Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Cranial Remolding Orthosis
(TX.CP.MP.523)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP
| Policy updates include:
- Section III updated to state “beyond the once-per-lifetime limitation” for device
- Section III. A.2 updated to include “Non-synostotic plagiocephaly, brachycephaly, asymmetric brachycephaly, or dolichocephaly” per new Texas Medicaid benefit
- Added to III.B. “and has not yet met the treatment goal”
- Added “Dolichocephaly” to definitions
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Custom Mobility Seating and Systems
(TX.CP.MP.599)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP
| Policy updates include:
- Combined Sections IX, X and XI under Section IX for ease of use
- Added language to Section IX to clarify “All modifications, adjustments, and repairs to a wheeled mobility system that occur within the first six months after delivery are considered part of the purchase price
- Added to Section IX Note: Rental of a wheeled mobility system during the time of repair should be offered at the time of equipment pickup if appropriate
- Added to Section IX Note: Members may use non-emergency medical transport to go to a wheelchair clinic
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Obstetrical Home Care Programs
(CP.MP.91)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- In I., updated page numbers in table of contents
- In I.E.1., revised to “one initial home or virtual visit, with additional phone or virtual follow-up as needed”
- In Table 1 in Background, added ondansetron and note regarding its use
- Updated Betamethasone therapy via intermittent injections section and added section regarding Makena injections in Background
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Orthognathic Surgery
(CP.MP.202)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Updated Criterion I.A.1.a. from an overjet of > 5 mm to ≥ 5 mm
- Updated Criterion I.A.1.b. from a maxillary/mandibular anteroposterior molar relationship discrepancy of > 4 mm to ≥ 4 mm
- Added Note at the end of Criteria I.A.1. stating that the values represent two or more standard deviations from published norms
- Added clarifying language in Criterion I.A.3.b. and Criterion I.B.5.a
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Pediatric Heart Transplant
(CP.MP.138)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Removed I.D.6. “Amyloid light-chain (AL) amyloidosis (exceptions may be made where curative therapy of amyloidosis has been performed or is planned, such as with stem cell transplantation in primary amyloidosis, or with liver transplantation in familial amyloidosis)
- Under I.D.16. added “irreversible” and “unrelated to the disease process of the organ requiring transplantation”
- Removed I.D.19. regarding adequate social system
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Private Duty Nursing
(TX.CP.MP.520)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS)
| Policy updates include:
- Moved Section II.E to Section I.D.1 as a note “ Note: PDN may be delivered in a member’s residence, school, or daycare facility, or nurse provider’s home
- Superior Healthplan will authorize medically necessary PDN for members at school”
- Moved Section III for SHARS to Background as program information
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Vagus Nerve Stimulation
(CP.MP.12)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter Health
| Policy updates include:
- Updated Criteria I. to specify “implantable” vagus nerve stimulation (VNS) for clarity
- Added language to include Lennox-Gastaut syndrome in Criterion I.A
- Removed one year requirement for adherent therapy of at least two anti-seizure drugs in Criterion I.B.1
- Added cluster headaches or migraines to Criterion II.B
- Removed Aspire SR Model 106 as not medically necessary for VNS in Criteria III
- Background updated to align with updated criteria regarding Aspire SR Model 106
- Added code C1827 to table of codes considered medically necessary
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