POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
|
Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Updated week requirement criteria I.B.4.a.-c
|
Hospice Services (CP.MP.54)
| Ambetter
| Policy updates include:
- Revised criteria II.D.3.c. added “after bronchodilator (if able to obtain);
- Under II.E.2.b. added “or upper urinary tract infection
- Updated II.E.2.f. “over” with “during the previous”
- Under II.G. removed “Failure” and replaced with “Disease”
- Under II.I.2.a. removed “up to” and replaced with “the last”
|
Intestinal and Multivisceral Transplant
(CP.MP.58)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- 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)
|
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (CP.MP.48)
| Ambetter
| Policy updates include:
- Removed contraindications under II.F. including uncontrolled cardiac arrhythmias, unstable angina, joint replacement in a location targeted by FES and seizure disorder
|
Pediatric Liver Transplant (CP.MP.120)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added HIV points a. - c., under I.C.2
|
Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Verbiage updated in criteria I.A.4.b
- Removed criteria I.A.4.c. and d. Criteria updated to include mammogram requirement for members/enrollees < 40 years of age with symptoms of breast cancer or high-risk factors for breast cancer in what is now I.A.4.c
- Clarifying language added to Criteria II.A.2
- Criteria II.B.3. updated to include clarifying language and to include gynecomastia that persists for more than three months after unsuccessful medical treatment for pathological gynecomastia
- Criteria II.B.4. updated to include clarifying language
|
