformatted criteria below
- Under I.B.2.a.ii. removed “directed by a physician”
- Under I.B.2.b. removed “For those with a female reproductive system < age 38, failure of at least three cycles of IUI with oral agents (i.e., clomiphene or letrozole)”
- Under I.B.5. replaced “less” with “fewer”
- Under I.B.5.e. replaced “(does not include obstruction due to voluntary sterilization)” and replaced with “***” to reference a note
- Under I.B.5.k
- replaced “i.e.:” with “e.g.:” and added hereditary hemoglobinopathies, myotonic dystrophy type I, Huntington’s disease, Duchenne’s muscular dystrophy, hemophilia and fragile X syndrome)
- Added ***Note: Does not include obstruction due to voluntary sterilization
- Under I.B.6.b. replaced “premature ovarian failure” with “primary ovarian insufficiency”
- Removed notes “Note: see CP.MP.130 Fertility Preservation if undergoing medical treatment that will result in infertility”
- Under I.B.10. removed “if meeting one of the indications above for cryopreservation of embryos, but is unable, or unwilling for ethical reasons, to cryopreserve embryos
- Under II.I. replaced “gender” with “sex”
|
Home Ventilators
(CP.MP.184)
| CHIP, and Ambetter
| Policy updates include:
Revision of section of I.B. including, addition of new I.B.3.a.-c. regarding ventilation requirements and restructuring with previous I.B.3.a.-b. becoming I.B.4.a.-b
Removed three-month specification in Criteria II
|
Lung Transplantation
(CP.MP.57)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Updated adult and pediatric interstitial lung disease criteria to include end-stage or refractory pulmonary alveolar proteinosis as criteria I.D.1.c.vii.a)-b) and I.D.2.c.vii.a)-b) respectively
|
Nonmyeloablative Allogeneic Stem Cell Transplants
(CP.MP.141)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added Criteria I.A.9. for Hodgkin lymphoma
- Updated verbiage in Criteria I.A.10.a. for clarity
|
Pediatric Kidney Transplant
(CP.MP.246)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Updated contraindications I.B.4 and I.B.5 to be in line with each specific body system
- Removed contraindication I.B.9 for acute pancreatitis contraindication
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