POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
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Assisted Reproductive Technology
(CP.MP.55)
| Ambetter
| Policy updates include:
- Added criteria I.B.5.j.-I.B.5.l. to include:
- HIV or hepatitis-discordant couples
- Need for preimplantation genetic testing for monogenic disorders (PGT-M) of embryos in settings requiring absence of extraneous DNA contamination from other sperm (i.e., members/enrollees with or carriers of cystic fibrosis, BRCA mutations and congenital adrenal hyperplasia)
- Treatment of elected types of female infertility such as members/enrollees with morphologic anomalies of oocytes and/or anomalies of the zona pellucida
- Removed “premature” in criteria I.B.6.c
- Removed criteria I.B.10. regarding cryopreservation of embryos
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Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder
(CP.BH.201)
| Ambetter
| Policy updates include:
- Removed verbiage indicating that the request must be reviewed by a medical director
- In I.E., changed the frequency of services from 30 to 36 approved sessions “Request is for up to 36 sessions (Note: Recommended schedule is for five days a week for six weeks, with an optional six sessions for tapering)”
- In I.H. removed the following relative contraindications
- history of seizures
- severe dementia
- severe cardiovascular disease
- active suicidal ideation with intent
- Deleted what was policy statement II. referencing tapering criteria
- In III. C. added statement indicating documented 6-month duration of response
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Heart-Lung Transplant
(CP.MP.132)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Changed I.A.1. to ≥ 18. I.A.1.a now reflects “severe” heart failure and I.A.1.b. now reflects “nonspecific idiopathic”
- In I.A.1.h.,
- Non-complex congenital heart disease associated with pulmonary hypertension that is not amenable to lung transplantation and repair by standard surgery was removed, and now reflects Congenital heart disease (CHD) meeting one of the following
- Adding I.A.1.h.i – iv., followed by i. and j
- Age changed to < 18 in I.A.2 and in I.A.2.d, added “pulmonary” Changes made to I.A.2.h in addition to adding h.i.-v
- Ages changed in I.B.1.a. “> 18” and I.B.1.b. “≤ 18”
- In I.C.1.a, added “for at least …transplantation”
- Added I.C.1.d “Member/enrollee…severe malnutrition”
- In I.C.8., added “unless being…transplant”
- Reworded I.C.16.a. now reflecting “alcohol or illicit drug use”
- Table 2 has been changed to the American Heart Association Heart Failure Stages, removing Heart Failure Stages in Pediatric Heart Disease
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Lung Transplantation
(CP.MP.57)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Updated glomerular filtration rate from < 30 to < 40 mL/min/1.73m2 in Criteria I.C.2
- Updated Criteria I.C.9.a. to include at least three months prior to transplantation
- Removed additional information regarding heart transplant waiting list in Criteria I.C.9.b
- Minor grammatical update in Criteria I.C.9.c
- Added Criteria I.C.9.d. regarding chronic wasting or severe malnutrition
- Expanded Criteria I.C.13. regarding active substance use or dependence and added Criteria I.C.14. regarding documentation of abstinence from substance use
- Added Criteria I.D.2.h., Criteria I.D.2.i, and Criteria I.D.2.j. regarding alveolar capillary dysplasia, pulmonary vein stenosis refractory to intervention, and pulmonary veno-occlusive disease
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Pancreas Transplantation
(CP.MP.102)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- In I.B.3. changed "myocardial infarction within 30 days" to "myocardial (within 6 months)" and reworded the information about "stroke or acute coronary syndrome"
- Added I.C.1.a.ii "Recurring severe hypoglycemic attacks"
- Added CPT code 50328
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Tandem Transplant
(CP.MP.162)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Updated I.A.3.b., c. and d. to reflect months of age instead of days
- Replaced all previous contraindications, I.B.1. through 15. with new contraindication list, I.B.1. through 6
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Total Parenteral Nutrition and Intradialytic Parenteral Nutrition
(CP.MP.163)
| CHIP and Ambetter
| Policy updates include:
- Updated criteria I.A.1.a. regarding low body weight to include details by age group and expanded to I.A.1.a. through c
- Removed previous criteria I.A.1.b. and c. regarding total protein and serum albumin
- Removed previous criteria I.A.2.d, CNS disorders from list of conditions that make oral or tube feedings inappropriate
- Updated criteria I.A.2.h. to include children with paralytic ileus and added I.A.2.m and n., to list conditions that make oral or tube feedings inappropriate
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Transcranial Magnetic Stimulation for Treatment Resistant Major Depression
(CP.BH.200)
| Ambetter
| Policy updates include:
- Criteria restructuring in policy statements I and III which apply to adults ≥ 18 years of age only
- Added new policy statements II and IV, which apply to adolescents 15-17 years of age only
- In policy statements I and III, added deep TMS (dTMS) as a form of TMS for adults ≥ 18 years of age
- In I.A. removed the psychosis exclusion from the diagnosis criteria
- In I.B. removed criteria statement “the major depressive disorder diagnosis is not part of a presentation with multiple psychiatric comorbidities and there is no evidence of psychosis or substance use” and replaced it with “The member/enrollee does not have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder
- In I.C.1. replaced the term “psychopharmacologic agents” with “antidepressants” and removed the statement "during the current depressive episode (and within if the current episode exceeds 24 months of duration)”
- In I.C.2. combined subpoints for clarity
- In I.D. removed requirement for PHQ-9 scores to be documented throughout treatment and added a broader statement referencing evidenced based treatment “ The member/enrollee has participated in an adequate trial of evidence-based psychotherapy (such as cognitive behavioral therapy and/or interpersonal therapy) during the current episode of illness, without significant improvement”; in the note associated, replaced “medication trials” with “antidepressant trials”
- In. I.F. added criteria statement “The member/enrollee is referred for TMS treatment by the provider treating the member/enrollee's MDD"
- In I.G. added criteria indicating that a comprehensive psychiatric evaluation has been completed by a qualified licensed provider (MD, DO or MBBS)
- In I.I added frequency of services “up to 36 sessions" and added a note indicating a schedule recommendation "Recommended schedule is for five days a week for six weeks, with an optional six sessions for tapering”
- In I.K. removed the following relative contraindications: “history of seizures, severe cardiovascular disease,” acute psychotic disorders in the current depressive episode, dementia, and active suicidal ideation with intent
- In I.L. added new criteria statement “Documentation of rTMS, iTBS or dTMS protocol used”
- In III. D. added the statement "with a documented 6-month duration of response"
- Added policy statement VI. which states that MRI guided theta burst is considered experimental and investigational
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