Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.

All policies found in the Coordinated Care Clinical Policy Manual apply to Coordinated Care members. Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a “Centene” heading. Coordinated Care utilizes InterQual^® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Coordinated Care clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual^® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Coordinated Care. In addition, Coordinated Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual^®criteria is payable by Coordinated Care.

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Ambetter Clinical Policies Listing

For Ambetter information, please visit our Ambetter from Coordinated Care website.

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Coordinated Care Payment Policy Manual apply with respect to Coordinated Care members. Policies in the Coordinated Care Payment Policy Manual may have either a Coordinated Care or a “Centene” heading. In addition, Coordinated Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Coordinated Care.

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Ambetter Payment Policies

For Ambetter information, please visit our Ambetter website.

Medicaid Payment Policies

1-Day Payment Window (PDF) (WA.PP.500)
Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
Assistant Surgeon (PDF) (CC.PP.029)
Bilateral Procedures (PDF) (CC.PP.037)
Cerumen Removal (PDF) (CC.PP.008)
Clean Claims (PDF) (CC.PP.021)
Coding Overview (PDF) (CC.PP.011)
Concert Laboratory Payment Policy (PDF) (CG.CC.PP.01) - effective 10/1/2024
Cosmetic Procedures (PDF) (CC.PP.024)
Distinct Procedural Modifiers (PDF) (CC.PP.020)
Duplicate Primary Code Billing (PDF) (CC.PP.044)
E&M Medical Decision-Making (PDF) (CC.PP.051)
EM Bundling Edits (PDF) (CC.PP.010)
Genetic and Molecular Testing Services (Version A) (PDF) (CG.PP.551) - effective 10/1/2024
Global Maternity Billing (PDF) (CC.PP.016)
Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)

Infectious Disease: Dermatologic Lab Testing (PDF) (CG.CP.MP.03) - effective 10/1/2024
Infectious Disease: Gastroenterologic Lab Testing (PDF) (CG.CP.MP.04) - effective 10/1/2024
Infectious Disease: Genitourinary Lab Testing (PDF) (CG.CP.MP.07) - effective 10/1/2024
Infectious Disease: Multisystem Lab Testing (PDF) (CG.CP.MP.02) - effective 10/1/2024
Infectious Disease: Primary Care & Preventive Lab Screening (PDF) (CG.CP.MP.05) - effective 10/1/2024
Infectious Disease: Respiratory Lab Testing (PDF) (CG.CP.MP.01) - effective 10/1/2024
Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (PDF) (CG.CP.MP.06) - effective 10/1/2024
Inpatient Consultation (PDF) (CC.PP.038)
Inpatient Only Procedures (PDF) (CC.PP.018)
IV Hydration (PDF) (CC.PP.012)
Leveling of Emergency Room Services (PDF) (CC.PP.053)
Maximum Units (PDF) (CC.PP.007)
Moderate Conscious Sedation (PDF) (CC.PP.015)
Modifier -25 clinical validation (PDF) (CC.PP.013)
Modifier -59 clinical validation (PDF) (CC.PP.014)
Modifier DOS Validation (PDF) (CC.PP.034)
Modifier to Procedure Code Validation (PDF) (CC.PP.028)
Multiple CPT Code Replacement (PDF) (CC.PP.033)
Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
NCCI Unbundling (PDF) (CC.PP.031)
Never Paid Events (PDF) (CC.PP.017)
New Patient (PDF) (CC.PP.036)
Outpatient Consultation (PDF) (CC.PP.039)
Pelvic and Transabdominal US (PDF) (CC.PP.061)
Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
Place of Service Mismatch (PDF) (CC.PP.063)
Post-Operative Visits (PDF) (CC.PP.042)
Pre-Operative Visits (PDF) (CC.PP.041)
Professional Component (PDF) (CC.PP.027)
Provider Preventable Readmissions (PDF) (WA.PP.501)
Pulse Oximetry (PDF) (CC.PP.025)

Renal Hemodialysis (PDF) (CC.PP.067)
Same Day Visits (PDF) (CC.PP.040)
Sepsis Diagnosis (PDF) (CC.PP.073)
Severe Malnutrition (PDF) (CC.PP.145)
Skilled Nursing Facility Leveling (PDF) (CC.PP.206)
Sleep Studies Place of Services (PDF) (CC.PP.035)
Status "B" Bundled Services (PDF) (CC.PP.046)
Status P Bundled Services (PDF) (CC.PP.049)
Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
Transgender Related Services (PDF) (CC.PP.047)
Unbundled Surgical Procedures (PDF) (CC.PP.045)
Unbundled Professional Services (PDF) (CC.PP.043)
Unlisted Procedure Codes (PDF) (CC.PP.009)
Wheelchair Accessories (PDF) (CC.PP.502)

Policy Revision Summary (Clinical)

Policy Number	Policy Title	Revision Notes
CP.MP.93	Bone-anchored Hearing Aid	Annual review. Updated criteria in I.C. to specify “is consistent with the FDA indications for the requested device”. Added “(provided that the nerve is functional)” to I.F.1. Minor updates made to I.F4. and the policy statements in II. and III. Reference reviewed and updated.
CP.MP.129	Fetal Surgery in Utero for Prenatally Diagnosed Malformations	Annual review. Description updated with no impact to criteria. Under I.A. added “with treatment including”. Added criteria to I.A.1.-I.A.2. to include: Correction via a minimally invasive approach; SCT resection when meeting all of the following: Fetuses with high-risk SCT and hydrops developing at a gestational age earlier than appropriate for delivery and neonatal care (eg. 28-32 weeks gestation); Does not have the following contraindications: Type III or IV Altman-type tumors; Severe placentomegaly; Maternal cervical shortening. Removed indication I.F.5. Normal fetal karyotype. Quantified criteria I.F.5.c. to include (≥30 degrees). Added criteria I.G. Fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) when all of the following criteria are met: Severe left-sided CDH; Severe pulmonary hypoplasia defined as a quotient of the observed-to-expected lung-to-head ratios of less than 25%; Gestational age ≤ 30 weeks. Removed III.A. Open or endoscopic fetal surgery for congenital diaphragmatic hernia (CDH), including temporary tracheal occlusion. References reviewed and updated. Reviewed by external specialist.

