Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Caudal or Interlaminar Epidural Steroid Injections
(CP.MP.164)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Removed informational note about discontinuing anti-platelet therapy
- Updated Criteria I.D.1 from two months to three months regarding relief and functional movement
- Removed Criteria I.D.2. regarding length of time since last ESI
|
Evoked Potential Testing
(CP.MP.134)
| Ambetter Health
| Policy updates include:
- Annual review
- In I.B.4., revised “within the initial 72 hour” to “after the initial 72 hours”
- Added Note under I.B.4. to clarify that brainstem auditory evoked potential testing should be performed in conjunction with standard prognostication methods (e.g., electroencephalogram [EEG])
- In I.C.2., added “when not explained by magnetic resonance imaging (MRI) or computed tomography (CT), infectious diseases, or metabolic diseases” to existing criteria
- Coding reviewed and updated
- Updated titles of coding tables
- In Table 2, removed ICD-10 code G35, and added the following codes: G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, and G35.D
|
Fetal Surgery in Utero for Prenatally Diagnosed Malformations
(CP.MP.129)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Annual review
- Under I.C. added “with treatment including”
- Added additional criteria I.C.1.a. Hydropic fetus or at risk of developing hydrops, I.C.1.b. Failure of one round of maternal antenatal corticosteroid, unless contraindicated
- Added note under criteria I.D. to include “Note: May include fetal pleural aspiration only when performed along with and prior to thoraco-amniotic shunt placement”
- Added additional criteria I.H.2
- Under I.G.6.a added “fetal”. Singleton pregnancy
- Added CPT 59074
|
Hospice Services
(CP.MP.54)
| Ambetter Health
| Policy updates include:
- Description updated for clarity
- Under the Policy Initial Request section, updated Criteria section II. to state the member/enrollee meets one of the disease specific guidelines or decline in clinical status criteria, Criteria section II.E. updated from “Dementia” to “Dementia due to Alzheimer's Disease and Related Disorders,” Criteria section II.K. updated from “Non-Disease Specific Decline in Clinical Status” to “Decline in Clinical Status,” and added Criteria section V. for Recertification of Hospice Services
- Verbiage and formatting updated in Criteria I.A. for clarity
- Added Criteria I.B. for plan of care (POC) requirements
- Updated title of Criteria II. From “Severity of Illness” to “Disease Specific Guidelines”
- Minor rewording and formatting to Criteria II.A.3.a. and II.A.3.b. for clarity
- Expanded Criteria II.B.3.b. to include specific examples of critical nutritional impairment related to rapid progression of amyotrophic lateral sclerosis (ALS)
- Added clarifying language to Criteria II.B.3.c. and specified recurrent aspiration pneumonia and added recurrent fever after antibiotic therapy as examples of rapid progression of ALS with other life-threatening complications
- Added note regarding rapid progression of ALS after Criteria II.B.3.c
- Updated verbiage and formatting in Criteria II.C.3.a. and added criteria that member/enrollee is not a candidate for a surgical procedure or declines a procedure
- Removed Criteria for coronary artery disease under Criteria II.C.3
- Updated Criteria II.D.3.a. to specify disabling dyspnea
- Added additional examples of fatigue and cough to Criteria II.D.3.b. for diminished functional capacity for pulmonary disease
- Updated verbiage and formatting in Criteria II.D.4. for clarity, removed specific number of emergency room visits and hospitalizations and their specific time frames, and removed criteria that member/enrollee states they do not want to be intubated
- Reformatted and expanded Criteria II.D.5. to include hypoxemia at rest on room air and to include oxygen saturation measured by non-arterial methods
- Updated title of Criteria II.E. from “Dementia” to “Dementia due to Alzheimer's Disease and Related Disorders”
- Updated Criteria II.E.2.f. from weight loss > 10% to weight loss of at least 10%
- Removed “refractory” from Criteria II.F.3.g. regarding cryptosporidium infection
- Removed requirement that member/enrollee is not on the transplant list under Criteria II.G.3. for liver disease
- Added requirement that the member/enrollee is not seeking a renal transplant in Criteria II.H.3
- Added clarifying language in Criteria II.H.3.a
- Added Note at the end of Criteria II.H.3.b. stating that member/enrollee may still qualify for hospice if receiving dialysis for a condition not related to the terminal illness
