Policy
| Applicable Products
| Policy Revisions or Criteria
|
|---|
Applied Behavioral Analysis
CP.BH.104
| Ambetter
| Policy updates include:
- Policy number changed from CP.MP.104 to CP.BH.104
- Replaced “Applied Behavioral Analysis” with “Applied Behavior Analysis”
- Replaced “Lovaas therapy” with “Early Intensive Behavior Intervention (EIBI)”
- Updated Section I.A. to include “ABA recommended by a qualified licensed professional” and added definition of “qualified licensed professional”
- Removed DSM-5 Criteria from Section I.B, as this was duplicative
- Replaced “plan of care” with “treatment plan” in Section I.D.
- Added “the number of service hours necessary to effectively address the skill deficits and behavioral excesses is listed in the treatment plan and considers the member’s age, school attendance requirements, and other daily activities when determining the number of hours of medically necessary direct service, group and supervision hours” to Section I.E
- Replaced “challenging behaviors” with “skill deficits and behavioral excesses” in Section II.E
- Added “and align with the identified areas of need in the assessments” to Sections I. I. and II.C
- Added “Assessments, evaluations, treatment plans, and documentation is expected to be current within each profession, licensure, and state standards.” to Section II.J
|
Cell-free Fetal DNA Testing
CP.MP.84
| Ambetter
| Policy updates include:
- Replaced I.B. “A cell-free fetal DNA test has not been performed in this pregnancy” with “No documentation that a chromosomal abnormality screening test has been performed in this pregnancy,” with examples noted
- In section I added requirement C. of no documentation of a prior abnormal nuchal translucency screening in this pregnancy
- Removed restriction that fetus is < 23 weeks gestation at the time of the blood draw
- Removed requirement and criteria for high risk for aneuploidy
- In section I.D. added twin gestation as an option in addition to singleton
- Removed section on Authorization Protocols
- Added CPT: 0168U as medically necessary
- Replaced all instances of “members” with “members/enrollees”
|
Cosmetic and Reconstructive Procedures
CP.MP.31
| Ambetter
| Policy updates include:
- Clarified in section II.N. that hair transplant is not medically necessary, when not performed to correct permanent hair loss caused by disease or injury
- Added the following applicable CPT codes: 15220, 15221, 15775, 15776
|
Enteral Nutrition
TX.CP.MP.550
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP
| Policy updates include:
- In Section IV created A and B to clarify Medicaid and CHIP non-covered services.
|
Genetic Testing
TX.CP.MP.531
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and CHIP Perinate
| Policy updates include:
- Added criteria to Section V. regarding Cell-Free Fetal DNA testing or noninvasive prenatal testing that members current pregnancy is a singleton or twin gestation; and at least 10 weeks gestation at the time the blood was drawn
- For clarification added whole exome sequencing CPT codes 81415, 81416, 81417 to Section VI. Non-Covered Benefits A
- Added criterion B. Mitochondrial genome sequencing (CPT 81440, 81460, 81465) to Section VI
|
Home Births
CP.MP.136
| Ambetter
| Policy updates include:
· Added to I.A.1.a., “and practicing within an integrated and regulated health system”
- Added to I.E that singleton pregnancy “is estimated to be appropriate for gestational age”
- Added criteria in I.B. that 2 caregivers are planned to attend the birth, and that the one responsible for providing care to the infant is trained in NRP
- Revised criteria in I.H: Changed “Spontaneous labor in a pregnancy that has lasted at least 38 weeks” to specify 37 0/7 weeks clarified that no more than 41 weeks is no more than 41 6/7 weeks. Added separate criteria for home birth in a pregnancy induced as an outpatient
- Updated background section, American Academy of Pediatrics (AAP), with most current recommendations
- Replaced “members” with “members/enrollees” in all instances
|
Magnetoencephalography
TX.CP.MP.570
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP | Policy retired:
- Medicaid: Superior HealthPlan will begin utilizing criteria set forth in the Texas Medicaid Provider Procedures Manual for processing requests related to Magnetoencephalography.
- CHIP: Superior HealthPlan will begin utilizing Change Healthcare’s InterQual criteria for processing requests related to Magnetoencephalography.
|
Neonatal Abstinence Syndrome Guidelines
CP.MP.86
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Ambetter
| Policy updates include:
- In section I.A. asymptomatic infants, specified that transitional care or newborn level 1 is appropriate if being assessed with modified Finnegan’s scoring; added an alternative option for Level 2 nursery if being assessed and treated using Eat, Sleep, Console
- Replaced “members” with “members/enrollees” in all instances
|
Oxygen Use and Concentrators
CP.MP.190
| Ambetter and CHIP
| New Policy Description:
“Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxemia.”
CPT Codes included in policy:
- E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0440, E0441, E0442, E0443, E0444, E0445, E1390, E1391, E1392, E1405, E1406, K0738, S8120, S8121
|
Transcranial Magnetic Stimulation
CP.BH.200
| Ambetter
| Policy updates include:
- Policy/Criteria section updated to clarify that Section I. refers to initial approval of TMS sessions
- Updated Section I.B. to reflect “Oversight of treatment is provided by a licensed psychiatrist”
- Updated Section I.C. to include “Other standardized scale indicating moderately severe to severe depression”
- Added Section I.I., “The initial request can be reviewed for up to 20 TMS sessions”
- Added Section II. to include criteria for authorization of additional TMS sessions
|
