Skin Substitutes for Chronic Wounds
(CP.MP.185)
| Ambetter
| Policy updates include:
- Changed policy title and statements in I. and II. to reflect the inclusion of soft tissue substitutes for chronic wounds
- Added note specifying that requests for skin and soft tissue substitutes other than for the indications noted in the policy is outside of the scope of the policy
- Updated policy statement I. to include full thickness skin-loss ulcers
- Revised criteria I.G. In I.H clarified that the request complies with FDA-approved indications and application limits
- Removed criteria II.A. Reworded extraneous language and background updated with no clinical significance. Removed deleted HCPCS code A2003
- Labeled HCPCS Table 1 to note support of medical necessity
- Added HCPCS Table 2 of codes that do not support medical necessity
- Moved the following codes from the previous code reference table to table 2, HCPCS codes that do not support medical necessity: A2002, A2005, A2006, A2007, A2009, A2010, Q4184, Q4199, Q4237, Q4238, Q4239, Q4262, Q4263, and Q4264 Added new codes Q4253, Q4262, Q4263 and Q4264 to HCPCS table 1
- Added additional codes to not medically necessary table, Table 2
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Therapeutic Utilization of Inhaled Nitric Oxide
(CP.MP.87)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Policy title updated from “Inhaled Nitric Oxide” to “Therapeutic Utilization of Inhaled Nitric Oxide”
- Minor rewording in Description, criteria I.B.1., I.B.1.a., I.B.1.b., and I.B.1.c
- Added recommended iNO dose in criteria I.B.1.e
- Minor rewording in criteria I.B.2.b
- Minor rewording in criteria II., II.B.1.a., II.B.1.c., and II.B.1.d
- Removed response requirement of “within two hours” in criteria II.B.1.e. and added recommended iNO dose in criteria II.B.1.e
- Minor rewording in criteria II.B.2.b. and in criteria III
- Added clarifying language to criteria III.A.1. and minor rewording to criteria III.A.2
- Updated notation in criteria III. from 48 hours to 72 hours
- Minor rewording in criteria IV. and in criteria Treatment Regimen section
- Removed ICD-10 codes
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Wheelchair Seating
(CP.MP.99)
| Ambetter
| Policy updates include:
- Added "dementia" and "hereditary motor and sensory neuropathy" to I.B.2
- Added "congenital absence of thigh and/or lower limb" to I.C.2
- Added ICD-10 codes F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, G31.83, G60.0, Q79.60, Q79.61, Q79.62, Q79.63, Q79.69, Q90.0, Q90.1, Q90.2, Q90.9, G71.031, G71.032, G71.033, G71.0340, G71.0341, G71.0342, G71.0349, G71.035, G71.038, and G71.039 to tables with the following HCPCS codes: E2603, E2604, E2622, and E2623; E0953, E0956, E0957, E0960, E2605, E2606, E2613, E2614, E2615, E2616, E2617, E2620, and E2621; E2607, E2608, E2624, and E2625; and E2609
- Added Q72.01, Q72.02, Q72.03, Q72.11, Q72.12, and Q72.13 to tables with the following HCPCS codes: E2607, E2608, E2624, and E2625; and E0953, E0956, E0957, E0960, E2605, E2606, E2613, E2614, E2615, E2616, E2617, E2620, and E2621; and E2609
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