- Updated Karnofsky performance status (KPS) from < 40 to ≤ 40 under Criteria II.I.1. for stroke
- Updated Criteria II.I.2.c. to specify recurrent pulmonary aspiration unresponsive to speech-language pathology intervention
- Updated title of Criteria II.K. from Non-Disease Specific Decline in Clinical Status to “Decline in Clinical Status”
- Added decreasing cholesterol as an additional example of worsening clinical status in Criteria II.K.2.d.i
- Added venous, arterial or lymphatic obstruction due to local progression or metastatic disease, and weakness as additional examples of worsening signs in Criteria II.K.2.d.ii
- Added clarifying language to examples of worsening symptoms in Criteria II.K.2.d.iii. and expanded nausea example to include nausea or vomiting that is poorly responsive to treatment
- Updated Criteria II.K.2.d.iv. to specify when laboratory results are available and added calcium laboratory result
- Added Criteria II.K.2.f. for progressive decline in FAST for dementia not related to Alzheimer’s disease
- Under Criteria II.B. for continuous hospice home care, removed requirement that 24-hour time period begins and ends at midnight, removed “up to five days of continuous home hospice care may be approved with ongoing concurrent review for additional days requested“ and added “continuous home care is only furnished during brief periods of crisis and only as necessary to maintain the terminally ill member/enrollee at home”
- Under Criteria III.D.2 for general inpatient, short term (non-respite) hospice care, specified that the treatment plan is not intended for curative treatment of the terminal illness and removed “up to five days of general inpatient, short term care may be approved with ongoing concurrent review for additional days requested”
- Reformatted Criteria IV.E. and added Note at the end of criteria to expand on hospice discharge guidelines and when a new certification period is required any time a member/enrollee is discharged from hospice and then re-elects hospice. There is no waiting period for the member/enrollee to re-elect hospice benefits. The member/enrollee forfeits hospice coverage for any remaining days in the current certification period
- Reformatted Criteria V. and updated title from “Subsequent Requests” to “Recertification of Hospice Services”
- Added Criteria V.A.1. regarding request for recertification within 180 days of beginning hospice services and submission of a renewed certification of terminal illness from the hospice medical director detailing the need for continued hospice services based on clinical findings supporting a life expectancy of six months or less if the terminal diagnosis runs its normal course
- Added Criteria V.A.2. regarding request for recertification beyond 180 days of hospice services and added Criteria V.A.2.a. for submission of a renewed certification of terminal illness from the hospice medical director detailing the need for continued hospice services based on clinical findings supporting a life expectancy of six months or less if the terminal diagnosis runs its normal course
- Added Criteria V.A.2.b. regarding “documentation of a face-to-face encounter with the member/enrollee and a hospice physician or nurse practitioner completed prior to the end of each previous certification period.” Added a Note under criteria regarding members/enrollees who stabilize or improve and regarding submission of the current hospice POC when requesting recertification
- Removed requirement that 24-hour time period begins and ends at midnight under Definition B. section for continuous hospice home care
- Appendix A: Palliative Performance Scale (PPS) revised to update the PPS 10% level of consciousness from “drowsy or coma” to “full or drowsy +/- confusion”
- Coding and descriptions reviewed
|
Pediatric Liver Transplant
(CP.MP.120)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Removed criteria under I.A
- Removed “is” under previous I.B
- Under previous I.B.4.c. added “radiological”
- For previous I.B.5.j. removed “complications” and added “pediatric acute liver failure (PALF)”
- For previous I.B.5.l. added “while receiving conventional medical therapies, any of the following”
- For previous I.B.5.i. removed “conventional therapy”
- For previous I.B.5.iv. removed “despite conventional therapy”
- Under new I.B.14. added “irreversible” and “not attributable to the underlying organ disease (i.e., cognitive impairment unrelated to hepatic encephalopathy)”
|
