POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
|
|---|
Applied Behavior Analysis
(CP.BH.104)
| Ambetter
| Policy updates include:
- Updated the description section to incorporate changes to the level of intensity hours for Comprehensive ABA from “25-40 hours” hour to “30-40 hours”
|
Durable Medical Equipment and Orthotics and Prosthetic Guidelines
(CP.MP.107)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Updated policy statement in I. and added general criteria I.A.1. and I.A.2
- Removed ambulatory assist products and updated I.B. policy table
- Retired gait trainers and standing frame criteria, defer to standard IQ criteria
- Updated pneumatic compression device criteria and added non-pneumatic compression device criteria
- Added "one month’s rental for a standard manual wheelchair is considered medically necessary if a member/enrollee owned wheelchair is being repaired" to wheelchair repair
- Added foot orthotics, custom criteria and codes
- Removed "male" from male vacuum erection device
- Added criteria section for walkers
|
Electric Tumor Treating Fields (Optune)
(CP.MP.145)
| Ambetter
| Policy updates include:
- Added Criteria I.A.3. and Criteria I.B.2. to include that the member/enrollee agrees to wear the device 18 hours per day, and for continuation of therapy, has also been compliant with the wearing the device in the prior authorization period
- Removed ICD-10 codes
|
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
(CP.MP.180)
| Ambetter
| Policy updates include:
- I.C. Changed BMI to 35 kg/m2
- I.E. Adjusted AHI to ≥15 to ≤ 65 events per hour
- I.F.1. Adjusted 20 to 15.
- Added criteria I.I.5. and I.I.8. through 14
- Added CPT codes 64582, 64583, and 64584
- Removed CPT codes 0466T, 0467T, 0468T, 61886, 61888, 64568, 64569, 64570, and 64585
- Removed ICD-10 diagnosis table
|
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression
(CP.BH.200)
| Ambetter
| Policy updates include:
- Deleted criteria point I.D as the information was redundant to I.B
- In criteria subsection I.I. (5), clarified that three months or less of remission constitutes a contraindication
- Added the statement “requests for 6 tapered final sessions of TMS (over a 3-week period)” to the revised criteria point II
- Added criteria point II.A to indicate that “all initial criteria must be met prior to request for additional sessions”
- Deleted what was criteria III as the information was redundant to criteria II
- In criteria section III, replaced “maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it” with “It is the policy of health plans affiliated with Centene Corporation that maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it”
- Added criteria point IV.A to indicate that “criteria for initial TMS treatment guidelines continues to be met”
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