20-712 Medical Policies - 2nd Quarter 2020

Date: 09/25/20

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

Read the new and updated policies about clinical criteria for procedures and services

The medical policies listed in this update were approved in the second quarter of 2020. These policies may apply to CalViva Health Medi-Cal members if there are no available medical policies from the California Department of Health Care Services (DHCS). For a complete description of the background, criteria, references, and coding implications for the medical policies, log on to the provider website and select Medical Policies under Resources for you. Or, go directly to the Provider Library.

Purpose of medical policies

Medical policies offer guidelines to help determine medical necessity for certain procedures, equipment and services. They are not intended to give medical advice or tell providers how to practice. If required, providers must get prior authorization before services are given.

Medical policies vs member contract

All services must be medically needed, unless the member’s individual benefits contract states otherwise. The member’s benefits contract defines benefits in addition to eligibility requirements, and coverage exclusions and limits.

• If legal or regulatory mandates apply, they may override medical policy.
• If there are any conflicts between medical policy guidelines and related member benefits contract language, the benefits contract will apply.

For Medi-Cal plans, appropriate coverage guidelines take precedence over these plan policies and must be applied first.

New Policies

Medical policy	Policy statement
Burn Surgery	Policy provides medical necessity criteria for burn debridement and/or excision and the use of skin substitutes for burns during the acute phase of treatment
Pediatric Oral Function Therapy	Policy includes medically necessary indications for this therapy
Radiofrequency Ablation of Uterine Fibroids	Considered investigational/experimental
Skin Substitutes for Chronic Wounds	Policy provides medical necessity criteria for skin substitutes in the treatment of chronic wounds and lists various products

 

Updated Policies

Medical policy	Change
ADHD Assessment and Testing	Attention Deficit Hyperactivity Disorder (ADHD): Updated Section I.A.3. to include “collection of collateral information” and I.A.5.c. “toxicology screen” Updated Section I.B.5. to include “ongoing assessment and application of standardized scales to assess treatment benefit” Updated Section II. “investigational or unproven” assessments and treatments with the following: pharmacogenetic tools; Cannabidiol oil; cognitive training; external trigeminal nerve stimulation (eTNS); mindfulness; and supportive counseling Added information from various clinical guidelines, updated references Added and deleted CPT Codes and HCPCS codes which may affect payment. See policy on website for complete listing of codes
Ambulatory EEG	Ambulatory electroencephalography (EEG): Added the following 2020 CPT codes: 95700, 95705, 95708, 95717, 95719, 95721, 95723, and 95725
Biofeedback	Updated codes 90912 and 90913 Removed I.B.5 “Anal muscle abnormalities..” and revised language in I.B.3 Added contraindications to I.B.3
Bronchial Thermoplasty	Revised to consider investigational instead of not medically necessary
Cardiac Rehabilitation, Outpatient	Removed uncontrolled diabetes from the list of contraindications
Diagnostic Testing Guidelines for 2019 Novel Coronavirus	Note that this policy is subject to change as new guidelines and recommendations are published. Revised ICD-10, CPT and HCPCS codes Added that state and local health departments may adapt testing recommendations to respond to rapidly changing local circumstances Specified that the first medical necessity statement applies to nucleic acid/antigen testing Updated priority groups per CDC update on May 3, 2020 Added statement that antibody testing is not medically necessary for diagnosing acute infection, with background support Categorized codes as supporting coverage criteria or not supporting coverage criteria
Electric Tumor Treating Fields	Added age restriction of ≥ 22 years
Facet Joint Intervention	In III, Clarified that facet joint injections of the thoracic region are not medically necessary
Genetic and Pharmacogenetic Testing	Added general criteria and background for pharmacogenetic testing
Heart-Lung Transplant	Removed various contraindications related to pulmonary and cardiovascular diseases and edited various malignancy contraindications
Homocysteine Testing	Changed borderline B12 deficiency and idiopathic venous thromboembolism (VTE) indications from medically necessary to investigational and revised codes ICD-10 to reflect this change
Hospice Care	Replaced “glomerular filtration rate” with “creatinine clearance” in H.3.b and H.3.c
Implantable Wireless Pulmonary Artery Pressure Monitoring	Revised to consider investigational instead of not medically necessary
Inhaled Nitric Oxide Therapy	Added iNO as medically necessary for COVID-19, severe acute respiratory distress syndrome (ARDS) and hypoxemia despite optimized ventilation and other rescue strategies Added the following ICD-10 codes: J80, J96.01, U07.1, and U07.2
Intestinal and Multivisceral Transplant	Edited malignancy contraindications
Lung Transplantation	Edited malignancy contraindications
Mechanical Stretching Devices for Joint Stiffness and Contracture	Updated I. Added knee, elbow, and wrist injuries as medically necessary indications Specified that criteria I.A-I.B be met for low-load prolonged-duration stretch (LLPS). Changed the not medically necessary statements regarding LLPS for other indications, patient-actuated serial stretch (PASS) and static progressive stretch (SPS) devices to experimental/ investigational Revised ICD-10, CPT and HCPCS codes Added HCPCS codes E1800, E1802, E1805, E1810, E1812 as supporting coverage criteria
Non-Invasive Home Ventilator	Added criteria for second/back up noninvasive ventilator from CP.MP.107 DME
Pancreas Transplant	Edited malignancy contraindications Clarified that body mass index (BMI) maximal allowable value in I.B.2 is (i.e., ≤ 30 to 35 kg/m2, depending on transplant center)
Pediatric Liver Transplant	Edited malignancy contraindication
Sclerotherapy for Varicose Veins	Changed requirement for junctional reflux of greater saphenous veins to ≥ 3 mm, from 2.5 mm Specified Varithena®️ as an example of a foam irritant
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition	Revised I.A.1. “documentation of failure of enteral (i.e., oral or tube feeding) nutrition” to “Documentation of nutritional insufficiency, in the absence of total parenteral nutrition (TPN)”
Trigger Point Injections	CPT 20560 and 20561 added as not supporting coverage criteria

Additional information

If you have questions regarding the information contained in this update, contact CalViva Health at 1-888-893-1569.