Policy Number	Policy Title	Revision Notes
CP.MP.107	Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines	Updated verbiage in Newborn Care Equipment, Breast Pumps for inclusivity. Added new criteria section titled Lumbar-Sacral Orthotics (LSO) and included codes L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0643, L0648, L0649, L0650, L0651, L0700, L0710, L0999, L1000, L1001, L1005. Renamed original “Spinal Orthotics” criteria “Other Spinal Orthotics”. Updated manual wheelchair initial request criteria A., A.2. and 4., B.1. and 2., and removed C. Reformatted and updated manual wheelchair replacement request criteria. Deleted codes E1091 and K0009. Reviewed by internal specialist.
CP.MP.184	Home Ventilators	Annual review. Added note for corresponding Medicare policy. Updated all policy statements to indicate "non-Medicare" health plans. In I.A.1 changed "both" to "one" of the following and added "taken while member/enrollee was stable (not in acute respiratory failure)". Removed criteria for BiPAP failure and contraindications in sections I and II, and replaced with criteria requiring documentation that "member/enrollee could not be appropriately treated with a RAD" and "non-invasive home ventilator will not be used to provide RAD or CPAP therapy...". Removed criteria in I.A.1.a. and b. for members/enrollees < 18 years. In 1.A.1a. updated PaCO2 > to greater than or equal to. In I.C.1 updated BMI > than 30 to greater than or equal to 30. In 1.C.2 added "at baseline". Added criteria I.C.3. "Hypoventilation has been documented by polysomnography and other conditions are not considered the primary cause of hypoventilation..." Removed medical necessity criteria I.D. for home ventilators for treatment failure of BiPAP. In II.B. replaced "medical records document improvement..." with II.B.1. and 2. "Documentation supports: Ongoing benefits... and "non-invasive home ventilator will not be used to provide RAD or CPAP therapy...". Minor rewording throughout policy with no clinical significance. References reviewed and updated. External specialist review.
CG.CP.MP.01	ID Respiratory Lab Testing	New policy
CG.CP.MP.02	ID Multisystem Lab Testing	New policy
CG.CP.MP.03	ID Dermatologic Lab Testing	New policy
CG.CP.MP.04	ID Gastroenterologic Lab Testing	New policy
CG.CP.MP.05	ID Primary Care Preventive Lab Testing	New policy
CG.CP.MP.06	ID Vector-Borne and Tropical Diseases Lab Testing	New policy
CG.CP.MP.07	ID Genitourinary Lab Testing	New policy
WA.CP.MP.69	Intensity-Modulated Radiotherapy	Removed section I. A. (Age <= 18 years) and section I. C. Added section I. B. documentation of critical structure and re-worded section I. A. to align with HCA Billing Guidelines. References reviewed and updated.
WA.CP.MP.522	Varicose Vein Treatment	Annual review. References reviewed and updated. Background updated with no impact on criteria. Section I. A. a. reflux measurement removed to align with billing guidelines. Section I. C. removed criteria and added note for reviewer to utilize CP.MP.146 for procedures 36482, 36483. Section II. removed. Codes 36482, 36483 and 0524T removed from coding table. Code 37799 removed from note regarding ligation/stripping procedures.

Policy Number	Policy Title	Revision Notes
CP.BH.500	Behavioral Health Treatment Documentation Requirements	Annual Review. No changes to criteria. Background updated. References reviewed and updated
CP.MP.14	Cochlear Implant Replacements	Annual review. Updated description and background with no clinical significance. Coding reviewed, updated description for L8623. References reviewed and updated.
CP.MP.94	Clinical Trials	Annual review. Updated policy statement in I. to include “Centene Advanced Behavioral Health”. References reviewed and updated.
WA.CP.MP.514	Extracorporeal Membrane Oxygenation Therapy	Annual review. References updated.
CP.MP.137	Fecal Incontinence Treatments	Annual review. Minor rewording in Description and in Background with no impact on criteria. References reviewed and updated.
CP.MP.40	Gastric Electrical Stimulation	Annual review. Updated description and background with no clinical significance. Added I.A. "Member/enrollee is ≥ 18 years of age". Updated I.B. to include "diabetic or" in describing type of gastroparesis. Updates made to CPT code descriptions. References reviewed and updated.
CP.MP.132	Heart-Lung Transplant	Annual review. Added indication to criteria I.A.1.j. Expanded criteria I.C.1. to I.C.1.a. through c. Removed contraindication I.C.17., active peptic ulcer disease. References reviewed and updated.
CP.MP.141	Non-Myeloablative Allogenic Stem Cell Transplants	Annual review. Removed Hodgkin’s lymphoma from Criteria I.A.9. per updated National Comprehensive Cancer Network (NCCN) recommendations. Added Criteria I.A.13.e. to include polycythemia vera. Updated Criteria I.B.4.b. from diffusing capacity of the lung for carbon monoxide (DLCO) ≤ 50% of predicted value to DLCO ≤ 60% of predicted value. Removed absolute contraindications in Criteria I.C. References reviewed and updated. Reviewed by internal specialist and reviewed by external specialist.
CP.MP.249	Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy	Annual review. Added note to policy to refer to MC.CP.MP.249 for Medicare criteria. Added “non-Medicare” to health plans in Policy/Criteria I. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.
CP.MP.49	Physical, Occupational and Speech Therapy Services	Annual review. Minor rewording in Criteria I.G.1., Criteria I.G.2., Criteria II.A., and Criteria II.A.10. Updated formatting in Criteria III.A.2. with no impact on criteria. Minor rewording in Background with no impact on criteria. Reviewed by external specialist.
WA.CP.MP.185	Skin and Soft Tissue Substitutes for Chronic Wounds	Annual review. References reviewed and updated. Reviewed by external specialist. Policy description updated with no impact on criteria. Section V corrected to reflect “all indications in section I-III.” HCPCS covered and non-covered coding tables removed and added note for providers to contact Coordinated Care for current coding implications and coverage determinations.
CP.MP.127	Total Artificial Heart	Annual review. References reviewed and updated. Reviewed by external specialist.

Policy Number	Policy Title	Revision Notes
CP.MP.114	Disc Decompression Procedures	Annual review. Removed “unilateral” for radiculopathy in Criteria I.C.1. Updated muscle strength score in Criteria I.C.1.a. from < 3 to ≤ 3. Updated muscle strength score in Criteria I.C.1.b. from 3 or 4 to 4. Added “within the last year” for conservative therapy in Criteria I.C.1.b.ii. Updated physical therapy from ≥ six weeks to ≥ four weeks in Criteria I.C.1.b.ii.a). Updated activity modification from ≥ six weeks to ≥ four weeks in Criteria I.C.1.b.ii.b). Updated Criteria I.C.1.b.ii.c) to specify one of the following: 1) NSAID or acetaminophen ≥ 3 weeks unless contraindicated or not tolerated 2) Epidural steroid injection. Removed “unilateral” for radiculopathy in Criteria I.C.2. Updated physical therapy from ≥ six weeks to ≥ four weeks in Criteria I.C.2.a. Updated activity modification from ≥ six weeks to ≥ four weeks in Criteria I.C.2.b. Updated Criteria I.C.2.c. to specify one of the following: i. NSAID or acetaminophen ≥ 3 weeks unless contraindicated or not tolerated ii. Epidural steroid injection. References reviewed and updated. Reviewed by external specialist.
CP.MP.115	Discography	Annual review. Background updated with no impact on criteria. References reviewed and updated.
CP.MP.58	Intestinal and Multivisceral Transplant	Annual review. Expanded criteria under II.A.4. to include (e.g. opioid dependency, or pseudo-obstruction). Updated contraindication under II.B.3. Glomerular filtration rate < 40 mL/min/1.73m2 to <30mL/min/1.73m2. Expanded contraindication under II.B.4.a-II.B.4.c. to include CD4 cell count >200 cells/mm3; Absence of active AIDS-defining opportunistic infection (unless treated efficaciously or prevented, can be included on the heart transplant waiting list) or malignancy; Member/enrollee is currently on effective ART (antiretroviral therapy). References reviewed and updated. Reviewed by external specialist.
CP.MP.244	Liposuction of Lipedema	Annual review. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.
CP.MP.116	Lysis of Epidural Lesions	Annual review. Updated description and background with no clinical significance. References reviewed and updated. Reviewed by external specialist.
CP.MP.24	Multiple Sleep Latency Testing	Annual review. References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.518	Negative Pressure Wound Therapy for Home Use	Annual review. References reviewed and updated. Section I. A. i. and ii. diagnoses of seroma and wound dehiscence removed.
CP.MP.120	Pediatric Liver Transplant	Annual review. Added HIV points a. - c., under I.C.2. Minor edits to Background with no effect on criteria. References reviewed and updated.
CP.MP.188	Pediatric Oral Function Therapy	Annual review. References reviewed and updated. Reviewed by external specialist.
CP.MP.210	Repair of Nasal Valve Compromise	Annual review. Background updated with no impact to criteria. References reviewed and updated.
CP.MP.87	Therapeutic Utilization of Inhaled Nitric Oxide	Annual review. Condensed criteria statement II. to, "while the medical literature predominantly does not support the use of inhaled nitric oxide (iNO) in premature infants < 34 weeks gestational age at birth, requests for initiation of iNO therapy in these infants may be reviewed on a case-by-case basis with consideration of the criteria for premature newborns ≥ 34 weeks gestational age at birth in section I.” References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.509	Upper GI Endoscopy for GERD	Annual review. References reviewed and updated. CPT codes 43237, 43238 and 43242 added per billing guidelines. Description and section I. updated to reflect diagnostic endoscopy per billing guidelines. Removed section II. header and use of InterQual guidelines; converted policy to billing guidelines/HTA only.

