Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Burn Surgery (CP.MP.186)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Description revised to exclude skin grafting
- Updated “Note” section
- Moved all of criteria section II to CP.MP.185 Skin and Soft Tissue Substitutes
- Removed CPT codes 15271 to 15278 from CPT code table
- Removed HCPCS code table. Removed skin graft information from the background
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Clinical Trials
(CP.MP.94)
| CHIP, Ambetter Health
| Policy updates include:
- Removed “Centene Advanced Behavioral Health” from Criteria I
- Updated verbiage in criteria I.D.4. from “patients” to “members/enrollees”
- Updated Criteria I.D.5.d. to include the following institutes: National Institute of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute of Child Health and Human Development (NICHD), and National Institute on Aging (NIA)
- Added Criteria I.D.5.e. to include Advanced Research Projects Agency for Health (ARPA-H)
- Background updated to align with criteria
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Neonatal Abstinence Syndrome Guidelines (CP.MP.86)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Updated verbiage in Criteria I.A. for clarity
- Removed use of the modified Finnegan Neonatal Abstinence Scoring Tool (FNAST) from Criteria I.A.1
- Removed requirement for using the Eat, Sleep, Console (ESC) approach and added duration of treatment language in Criteria I.A.2
- Added Note at the end of Criteria I.A.2. regarding assessment and management utilizing the modified FNAST or the ESC approach
- Removed language regarding level II nursery in Criteria I.B
- Added “with no significant clinical signs of withdrawal for 24 to 48 hours after applicable pharmacologic therapy” and removed language specific to morphine in Criteria I.C.2
- Removed Note at the end of Criteria I.C.2. regarding the half-life of morphine and added this information to the Background section
- Updated verbiage in Criteria I.C.4. to specify that parent(s) or caregiver(s) have received education regarding NAS and routine infant care and demonstrate understanding of and agreement with the plan of care
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Neonatal Sepsis Management
(CP.MP.85)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Updated Criteria I.A.1. to include level I nursery
- Removed all instances of revenue codes throughout policy criteria
- Background updated and added Table 1. regarding nursery level and corresponding revenue code
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NICU Apnea Bradycardia Guidelines
(CP.MP.82)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Updated Criteria I.A.1.b. to clarify clinically significant bradycardia
- Updated verbiage in Criteria I.A.2. for clarity
- Updated language in Criteria I.A.2.a. for clarity and included “with no evidence of another acute condition requiring inpatient management”
- Updated formatting and added clarifying language in Criteria I.A.2.b
- Removed previous Criteria I.A.3.b. regarding being discharged home with a cardiorespiratory monitor
- Removed verbiage regarding cardiorespiratory monitor and providing stimulation in Criteria I.A.3.c
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NICU Discharge Guidelines (CP.MP.81)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Under I.B. replaced “enteric” with “enteral”
- I.B.2.d.i. replaced “who cannot feed well enough orally and for whom feeding is the last issue requiring continued hospitalization” with “who is unable to take adequate oral feeds and whose ongoing hospitalization is primarily for feeding support”
- I.B.2.d.ii. reworded with no impact on criteria and moved note to a separate line
- In Note under I.B.2.d.ii. removed “gastrostomy tube placement generally requires a seven days post-operative stay for recovery and parent/caregiver education”
- I.B.2.d.iii. removed “(short gut)” and added “enterally”
- Under Authorization Protocol, C.1.a. replaced “No” with “Absence of”
- Under C.1.b. replaced “Lack” with “Absence”
- Under NICU Discharge Recommended Practices, A.3. replaced “between” with “with”. Under C.2. removed “immunoglobulin” and added “including monoclonal…” and “verified”
- Under C.3. replaced “assure” with “ensure”, added “and influenza” and removed “with the Tdap vaccine; and the flu with the”
- Under E.3. added “and meet manufacturer minimum weight limits”
- Removed E.5. “Four pound (1815 gram) car seat for those infants weighing less than five pounds (2268 grams)”
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Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Annual review
- Under I. replaced “guidelines” with “criteria”
- Under I.I. added “Ability to measure” and removed “will be measured”
- Removed previous risk factors I.J.10., 12., 16., and 17
- Under I.K. removed “TSB is within the levels noted in Table 1 below: Table 1. Acceptable TSB levels for home phototherapy in infants without risk factors, by age” along with Table 1 and added “TSB level is equal to the phototherapy treatment threshold, as determined by the American Academy of Pediatrics (AAP) guidelines in the hyperbilirubinemia risk calculator at https://bilitool.org/, or up to 2 mg/dL below”
- Removed “*Note: The TSB home phototherapy table above allows for conservative TSB levels to align with the lower age limit in hours provided in the age ranges for inpatient criteria for hyperbilirubinemia (see section II)”
- Under II. removed “American Academy of Pediatrics” due to redundancy
- Removed “The values in Table 1 above offer phototherapy at levels consistent with the AAP statement that phototherapy can be offered below the AAP treatment threshold per the provider’s discretion” and replaced with “at or above the “escalation of care”
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Transcranial Magnetic Stimulation for Treatment Resistant Major Depression
(CP.BH.200)
| Ambetter Health
| Policy updates include:
- Ad hoc review
- Updated policy sections II.A and IV.A to include the FDA cleared Magstim Horizon 3.0 TMS Therapy Systems as an option for adolescents
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