Effective January 27, 2025: Clinical Policies

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Implantable Intrathecal or Epidural Pain Pump

(CP.MP.173)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Removed criteria I.A.2.f. regarding active participation in psychotherapeutic interventions

Outpatient Oxygen Use (CP.MP.190)

CHIP and Ambetter

Policy updates include:

• Removed criteria I.C. The qualifying blood gas study or pulse oximetry measurement was performed by a physician or by a qualified provider or supplier of laboratory services
• Added CPT E0447 to coding table

Short Inpatient Hospital Stay

(CP.MP.182)

Ambetter

Policy updates include:

• Updated to policy description
• Changed policy statement I. to “an inpatient level of care for hospital stays of less than three midnights is medically necessary”
• Added “in use by the applicable plan” to criteria I.B
• In I.F. clarified that the transfer is from an “inpatient” stay and changed “of two days or more” to “of three midnights or more”
• Updated policy statement II. to “inpatient hospital stays lasting three midnights and beyond”

Short Inpatient Hospital Stay

(TX.CP.MP.582)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP

Policy updates include:

• Updated applicable products
• Updated policy description “for inpatient stays where there is a reasonable expectation that the client will be discharged within 48 hours”
• Removed MMP and Marketplace from product listing
• Updated Section I to remove “day 1 and day 2” and replaced with “for inpatient stays where there is a reasonable expectation that the client will be discharged within 48 hours”
• Added Section I. G. “Add Admission to an approved Acute Hospital at Home Program that meets criteria per a nationally-recognized clinical decision support tool”