August 2024 – Genetic Testing
Policy Number	Policy Title	Revision Notes
V2.2024	CG Aortopathies and Connective Tissue Disorders	See policy posted on Website
V2.2024	CG Cardiac Disorders	See policy posted on Website
V2.2024	CG Dermatologic Conditions	See policy posted on Website
V2.2024	CG Epilepsy Neurodegenerative and Neuromuscular Conditions	See policy posted on Website
V2.2024	CG Exome and Genome Sequencing for DX of Genetic Disorders	See policy posted on Website
V2.2024	CG Eye Disorders	See policy posted on Website
V2.2024	CG Gastroenterologic Disorders Non-cancerous	See policy posted on Website
V2.2024	CG General Approach to Genetic Testing	See policy posted on Website
V2.2024	CG Hearing Loss	See policy posted on Website
V2.2024	CG Hematologic Conditions Non-cancerous	See policy posted on Website
V2.2024	CG Hereditary Cancer Susceptibility	See policy posted on Website
V2.2024	CG Immune Autoimmune and Rheumatoid Disorders	See policy posted on Website
V2.2024	CG Kidney Disorders	See policy posted on Website
V2.2024	CG Lung Disorders	See policy posted on Website
V2.2024	CG Metabolic Endocrine Mitochondrial Disorders	See policy posted on Website
V2.2024	CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay	See policy posted on Website
WA.CP.MP.230	Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay	See policy posted on Website
V2.2024	CG Non-Invasive Prenatal Screening	See policy posted on Website
WA.CP.MP.231	Genetic Testing Non-Invasive Prenatal Screening (NIPS)	See policy posted on Website
V2.2024	CG Oncology Algorithmic Testing	See policy posted on Website
V2.2024	CG Oncology Cancer Screening	See policy posted on Website
V2.2024	CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy	See policy posted on Website
V2.2024	CG Oncology Cytogenetic Testing	See policy posted on Website
V2.2024	CG Oncology Molecular Analysis Solid Tumors & Hematologic Malignancies	See policy posted on Website
V2.2024	CG Pharmacogenetics	See policy posted on Website
WA.CP.MP.232	Genetic Testing Pharmacogenetics	New policy
V2.2024	CG Preimplantation Genetic Testing	See policy posted on Website
V2.2024	CG Prenatal and Preconception Carrier Screening	See policy posted on Website
V2.2024	CG Prenatal Diagnosis Pregnancy Loss	See policy posted on Website
V2.2024	CG Skeletal Dysplasia Rare Bone Disorders	See policy posted on Website

Policy Number	Policy Title	Revision Notes
WA.CP.MP.519	Administrative Days	References reviewed and updated. Removed note requiring providers to request administrative days. Section I. subsections D. and E. and section IV. subsections E. and F. facility requirements for discharge planning removed to align with WAC. Billing section updated to include other service categories that may be billed per revenue codes in the billing guidelines. Section II. E. added to reflect additional newborn administrative day services per the billing guidelines. Added references for acute PM&R. Description updated to clarify the process for social admissions per WAC 182-550-4550. WAC reference removed from description and replaced with Washington State Health Care Authority. Section I. approval requirements changed from “all” to “A. and B. or C.” per the HCA billing guidelines. Section IV. D. removed.
WA.CP.BH.521	Behavioral Health Wraparound Support (BHWS)	Annual review. Renamed policy from “Behavioral Health Personal Care Services” in preparation for July contract change. Updated Description. Policy criteria rewritten to match new contract language. Reference updated. Changed policy number to WA.CP.BH.521 from WA.CP.MP.521 to reflect behavioral health nature of the policy.
WA.CP.MP.513	Cardiac Stents	Annual review. References reviewed and updated. CPT codes added per HCA Billing Guidelines: 92933, 92934, 92937, 92938, 92941, 92943 and 92944.
WA.CP.BH.529	Community Behavioral Health Support - Supportive Supervision (CBHS)	New policy.
CP.MP.101	Donor lymphocyte infusion	Annual review. Minor rewording in Description with no impact on Criteria. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.504	Elective Deliveries Before 39 Weeks	Annual review. References updated. Added reference for WAC 182-500-0030. Removed all ICD-10 diagnosis codes with instruction to reference the current Joint Commission document for a complete list of diagnosis codes for Conditions Possibly Justifying Elective Delivery.
CP.MP.248	Facility Based Sleep Studies for Obstructive Sleep Apnea	Annual review. Updated description and included “Notes”. Added non-Medicare to all policy statements. Added superscript citations throughout policy. In I.B.8.a. added "documentation". Updated I.B.8.a.i. to "Moderate to severe, chronic pulmonary disease". Removed criteria I.B.8.a.i.a) and b). Updated I.B.8.a.ii. to "Congestive heart failure...". Updated I.B.8.a.v. to "Concern for significant non-respiratory sleep disorder(s)...". Added I.B.8.a.vi "Hypoventilation syndrome". Updated I.B.8.b.ii to "Daytime sleepiness...". Added I.B.8.b.ii.a "Habitual loud snoring". Removed I.B.8.b.iv. "Significant oxygen desaturation...". Updated III.A. to "Meets criteria in section I...". Removed III.C and D. for central sleep apnea. References reviewed and updated. Internal and external specialist reviewed.
CP.MP.62	Hyperhidrosis treatments	Annual review. Minor rewording of pharmacy policy title (in description). Changed order of criteria. Added criteria point III.I. regarding counseling on risks. Background updated with no clinical significance. Removed CPT codes 64802 through 64823. References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.27	Hyperbaric Oxygen Therapy	Annual review. References reviewed and updated. Section II. G. wording updated to align with billing guidelines. Section I. multiple punctuation corrections, no impact on criteria.
CP.MP.173	Implantable Intrathecal or Epidural Pain Pump	Annual review. Restructured and reformatted criteria section. In I.B. and II.B. added contraindications to include known allergies to materials in the implant; active alcohol or drug abuse, including but not limited to opioid addiction and intravenous drug abuse, diagnosis of dementia or psychosis; active systemic infection, active infection at the site of implantation. Background updated with no impact to criteria. References reviewed and updated.
CP.MP.243	Implantable Loop Recorder (Implantable Cardiac Monitor)	Annual review. Added criteria III. to include requests for replacement implantable loop recorders. Background updated with no impact to criteria. References reviewed and updated. Reviewed by external specialist.
WA.CP.BH.528	Intensive Behavioral Supportive Supervision (IBSS)	Added Tiering Guidelines. Changed “IBSS Modifier” to “ILOS Modifier”
CP.MP.57	Lung Transplantation	Annual review. Updated I.C.2. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2. Expanded I.C.9. with qualifying criteria for members who are HIV positive. Updated I.D.2.a.1. from FEV1<25% to FEV1<30%. Background updated with no impact to criteria. References reviewed and updated.
CP.MP.170	Nerve Blocks and Neurolysis for Pain Management	Annual review completed. Minor rewording with no clinical significance. References reviewed and updated.
CP.MP.82	NICU Apnea Bradycardia Guidelines	Annual review. Minor rewording throughout criteria with no impact on criteria. Added clarifying language to Criteria I.A.1.c. and updated oxygen saturation percentage from < 85% to ≤ 85%. Updated wording in Criteria I.A.2.a. for clarity and flow. Updated Criteria I.A.2.b. to include verbiage for significantly reducing the severity and duration of bradycardia or apnea events. Updated Criteria I.A.3.d. to include that parents or caregivers agree with the plan of care. Added Criteria I.A.3.e. regarding the home situation being assessed and deemed adequate. Expanded information on CPR requirement in Note section at end of Criteria. Updated Note section at end of Criteria to include when additional observation days may be needed. Minor rewording in Background with no impact on criteria. References reviewed and updated. Criteria I.A.1.c., Criteria I.A.2.a., and Criteria I.A.2.b. reviewed by internal specialist
CP.MP.246	Pediatric Kidney Transplant	Annual review. Updated contraindication I.B.2, adding a. through c. References reviewed and updated. Reviewed by external specialist.
CP.MP.182	Short Inpatient Hospital Stay	Annual review. Updated criteria I.A. from 2023 inpatient only link to 2024 link. Updated description and background with no clinical significance. References reviewed and updated.
WA.CP.MP.22	Stereotactic Body Radiation Therapy	New policy
CP.MP.22	Stereotactic Body Radiation Therapy	Annual review. Updated cancer staging in Criteria I.A. to align with National Comprehensive Cancer Network (NCCN) guidelines. Criteria II.C. updated to include details regarding positive clinical indications regarding stable systemic disease, Karnofsky Performance Score, survival expectations, and Eastern Cooperative Oncology Group (ECOG) Performance Status to align with ASTRO 2022 Model Policy for SRS. Criteria II.J. added to include trigeminal neuralgia and select cases of medically refractory epilepsy, movement disorders such as Parkinson’s disease and essential tremor, and hypothalamic hamartomas to align with 2022 ASTRO Model Policy for SRS. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.501	Continuous Glucose Monitor	Annual review. References updated. Updated section I. and Background to include reference to HCA Billing Guidelines.
WA.CP.MP.50	Drugs of Abuse: Definitive Testing	Annual review. Updated policy statements in I. and II.. Updated background with no clinical significance. References reviewed and updated. Internal specialist review.
WA.CP.MP.36	Experimental Technologies	Annual review. Added updated background with no clinical significance. References reviewed and updated. Removed definition of Humanitarian Use Device (HUD) from section 11. a. and updated language to correspond with WAC 182-501-0165.
CP.MP.62	Hyperhidrosis Treatments	Added note regarding the normal line of medical therapy back into policy after erroneously removing during January 2024 annual policy review.
CP.MP.250	Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy	Added note to description regarding Medicare policy version. Removed maximum age requirement from Criteria I.A.
WA.CP.MP.505	Microprocessor-Controlled Lower Limb Prosthetics	Annual review. References updated. Removed HCPCS L2006 and L5973 per previous revision.
CP.MP.102	Pancreas Transplantation	Annual review. Expanded criteria I.B. to I.B.a. through c. Updated description and background with no clinical significance. Coding reviewed. References reviewed and updated. Reviewed by external specialist
WA.CP.MP.503	Private Duty Nursing	Annual review. References reviewed and updated. Section III. A. updated reference HCA Billing Guidelines. Section III. C. wording updated to include EPSDT WAC and clarified hours for limitation extension/EPSDT requests. EPSDT WAC added to references. Struck references to social/economic factors.
CP.MP.162	Tandem Transplant	Annual review. Added a. through c. to I.B.10.; a. CD4 cell count > 200 cells/mm3, b. Absence of active AIDS-defining opportunistic infection, and c. Member/enrollee is currently on effective ART (antiretroviral therapy). Updated background info on testicular cancer with no impact on criteria. References reviewed and updated.
WA.CP.MP.517	Testosterone Testing	Annual review. References updated.
CP.MP.163	Total Parenteral Nutrition and Intradialytic Parenteral Nutrition	Annual review completed. Minor rewording in Criteria section with no clinical significance. Background updated with no impact to criteria. References reviewed and updated. External specialist reviewed.
WA.CP.MP.520	Tympanostomy Tubes	Annual review. References updated.
WA.CP.MP.46	Ventricular Assist Devices	Annual review. References reviewed and updated. Minor rewording in description with no impact on criteria. Added FDA approval requirement to Sections I and II per billing guidelines. Updated section I. A. language for clarity, no impact on criteria.

