Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Durable Medical Equipment and Orthotics and Prosthetics Guidelines
(CP.MP.107)
| CHIP and Ambetter
| - Policy updates include:
- Minor update to "Considered not medically necessary" statements throughout policy for clarity
- Under burn garments:
- Removed criteria C. Garment is requested by the PCP and/or the treating specialist
- Added wearable cardioverter defibrillator criteria along with HCPCS code K0606
- Updated blood glucose monitor criteria from < 20/200 to 20/200 or worse in both eyes"
- Removed limit and cost criteria from breast pump section
- Updated criteria in A. under cervical traction equipment to “Musculoskeletal or neurologic impairment requiring traction equipment”
- Added HCPCS codes L0720 and L1006 to spinal orthotics section
- Removed HCPCS code L2006 and Microprocessor controlled KAFO criteria
- Added AFO section with HCPCS codes L1933 and L1952
- Under custom foot orthotics:
- Removed previous criteria A.1 Diplegic cerebral palsy
- Updated criteria in A.4 from three months to one month
- Removed "physical therapy intervention and stretching of calf muscles and plantar surface have failed to improve symptoms" and replace with “stretching of calf muscles and plantar surface have failed to improve symptoms”
- Removed HCPCS codes L3230 and custom orthopedic footwear criteria
- Added HCPCS codes L6028, L6029, L6031, L6032, L6033, L6037, L6700, and L7406 to upper extremity and myoelectric prosthetics and additions
- Added HCPCS code L5827 to lower extremity prosthetics and additions
- Updated previous "MyoPro Orthosis" section to "Myoelectric Rehabilitation Systems" removed HCPCS codes L8701 and L8702 and added E0738 and E0739 with updated "Not medically necessary" statement
- Added "Facial Prosthetics" section and included HCPCS codes L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, and L8499 previously included in "Other surgical supplies section"
- Removed HCPCS codes E0455 and oxygen tent criteria
- Removed HCPCS codes L8600, L8609, L8610, L8612, L8615, L8631, and L8659 and "Other surgical supplies" section
- Removed HCPCS codes E1310 and "Whirlpool tub" section
- Added criteria I.A.1. “Equipment is necessary and reasonable for the treatment of an illness or injury or to improve the functioning of a physical deficit” along with corresponding note
- Added codes E0680 and E0681 to non-pneumatic compression devices
|
Orthognathic Surgery
(CP.MP.202)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Updated I.A.2.c. to "with impingement of palatal soft tissue"
- Updated I.B.5.a. to Intolerant to or failed a trial of PAP and I.B.5.b to "Has failed or is not a candidate for less invasive surgical procedures”
|
Pediatric Heart Transplant
(CP.MP.138)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Updated verbiage in I.D.10. regarding liver disease and removed I.D.18. "BMI ≥ 35 or BMI ≥ 120% of the 95th percentile (varies by sex and age), whichever is
- lower.; see https://www.cdc.gov/growthcharts/clinical_charts.htm for BMI percentile by age, and refer to Appendix A for 120% of the 95th percentile values)”
- Edit made to I.D.21. removing the sentence "Serial blood and urine testing may be used to verify abstinence from substances that are of concern”
- Removed Appendix A regarding BMI charts
|
Sacroiliac Joint Interventions for Pain Management
(CP.MP.166)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added note regarding criteria applicable to Medicare plans
- Updated I. to specify that imaging guidance must be fluoroscopic or computed tomography
- Added “posterior pelvic pain provocation test” to I.A.1.c. for clarity
|
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections
(CP.MP.165)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added note in Description regarding policy for caudal or interlaminar epidural steroid injections
- Removed anticoagulation therapy requirement in Criteria and added anticoagulation therapy as a note in Criteria
- Updated Criteria II.D.3. from two months to three months regarding relief and functional improvement
- Removed Criteria II.D.4. regarding length of time since last transforaminal epidural steroid injection (TFESI)
|
Skilled Nursing Visits
(TX.CP.MP.538)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Updated references. Section IV Discharge Planning added in it’s entirety to policy
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