Bariatric Surgery
CP.MP.37
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) CHIP | Policy revisions include:
- Section I:
- Added BMI criteria for Asian ethnicity to IA.1.a, I.A.1.b and I.A.1.c
- Added high risk of T2D to list of severe obesity related complications
- Added “inadequate glycemic control…” to I.A.1.c.i
- Section II:
- Removed criteria for ECG during cardiac clearance except for high risk
- In II.B, added note about medical director review if A1C ≥8
- Removed requirement of chest x-ray and specific criteria for PSG, noting that PSG is warranted if OSA screening is positive in II.C
- Pulmonary Evaluation
- added examples of nutritional tests to be conducted, and that malabsorptive procedures may require further testing to section II.D
- removed requirement of 1 year abstinence of drug & alcohol use and urine drug screen if history of abuse in II.F
- added “current drug and alcohol abuse” to list of contraindications
- added clinically significant GI symptoms should be evaluated & treated prior to surgery in II.I
- In III.A.2.e, removed option for non-compliance with post-operative regimen if completing a multidisciplinary bariatric program
- In III.A.2.f., removed option for non-compliance
- Reworded V
- replacing “investigational” with “current medical literature is inadequate to determine the safety, efficacy and long-term outcomes”
- added to the list
- one-anastomosis gastric bypass
- endoscopic sleeve gastroplasty
- transoral endoscopic surgery
- vagus nerve blocking (e.g., Maestro)
- gastric balloon (e.g., ReShape Duo Orbera intagastic balloonObalon Balloon)
Added the following CPT codes as not supporting medical necessity: 43648, 43882, 64595, 0312T, 0313T, 0314T, 0315T, 0316T and 0317T
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NICU Discharge Guidelines
CP.MP.81
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) CHIP and Ambetter
| Policy revisions include:
- Added I.A.3 regarding weight lost in preterm infants less than a week old
- Added a note regarding gastrostomy tube placement recovery/education to I.B.2.d.ii
- Updated II.A with temperature range and in note changed 1600 grams to1800 grams
- Added “Chronic Lung Disease/” to “Bronchopulmonary dysplasia” for condition in III.B.3.a
- Added note under III.B.3.b.i explaining stability on home ventilator in hospital prior to discharge
- Removed V.A and B, updating the “free of infection” criteria statement Added new section VI regarding caregiver competency
- In section VII
- clarified in A “should be approved for any of….”
- added A.5 regarding caffeine for apnea
- added B regarding parent/caregiver refusal to sign
- added C.1 and 2 regarding nondenial of care
- updated the note under describing rooming-in
- In Discharge Recommended Practices
- added “immunoglobulin” to C.2
- updated C.3 with influenza injection
- added “hospital developed education program” under D
- added E.1-4 regarding car seats
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Sacroiliac Joint Interventions for Pain Management
CP.MP.166
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) CHIP and Ambetter
| Policy revisions include:
- Updated I.A. to specify that the criteria applies to therapeutic injections as well as diagnostic
- Updated I.B. to state “A second diagnostic or confirmatory sacroiliac joint injection when pain was improved by at least 75% after the first diagnostic SIJ injection”, rather than that pain did not improve
- I.C. was updated to specify “therapeutic” SIJ injection
- II was changed from 50% to 75%
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