Policy Number	Policy Title	Revision Notes
CP.MP.186	Burn Surgery	Annual review. Added criteria II.C. that burn must be deep partial-thickness or full-thickness. Added used according to FDA indications to II.D.3. References reviewed and updated. Reviewed by internal specialist
WA.CP.MP.200	Transcranial Magnetic Stimulation for Treatment Resistant Major Depression	Revised to reflect updated Billing Guideline and revised HTA
CP.MP.186	Psychological Testing	Archived

Policy Number	Policy Title	Revision Notes
CP.BH.104	Applied Behavioral Analysis	Annual review. Replaced all instances of “DSM-5” with “DSM-5 TR”. Added requirement for a comprehensive diagnostic evaluation to have been conducted within the past five years in I.A.1. Added Social Skills Improvement System (SSIS) as an additional skill assessment option in I.E.1.b.ii.e. In I.E.,2.b. deleted “comprehensive.” Deleted I.E.,2.b.ii.e). and replaced it as a “note” under I.2.b.ii.d). In I.E.2.c.vi. deleted “in the home or community activities.” Added I.E.2.f.i. “Behavioral health outpatient services” to the list. Added statement to I.E.3.b. “Assessments are performed consistent with criteria in I.E.1. b.” Rearranged criteria point in I.E.3 for clarity. In II.A. added statement “… and generally involve a gradual step-down in services.” In II.C. Removed the statements “Services may be appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care.” Removed ICD 10 chart. Updated description and background with no clinical significance. References reviewed and updated. Annual review. Replaced all instances of “DSM-5” with “DSM-5 TR”. Added requirement for a comprehensive diagnostic evaluation to have been conducted within the past five years in I.A.1. Added Social Skills Improvement System (SSIS) as an additional skill assessment option in I.E.1.b.ii.e. In I.E.,2.b. deleted “comprehensive.” Deleted I.E.,2.b.ii.e). and replaced it as a “note” under I.2.b.ii.d). In I.E.2.c.vi. deleted “in the home or community activities.” Added I.E.2.f.i. “Behavioral health outpatient services” to the list. Added statement to I.E.3.b. “Assessments are performed consistent with criteria in I.E.1. b.” Rearranged criteria point in I.E.3 for clarity. In II.A. added statement “… and generally involve a gradual step-down in services.” In II.C. Removed the statements “Services may be appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care.” Removed ICD 10 chart. Updated description and background with no clinical significance. References reviewed and updated.
CP.BH.105	Applied Behavioral Analysis Documentation Requirements	New Policy
CP.MP.186	Burn Surgery	Annual review. Added criteria II.C. that burn must be deep partial-thickness or full-thickness. Added used according to FDA indications to II.D.3. References reviewed and updated. Reviewed by internal specialist.
CP.MP.105	Digital EEG Analysis	Added new for 2024 ICD-10 codes G40.C11 and G40.C19 to ICD-10 coding table.
WA.CP.MP.515	Fecal Microbiota Transplantation	Annual review. References updated.
WA.CP.MP.130	Fertility Preservation	Annual review. Reference updated.
CP.MP.129	Fetal Surgery in Utero for Prenatally Diagnosed Malformations	Updated criteria I.G.6. to maternal body mass index of ≥ 40 and added supportive references.
CP.MP.136	Home Birth	Annual review. Minor rewording in Criteria and Background sections with no impact on policy criteria. References reviewed and updated.
CP.MP.81	NICU Discharge Guidelines	Annual review. References reviewed and updated.
CP.MP.86	Neonatal Abstinence Syndrome Guidelines	Annual review. Updated description, criteria and background with equitable and inclusive language and no impact on criteria. References reviewed and updated. Reviewed by external specialist.
CP.MP.85	Neonatal Sepsis Management	Annual review. Reworded description with no clinical significance. Reworded criteria under I.A.2. "when meeting all of the following criteria" with no impact to criteria. Expanded criteria under I.A.2.a. and I.B.2.a. “Signs of neonatal sepsis (e.g.: hypotonia, lethargy, poor oral feeding, tachycardia, bradycardia, grunting, nasal flaring, cyanosis). Reworded criteria under II.D.1., II.D.3. and II.E. with no impact to criteria. References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.117	Percutaneous Electrical and Peripheral Nerve Stimulation	Annual review. Added section II.D. to correspond to CP.MP.117. Coding reviewed and updated. References reviewed and updated. Updated description and background with no clinical significance.
WA.CP.MP.526	Stem Cell Therapy for Musculoskeletal Conditions	Annual review. References updated. Background updated to include HCA Billing Guidelines.
WA.CP.MP.510	Tinnitus Treatment	Annual review. References updated. Background updated to include HCA Billing Guidelines.
V1.2024	All Genetic Testing Policies	Twice-per-year review

