Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Applied Behavior Analysis
(CP.BH.104)
| Ambetter
| Policy updates include:
- Updated ASD dx information in I.A. to include identification of severity level, intellectual impairment, language impairment and known medical, genetic, or environmental factors
- Added clarifying timeframe components for treatment initiation to I.B.1.a
- Added “diagnostic interview/evaluation has been conducted within 12 months authorization request if the CDE was conducted more than three years ago and less than five years ago, meeting all the following..." to I.B.1.a. ii
- Reason member/enrollee is seeking services;
- Comprehensive mental status exam that supports the treatment;
- DSM diagnosis (current version), including recommendations for active treatment interventions;
- History & symptomology consistent with DSM (current version) criteria;
- Psychiatric treatment history;
- Assessment of current and past suicide/homicide danger;
- Level of familial support assessed and involved as indicated;
- Identified areas for improvement;
- Assessment of strengths, skills, abilities, motivation;
- Medical history;
- All current medications with dosages
- Added clarifying conditions to determine the need for a diagnostic reevaluation to I.B.1.b
- Added CDE documentation requirements to I.B.2
- Separated assessment tools (primary and parent caregiver) and clarified the need for two assessment tools including at least one primary clinician tool in I.B.2.c. vi
- Moved the ADOS2 to the list of clinician assessment tools in I.B.2.c.vi.a)v)
- Added physical health concerns to I.B.3
- Added specific provider recommendation information to I.C
- Added signature requirements to I.D
- Added clear verbiage regarding visual representation to I.E.2.b.vi
- Removed “FBA assessment” and replaced with distinctive “maladaptive and skills acquisition assessments.” to I.E.2.b.vi a) and b)
- Added a note to I.E.2.b.vi.b) vii) indicating the need for an additional direct skills assessment if Vineland is used
- Added clarifying details to the individualized treatment plan to I. E. 2.c. i-iii
- Added a dedicated crisis plan to I.E.2.c. iv
- Added detailed school-based criteria to I.E.2.c.v
- Added detailed criteria to justify treatment hours to I.E.2.c.vii. a)-c)
- Revised treatment hours from "focused aba (10-25) comprehensive aba (30-40)" to "does not exceed six hours per day up to 30 hours per week" to I.E.2.c.vii.d) i) 1)
- Added clinical justification for hours beyond 6 days, 30 hours per week to I.E.2.c.vii.d). i). 2)
- Added "treatment takes into consideration developmental level..." to I.E.2.c.vii.d). ii)
- Replaced “hours of supervision” with “Adaptive Behavior Treatment with Protocol Modification, for at least 2 hours per week or 10% of direct service” in I.E.2.c. ix
- Added coordination of care to I.E.2.c.x
- Added detailed parent/caregiver training to I.E.2.c. xi
- Added detailed transition planning to include discharge consideration to I.E.2.c.xii
- Added the need for an updated behavior assessment to I.E.3.c
- Added documentation of percentage of scheduled successful sessions with a note if attendance falls below 80% to I.E.3.d
- Added continuation of parent caregiver training to I.E.3.e
- Added coordination of care and communication to I.E.3.f
- Removed reference of “supervision hours, qualitative and quantitative data” from the updated treatment plan and replaced with clear guidance on “transition planning and titration plan” in I.E.3.g
- Added detailed criteria for progress/lack of progress with goals to I.E.3.i. and j
- Added clarifying information regarding lack of clinically significant progress to II.C
- Changed policy statement III. to reflect lack of medical necessity instead of lack of coverage
- Replaced "orientation and mobility" with "physical therapy" in III.B.7
|
Applied Behavior Analysis Documentation Requirements
(CP.BH.105)
| Ambetter
| New Policy:
- Description
- Policy and Criteria
- Background
- Coding Implications
|
Durable Medical Equipment and Medical Supplies
(TX.CP.MP.552)
| CHIP
| Policy updates include:
- Updated product “MMP” to D-SNP"
- Added Section I.A.3: “Date last seen by a physician or allowed practitioner must be within:
- Six months for the initial authorization of service, or
- Annually for the reauthorization of the same service
- Moved Section IV to Section I.A.4 for policy flow
|
Facility-based Sleep Studies for Obstructive Sleep Apnea
(CP.MP.248)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Description updated to include titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS)
- Added Criteria IV. to include titration PSG for HNS
- Added “non-Medicare” verbiage in Criteria V. for clarification
- Background updated to include information regarding titration PSG for HNS
|
Mechanical Stretching Devices for Joint Stiffness and Contracture
(CP.MP.144)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added “toe” to criteria under I
- Under I.A.1.a. added “therapist”
- Added CPT codes E1820, E1828, E1829, E1830, E1832
|
Skin and Soft Tissue Substitutes for Chronic Wounds
(CP.MP.185)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- In policy statement I., specified that criteria is applicable to “up to four initial applications…”
- Under criteria I.F. removed “FDA approved” and replaced with “labeled”
- Added criteria I.G.-I.I
- Created new policy statement II. and criteria for “beyond the initial four applications and up to a total of eight …”
- In III.A., added that non medically necessary indications include usage not listed in section II. of the policy
- Added the following to the table of HCPCS codes that do not support medical necessity:A2036, A2037, A2038, A2039, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397
- Removed Q4104 and Q4106 from list of codes not supported by medical necessity criteria, as they are on the preferred product list
|
Transplant Service Documentation Requirements (CP.MP.247)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added notes under Description regarding plan-approved criteria for medical necessity criteria for solid organ and stem cell transplant requests and criteria applicable to Medicare plans
- Added transplant consultation to Criteria I.
- Updated verbiage in Criteria I.A.2. for clarity
- Changed criteria I.A.2.a.-c. into a note
- Added additional note under Criteria I.A.2. regarding evaluation requests for sickle cell anemia and beta thalassemia
- Updated Criteria I.B. to specify initial and subsequent autologous stem cell transplants or initial and subsequent allogeneic stem cell or solid organ transplant listing requests
- Updated verbiage in Criteria I.B.4. for clarity
- Removed BMI from Criteria I.B.5.e. since BMI is addressed in Criteria I.B.3.c
- Updated Criteria I.B.5.g. to include lumbar puncture when clinically indicated
- Verbiage updated in Criteria I.B.6. for clarity
- Updated verbiage in Criteria I.B.7. to “breast cancer screening”, “cervical cancer screening,” and “colon cancer screening” and removed note that routine health screenings per standards of care are not required for autologous stem cell transplants
- Removed “including cardiology” from Criteria I.B.8
- Added Criteria I.B.9. regarding cardiology testing/clearance
- Removed verbiage specifying only solid organ or allogeneic stem cell transplants in Criteria I.B.11
- Updated verbiage in Criteria I.B.11., I.B.11.f., and I.B.11.h. for clarity
- Updated verbiage in Criteria I.D., I.D.2., and I.D.3. for clarity
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