Policy Number	Policy Title	Revision Notes
CP.MP.107	Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines	Annual review. Updated description with no impact on criteria. Changed Orthopedic Care Equipment to Prosthetics and Orthotics Equipment. Table of contents updated. Retired pneumatic compression device criteria (E0675) for IQ. Updated "Cabinet style..." note under Ultraviolet panel lights. Under “Other Equipment” added code E0240 to “Specialized supply or equipment” section and added section, criteria, and coding (E1399, A9900) for “ROMTech device”. Reformatted Foot orthotics, custom criteria in “Prosthetics and Orthotics Equipment” section. Added criteria for Prosthetics and additions: Upper Extremity and Myoelectric in “Prosthetics and Orthotics Equipment” section. Added section, criteria, and coding (L8701, L8702) for “MyoPro Orthosis” under “Prosthetics and Orthotics Equipment”. Removed code L8035 from "other surgical supplies" and added section and criteria for "Breast Prosthetics" (L8030, L8035). Removed pediatric wheelchair codes (E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1037) from manual wheelchair section. References reviewed, updated, and reformatted. Internal specialist review.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.525	Catheter Ablation for Supraventricular Tachyarrhythmia	Annual review. References updated. Use of InterQual guidelines removed and policy updated to align with current HCA billing guidelines. CPT 93654 removed per billing guidelines.
WA.CP.MP.500	Mandibular Advancement Devices	Annual review. Reference reviewed
CP.MP.38	Ultrasound in Pregnancy	Updated Table 4 (Diagnosis Codes that Support Medical Necessity for First Detailed Fetal Ultrasound) to include the following codes and code ranges: A92.5, D56.0 through D56.9, D57.00 through D57.819, M32.0 through M32.9, M33.00 through M33.99, M34.0 through M34.9, M35.00 through M35.09, M35.1, M35.5, M35.8 through M35.9, M36.0, M36.8, N18.9, O00.01, O00.111 through O00.119, O00.211 through O00.219, O00.81, O00.91, O09.892 through O09.93, O10.012 through O10.019, O10.112 through O10.119, O10.212 through O10.219, O10.312 through O10.319, O10.412 through O10.419, O10.912 through O10.919, O11.2 through O11.3, O12.00, O12.02 through O12.03, O12.10, O12.12 through O12.13, O12.20, O12.22 through O12.23, O13.2 through O13.3, O13.5 through O13.9, O14.00, O14.02 through O14.03, O14.10, O14.12 through O14.13, O14.20, O14.22 through O14.23, O14.90, O14.92 through O14.93, O15.00, O15.02 through O15.03, O15.9, O16.2 through O16.3, O16.9, O22.50, O22.52 through O22.53, O23.00, O23.02 through O23.03, O24.414 through O24.415, O26.20, O26.22 through O26.23, O26.30, O26.32 through O26.33, O26.40, O26.42 through O26.43, O26.612 through O26.619, O26.832 through O26.839, O26.843 through O26.849, O26.852 through O26.859, O26.872 through O26.879, O28.5, O28.8 through O28.9, O29.012 through O29.019, O29.022 through O29.029, O29.112 through O29.119, O29.122 through O29.129, O29.212 through O29.219, O29.292 through O29.299, O30.90, O30.92 through O30.93, O31.30X1 through O31.30X9, O31.32X0 through O31.32X9, O31.33X0 through O31.33X9, O31.8X20 through O31.8X29, O31.8X30 through O31.8X39, O31.8X90 through O31.8X99, O32.0XX3 through O32.0XX9, O32.1XX1, O32.2XX1, O32.3XX1, O32.6XX1, O32.8XX1, O32.9XX1, O34.02 through O34.03, O34.30, O34.32 through O34.33, O36.20X0 through O36.20X9, O36.22X0 through O36.22X9, O36.23X0 through O36.23X9, O36.4XX0 through O36.4XX9, O36.60X0 through O36.60X9, O36.62X0 through O36.62X9, O36.63X0 through O36.63X9, O36.70X0 through O36.70X9, O36.72X0 through O36.72X9, O36.73X0 through O36.73X9, O36.80X0 through O36.80X9, O36.8130 through O36.8139, O36.8190 through O36.8199, O36.8220 through O36.8229, O36.8230 through O36.8239, O36.8290 through O36.8299, O36.8320 through O36.8329, O36.8330 through O36.8339, O36.8390 through O36.8399, O41.8X20 through O41.8X29, O41.8X30 through O41.8X39, O42.00, O42.012 through O42.02, O42.10, O42.112 through O42.119, O42.912 through O42.919, O43.012 through O43.019, O43.022 through O43.029, O43.112 through O43.119, O43.122 through O43.129, O43.212 through O43.219, O43.222 through O43.229, O43.232 through O43.239, O43.812 through O43.819, O44.00, O44.02 through O44.03, O44.10, O44.12 through O44.13, O44.20, O44.22 through O44.23, O44.30, O44.32 through O44.33, O44.40, O44.42 through O44.43, O44.50, O44.52 through O44.53, O45.002 through O45.009, O45.012 through O45.019, O45.022 through O45.029, O45.092 through O45.099, O46.002 through O46.009, O46.012 through O46.019, O46.022 through O46.029, O46.092 through O46.099, O46.8X2 through O46.8X9, O46.90, O46.92 through O46.93, O48.0 through O48.1, O60.00, O60.02 through O60.03, O60.10X0 through O60.10X9, O60.12X0 through O60.12X9, O60.13X0 through O60.13X9, O60.14X0 through O60.14X9, O98.012 through O98.019, O98.112 through O98.119, O98.919, O99.280, O99.282 through O99.283, O99.330, O99.332 through O99.333, O99.512 through O99.519, O9A.112 through O9A.119, U07.1, Z20.821, Z20.822, and Z21. References reviewed and updated. Internal specialist reviewed.
WA.CP.MP.70	Proton and Neutron Beam Therapies	Annual Review. Updated criteria I.G. to, unresectable benign or malignant central nervous system tumors to include but not limited to primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations. Added criteria I.H., Pituitary neoplasms. Restructured and added section A. and B. to criteria II. References reviewed and updated.
CP.MP.142	Urinary Incontinence Devices and Treatments	Annual review. Added note under Description to refer to CP.MP.133 Posterior Tibial Nerve Stimulation for Voiding Dysfunction for posterior tibial nerve stimulation treatment for urinary incontinence. Updated criteria I.B. from, urinary retention have been present for at least 12 months, to, urinary retention have been present for at least 6 months. Minor rewording in Criteria with no clinical significance. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.
CP.MP.151	Transcatheter Closure of Patent Foramen Ovale	Annual review. Minor rewording in Background section with no impact on criteria. References reviewed and updated.
CP.MP.180	Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea	Annual review. Edits were made to criteria to align with the FDA updates issued June 8, 2023, for the Inspire Upper Airway Stimulation System. Updated criteria B. from "Age > 22 years" to "BMI ≤ 40 kg/m2"; changed C. from "BMI < 35 kg/m2" to "One of the following:" adding C.1 to C.3, indicating the updated age ranges and associated criteria. Contraindications were updated to I.D.a to I.D.g. The original criteria points I.E to I.I were removed. Background updated with no clinical significance. References reviewed and updated. Reviewed by external specialist.
CP.MP.181	Polymerase Chain Reaction Respiratory Viral Panel Testing	Updated description of Table 2 as Table 6 was removed. Added ICD-10 codes J15.61 and J15.69 to Table 4. Added ICD-10 codes J44.81 and J44.89 to Table 5. Deleted Table 6 from policy.
CP.MP.206	Skilled Nursing Facility Leveling	Retire
CP.MP.247	Transplant Service Documentation Requirements	Annual review. Minor rewording throughout Criteria with no impact on criteria. Criteria I.B.2. and Criteria I.B.3. updated to say “provider” instead of “physician.” Criteria I.B.5. updated to include documentation. C-peptide removed from Criteria I.B.5.e. Criteria I.B.5.f. updated to remove “no specific additional testing” and added documentation of failed total parenteral nutrition. Criteria I.B.10.g. updated to say rapid plasma reagin. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist.

Policy Number	Policy Title	Revision Notes
CP.BH.124	ADHD Assessment and Treatment	Annual Review. Changed reference number for the policy from “CP.MP.124” to “CP.BH.124”. Added the following statement to section I and II: “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. In criteria point II. A. 1. replaced “Actometer” with “Actigraphy”. In criteria point I.A. 2. added “Acoustic reflex testing”. In criteria point I.A.12: removed Magnetic resonance imaging, brain functional MRI as it is already captured in I.A.16: under MRI. Removed I.A.14. “Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping”. In criteria point I.A.16. added “brain mapping” to the brain imaging section. In Criteria point I.A. 24 removed “Triiodothyronine T3 levels in the blood” and reworded as “Measures of thyroid hormones”. Removed II.A.18 “neuropsychological testing from the insufficient evidence list”, with corresponding codes also removed. In criteria point II. B.2., added “Application of modality (e.g. hot or cold packs, traction, mechanical, electrical stimulation (unattended), vasopneumatic devices, paraffin bath, whirlpool, diathermy (eg, microwave), infrared, ultraviolet, electrical stimulation (manual), iontophoresis, contrast baths, ultrasound, hubbard tank)”. Removed education interventions from criteria point II.B.19. and added policy statement III. “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that interventions that are strictly educational in nature (e.g., classroom environmental manipulation, academic skills training training) are not medically necessary as they are not considered medical interventions”. Added criteria point II.B.19. “EndeavorRx®”. Replaced instances of dashes (-) with the word “to” within the CPT description code list. Coding reviewed. Added the following codes and related indications as not medically necessary when billed with a sole diagnosis of ADHD: 70496, 70554, 70555, 78610, 84436, 84437, 84439, 84442, 84443, 84445, 84478, 84479, 84481, 92568, 92569, 92570, 95954, 96020, 96902, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036. References reviewed and updated. Policy reviewed by internal specialist. Policy reviewed by an external specialist.
CP.MP.108	Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia	Annual review. Added note at end of Description regarding criteria related to Zynteglo. Criterion I.C.3. removed related to lack of adequate support system. Expanded Criteria II.A. and Criteria II.B. to specify not in the context of gene therapy. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal and external specialist.
WA.CP.MP.502	Cochlear Implants	Annual review. References updated. Removed “Bilateral vs. Unilateral” from policy title. Removed use of InterQual criteria for unilateral implants as the HTA/HCA Billing Guideline covers unilateral and bilateral. Policy description edited to reflect unilateral and bilateral implants. Section I. removed “bilateral.” Section I. A. age parameters updated per Billing Guideline. Section I. C. minor grammatical error corrected with no impact on criteria. Policy note added per Billing Guideline that implantation may be performed unilaterally or bilaterally. Added note referencing CP.MP.14.
CP.MP.31	Cosmetic and Reconstructive Procedures	Annual review. Minor edits to I.A.4.b with no clinical significance. Updated pharmacy policies for Serostim (somatropin) in note. Removed CPT code 11310. References reviewed and updated. Reviewed by internal specialist.
CP.MP.101	Donor lymphocyte infusion	Annual review. Minor rewording in Description with no impact on criteria. Criteria II.B. updated to state grade 2 or higher acute graft versus host disease (GvHD). Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. Updated policy description. Updated all criteria in statements I. and II.
CP.MP.209	GI Pathogen Nucleic Acid Detection Panel Testing	Annual review completed. Replaced previous criteria with current in sections I. and II. and removed section III. Background updated with no impact to criteria. Reworded some extraneous language with no clinical significance. Moved code 87506 from Table 1 to Table 2. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 to include ICD-10 diagnosis codes which support medical necessity. References reviewed and updated.
CP.MP.250	Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy	New policy
CP.MP.123	Laser Therapy for Skin Conditions	Annual review. Added medically necessary indications I.C. atopic dermatitis and I.D. cutaneous T-cell lymphoma. Removed II.B. atopic dermatitis from insufficient evidence section. Added codes L20.81, L20.82, L20.89, C84.00 through C84.09, and C84.10 through C84.19 to table of ICD-10-CM diagnosis codes that support coverage criteria. References reviewed and updated.
CP.MP.57	Lung Transplantation	Revised adult and pediatric criteria to align with ISHLT 2021 consensus document. References reviewed and updated.
CP.MP.202	Orthognathic Surgery	Annual review. Added CPT codes 21248 and 21249. References reviewed and updated.
CP.MP.109	Panniculectomy	Annual Review. Combined criteria I.D. and E. into criteria I.D.1. and 2. Removed CPT code 00802 from policy. References reviewed and updated. Reviewed by external specialist.
CP.MP.138	Pediatric Heart Transplant	Annual review. Added additional criteria I.A.1.b.vi.a., pulmonary hypertension and a potential risk of developing fixed, irreversible elevation of pulmonary vascular resistance that could preclude orthotopic heart transplantation in the future. Updated I.D.1. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2. Expanded I.D.2. with qualifying criteria for members who are HIV positive. Updated I.D.21. to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background reviewed and updated. References reviewed and updated. Reviewed by external specialist.
CP.MP.246	Pediatric Kidney Transplant	Annual review. Description updated to include source information for policy criteria. Updated Criteria I.A.1. from glomerular filtration rate (GFR) ≤ 15 mL/min/1.73m2 to GFR < 15 mL/min/1.73m2 to align with Kidney Disease: Improving Global Outcomes (KDIGO) guidance and Organ Procurement Transplant Network (OPTN) guidance. Updated Criteria I.A.2. to include members/enrollees with CKD stage 4 with GFR < 30 mL/min/1.73m2 who are expected to reach end stage renal disease (ESRD) to align with KDIGO guidance and OPTN guidance. Updated contraindications in I.B. consistent with KDIGO guidelines. References reviewed and updated.
CP.MP.150	Phototherapy for Neonatal Hyperbilirubinemia	Annual review. Reworded criteria I.C. for inclusive language. References reviewed and updated.
CP.MP.181	Polymerase Chain Reaction Respiratory Viral Panel Testing	Annual review. Replaced prior criteria in sections I. and II. with current criteria. Removed policy statement III. Background updated with no impact on criteria. Updated verbiage in Table 2 description to include new diagnosis code requirements. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 which include ICD-10 diagnosis codes. References reviewed and updated.
CP.MP.98	Urodynamic Testing	Annual review. Added criteria I.D.5. for 4.5. Prostate nodule, asymmetry or other suspicion of prostate cancer. Moved N40.3 from ICD-10 Table 2 to ICD-10 Table 1. References reviewed and updated.
WA.CP.MP.527	Vitamin D Testing	Annual review. Updated references.

Policy Number	Policy Title	Revision Notes
CP.MP.129	Fetal Surgery in Utero for Prenatally Diagnosed Malformations	Annual review. Criteria I.F.3. updated to include confirmation on fetal MRI. Added clarifying language to Criteria I.F.4. Background updated with no impact on criteria. Added CPT code 59072. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist.
WA.CP.MP.50	Drugs of Abuse: Definitive Testing	Annual Review. Added an example of synthetic cannabinoids to I.A.1., drugs for which presumptive testing is not reliable. Coding reviewed. Replaced all instances of dashes (-) with the word “to” within the CPT and HCPCS codes. Added 0082U to the CPT codes that do not support coverage criteria list. Removed table of ICD-10 CM codes. Updated background information to include information regarding American Society of Addiction Medicine (ASAM). Other minor wording changes made to background with no clinical significance. References reviewed and updated. Policy reviewed by an internal specialist. Removed deleted codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U from table of CPT codes that do not support coverage criteria.

Policy Number

Policy Title

Revision Notes

CP.MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Annual review. Criteria I.F.3. updated to include confirmation on fetal MRI. Added clarifying language to Criteria I.F.4. Background updated with no impact on criteria. Added CPT code 59072. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist.

WA.CP.MP.50

Drugs of Abuse: Definitive Testing

Annual Review. Added an example of synthetic cannabinoids to I.A.1., drugs for which presumptive testing is not reliable. Coding reviewed. Replaced all instances of dashes (-) with the word “to” within the CPT and HCPCS codes. Added 0082U to the CPT codes that do not support coverage criteria list. Removed table of ICD-10 CM codes. Updated background information to include information regarding American Society of Addiction Medicine (ASAM). Other minor wording changes made to background with no clinical significance. References reviewed and updated. Policy reviewed by an internal specialist.

Removed deleted codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U from table of CPT codes that do not support coverage criteria.

Policy Number	Policy Title	Revision Notes
WA.CP.MP.519	Administrative Days	Changed “denial” to “discharge” in Note.
CP.MP.100	Allergy Testing and Therapy	Annual review. Updated description and background with no clinical significance. References reviewed and updated. Coding reviewed. Reviewed by external specialist.
WA.CP.MP.37	Bariatric Surgery	Modified section II.B. to allow family practice in addition to internal medicine physicians conduct pre-operative assessments.
CP.MP.156	Cardiac Biomarker Testing	Annual review. Background updated with no impact on criteria. Coding reviewed. References reviewed and updated. Reviewed by external specialist.
CP.MP.105	Digital EEG Spike Analysis	Annual review. Minor rewording in Criteria I. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist
CP.MP.155	EEG in the Evaluation of Headache	Annual review. Edits to policy name in header. Background updated with no clinical significance. References reviewed and updated.
CP.MP.134	Evoked Potential Testing	Annual review. References reviewed and updated. Reviewed by external specialist.
CP.MP.153	Helicobacter Pylori Serology Testing	Annual review. References reviewed and updated. Reviewed by external specialist.
CP.MP.113	Holter Monitors	Annual review. Criteria I. updated to specify a Food and Drug Administration (FDA) approved Holter monitor device, and age in Criteria I. changed from > 18 years old to ≥ 18 years old. Criteria I.D. updated to include arrhythmogenic right ventricular cardiomyopathy (ARVC), hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy, or a first degree relative with HCM. Added Criteria I.O. for baseline or periodic screening for those with adult congenital heart disease. Criteria II. updated to specify an FDA approved Holter monitor device, and age in Criteria II. changed from ≤ 18 years old to < 18 years old. Minor rewording in background with no impact on criteria. References reviewed and updated. Reviewed by internal specialist.
CP.MP.102	Pancreas Transplantation	Added note to policy to see CP.MP.250 Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy for criteria related to Lantidra.
CP.MP.181	Polymerase Chain Reaction Respiratory Viral Panel Testing	Removed note after the policy description referring to CP.CPC.03 Preventive Health and Clinical Practice Guidelines for PCR testing for COVID-19. Added 0202U, 0223U and 0225U to CPT table 2.
CP.MP.154	Thyroid Hormones and Insulin Testing in Pediatrics	Annual review. Edits to title in header. References reviewed and updated. Reviewed by external specialist.
CP.MP.38	Ultrasound in Pregnancy	Annual review. Minor rewording in Description, in Table 1 under Criteria IV., and in Criteria V. Verbiage added to indicate list is not all inclusive under Classifications of fetal ultrasounds Section I. and Section II. Background updated with no impact on criteria. Updated Table 4 Coding description. The following retired code ranges were removed: O35.0XX0 through O35.0XX9 and O35.1XX0 through O35.1XX9. The following code ranges were added: O35.00X0 through O35.00X9, O35.01X0 through O35.01X9, O35.02X0 through O35.02X9, O35.03X0 through O35.03X9, O35.04X0 through O35.04X9, O35.05X0 through O35.05X9, O35.06X0 through O35.06X9, O35.07X0 through O35.07X9, O35.08X0 through O35.08X9, O35.09X0 through O35.09X9, O35.10X0 through O35.10X9, O35.11X0 through O35.11X9, O35.12X0 through O35.12X9, O35.13X0 through O35.13X9, O35.14X0 through O35.14X9, O35.15X0 through O35.15X9, O35.19X0 through O35.19X9, O35.AXX0 through O35.AXX9, O35.BXX0 through O35.BXX9, O35.CXX0 through O35.CXX9, O35.DXX0 through O35.DXX9, O35.EXX0 through O35.EXX9, O35.FXX0 through O35.FXX9, O35.GXX0 through O35.GXX9, O35.HXX0 through O35.HXX9. References reviewed and updated.

Policy Number	Policy Title	Revision Notes
CP.BH.500	Behavioral Health Treatment Documentation Requirements	Annual Review. No changes made to criteria. References reviewed and updated.
WA.CP.MP.516	Carotid Artery Stending	Annual review. References updated. Removed InterQual guidelines and edited section I. to reflect current HTA criteria.
CP.MP.203	Diaphragmatic/Phrenic Nerve Stimulation	Annual review. Product name updates in criteria II. and in background with no clinical significance. References reviewed and updated.
CP.MP.248	Facility Based Sleep Studies for Obstructive Sleep Apnea	Corrected I.B.8.a.i. to require either continuous, chronic nocturnal oxygen use or moderate to severe pulmonary function impairment instead of both.
WA.CP.MP.69	Intensity Modulated Radiation Therapy	Annual review. References updated.
CP.MP.167	Intradiscal Steroid Injections for Pain Management	Annual review. References reviewed and updated.
CP.MP.170	Nerve Blocks for Pain Management	Annual review completed. Examples added to I.B.1. and III.B.2. Minor rewording with no clinical significance. Background updated. Added CPT codes 64628. ICD-10 Diagnosis code table removed. References reviewed and updated. External specialist reviewed.
WA.CP.MP.507	Oral Enteral Nutrition	Added Exception to the Rule comment for adults requesting PKU formula
CP.MP.194	Osteogenic Stimulation	Annual review completed. Background and references reviewed and updated.
CP.MP.51	Reduction Mammoplasty and Gynecomastia Surgery	Annual review. Criteria I.A.1. updated for criteria for members/enrollees ≥ 18 years of age and members/enrollees < 18 years of age. Criteria I.A.2. updated to include note regarding medical director review on case-by-case basis when weight of tissue to be resected is less than the 22nd percentile minimum based on the Schnur Sliding Scale. Criteria I.A.3.b. updated to include pain in arm. Criteria II.A.1. updated to align with ASPS guidance regarding length of time gynecomastia persists in adolescents < 18 years. Criteria II.B.3. updated to align with ASPS guidance for length of time gynecomastia persists in adults ≥ 18 years. Removed Criteria II.B.6. regarding malignancy being ruled out. Minor rewording in background with no impact on criteria. ICD-10 codes removed. References reviewed and updated. Reviewed by internal specialist and external specialist.
CP.MP.182	Short Inpatient Hospital Stay	Annual review completed. Updated hyperlink to CMS inpatient only list in Criteria I.A. Added option in I.A. for procedure to be listed as an inpatient-only procedure in InterQual for those under 18 years of age, and noted that the CMS inpatient only list applies to those 18 years of age and older. Minor rewording with no clinical significance. References reviewed and updated. Internal specialist reviewed.
CP.BH.100	Substance Use Disorder Treatment and Services	Policy Retired
WA.CP.BH.200	Transcranial Magnetic Stimulation for Treatment Resistant Major Depression	Typos corrected
CP.MP.169	Trigger Point Injections for Pain Management	Annual review completed. Minor rewording with no clinical significance. Background updated. ICD-10 Diagnosis code table removed. References reviewed and updated.
CP.MP.12	Vagus Nerve Stimulation	Annual review completed. Removed II.B. “Obesity”. Additional minor rewording with no clinical significance. Background updated; moved “Removal of implant” section to background. ICD-10 Diagnosis code table removed. References reviewed and updated. External specialist reviewed.

Policy Number	Policy Title	Revision Notes
CP.MP.14	Cochlear Implant Replacements	Annual review completed. Changed verbiage in I.C. from “A sound processor replacement if the current processor is at least five years old” to “C. The existing component has reached the limit of its reasonable useful life. The reasonable useful life of a sound processor is not less than five years”. Minor rewording with no clinical significance. Background updated with no impact to criteria. ICD-10-CM Diagnosis Code table removed. References reviewed and updated. External specialist reviewed.
WA.CP.MP.514	Extra-Corporeal Membrane Oxygenation Therapy (ECMO)	Annual review. References updated.
CP.MP.137	Fecal Incontinence Treatments	Annual review. Removed “≥ 4 years age” criteria and added “in a member/enrollee that has previously achieved bowel control” to I.A. Also removed “more than twelve months after vaginal childbirth” from definition of severe, chronic fecal incontinence in I.A. Description and background section updated with no clinical significance. References reviewed and updated. External specialist reviewed.
WA.CP.MP.54	Hospice Services	References updated. Background information updated. Removed statement regarding previous investigational treatment from Initial Request paragraph. Updated Initial Request Section I. language to correspond to HCA billing guidelines. Updated Initial and Subsequent Request sections II. Continuous Homecare and General Inpatient descriptions to correspond to HCA billing guidelines. Removed debility and failure to thrive exclusion from section III. Updated section III. D. language re: hospice discharge per HCA billing guidelines. Covered and non-covered services sections updated to correspond to HCA billing guidelines.
CP.MP.127	Total Artificial Heart	Annual review. Removed criteria III. Updated background with no clinical significance. Removed ICD-10 code table. References reviewed and updated.
WA.CP.BH.200	Transcranial Magnetic Stimulation for Treatment Resistant Major Depression	New policy.
WA.CP.MP.522	Varicose Vein Treatment	Annual review. References reviewed and updated. Section I. medical necessity criteria revised to align with HTA/HCA billing guidelines. Removed ligation/stripping procedures from policy description and criteria. Added note below section II. regarding use of InterQual criteria for review of ligation/stripping procedures. Removed ligation procedure codes 37780 and 37785 from CPT code table. Updated section B. contraindications to correspond to HTA/billing guidelines and current corporate sclerotherapy/EVLA policy CP.MP.146. Updated section C. Venaseal requirements per CP.MP.146. Background updated with no impact on criteria. . Removed table of codes that do not support medical necessity.
V2.2023	CG Aortopathies and Connective Tissue Disorders	Annual review. Policy number change from CP.MP.215
V2.2023	CG Cardiac Disorders	Annual review. Policy number change from CP.MP.216
V2.2023	CG Dermatologic Conditions	Annual review. Policy number change from CP.MP.217
V2.2023	CG Epilepsy Neurodegenerative and Neuromuscular Conditions	Annual review. Policy number change from CP.MP.218
V2.2023	CG Exome and Genome Sequencing for DX of Genetic Disorders	Annual review. Policy number change from CP.MP.219
V2.2023	CG Eye Disorders	Annual review. Policy number change from CP.MP.220
V2.2023	CG Gastroenterologic Disorders Non-cancerous	Annual review. Policy number change from CP.MP.221
V2.2023	CG General Approach to Genetic Testing	Annual review. Policy number change from CP.MP.222
V2.2023	CG Hearing Loss	Annual review. Policy number change from CP.MP.223
V2.2023	CG Hematologic Conditions Non-cancerous	Annual review. Policy number change from CP.MP.224
V2.2023	CG Hereditary Cancer Susceptibility	Annual review. Policy number change from CP.MP.225
V2.2023	CG Immune Autoimmune and Rheumatoid Disorders	Annual review. Policy number change from CP.MP.226
V2.2023	CG Kidney Disorders	Annual review. Policy number change from CC.MP.227
V2.2023	CG Lung Disorders	Annual review. Policy number change from CC.MP.228
V2.2023	CG Metabolic Endocrine Mitochondrial Disorders	Annual review. Policy number change from CP.MP.229
WA.CP.MP.230	CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay	Annual review.
WA.CP.MP.231	CG Non-Invasive Prenatal Screening	Annual review.
V2.2023	CG Oncology Algorithmic Testing	Annual review. Policy number change from CP.MP.237
V2.2023	CG Oncology Cancer Screening	Annual review. Policy number change from CP.MP.238
V2.2023	CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy	Annual review. Policy number change from CP.MP.239
V2.2023	CG Oncology Cytogenetic Testing	Annual review. Policy number change from CP.MP.240
V2.2023	CG Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies	Annual review. Policy number change from CP.MP.241
V2.2023	CG Pharmacogenetics	Annual review. Policy number change from CP.MP.232
V2.2023	CG Preimplantation Genetic Testing	Annual review. Policy number change from CP.MP.233
V2.2023	CG Prenatal and Preconception Carrier Screening	Annual review. Policy number change from CP.MP.234
V2.2023	CG Prenatal Diagnosis Pregnancy Loss	Annual review. Policy number change from CP.MP.235
V2.2023	CG Skeletal Dysplasia Rare Bone Disorders	Annual review. Policy number change from CP.MP.236

Clinical & Payment Policies

Clinical Policies

Ambetter Clinical Policies Listing

Ambetter Pharmacy Policies Listing

A - G

H - Q

R - Z

Medicaid Clinical Policies Listing

A - G

H - Q

R - Z

GENETIC TESTING

Medicaid Pharmacy Policies Listing

A - G

H - Q

R - Z

Payment Policies

Ambetter Payment Policies

Medicaid Payment Policies

A - H

I - Q

R - Z

Policy Revision Summary (Clinical)

DECEMBER 2024

NOVEMBER 2024

SEPTEMBER 2024

August 2024

JULY 2024

JUNE 2024

MAY 2024

APRIL 2024

MARCH 2024

FEBRUARY 2024

JANUARY 2024

DECEMBER 2023

NOVEMBER 2023

OCTOBER 2023

SEPTEMBER 2023