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24-468m Medical Policies - April 2024

Date: 05/21/24

Check out the latest changes to existing medical policies for procedures and services

The medical policies listed in this update were approved by Centene’s Corporate Clinical Policy Committee and/or Health Net’s Medical Advisory Council (MAC) for April 2024. For a complete description of the background, criteria, references, and coding implications for the medical policies.

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 benefit plan coverage document states otherwise. That document defines member benefits in addition to eligibility requirements, and coverage exclusions and limits.

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

Policy number and name

Change

CP.MP.37 –

Bariatric Surgery

  • Removed high risk for type 2 diabetes mellitus (DM) in Criteria I.A.1.a.ii.c)i).
  • Changed Criteria I.A.1.a.ii.c)i) from poorly controlled hypertension to hypertension.
  • Removed severe urinary incontinence from Criteria I.A.1.a.ii.c)xii).
  • Updated verbiage in Criteria I.A.1.a.ii.c)xiii) to bone and joint diseases.
  • Removed idiopathic intracranial hypertension from Criteria I.A.1.a.ii.c)xiv) which is duplicative since pseudotumor cerebri is in criteria.
  • Added chronic kidney disease in Criteria I.A.1.a.ii.c)xiii).
  • Added infertility in Criteria I.A.1.a.ii.c)xiv).
  • Added polycystic ovarian syndrome in Criteria I.A.1.a.ii.c)xv).
  • Clarified verbiage in Criteria I.A.1.b.
  • Updated Criteria I.A.1.b.ii.d) to state nonalcoholic fatty liver disease or nonalcoholic steatohepatitis.
  • Criteria Clarified verbiage in Criteria I.B.1. and in Criteria I.B.1.a.
  • Updated Criteria I.B.1.b.iv. from glomerular filtration rate (GFR) < 30 mL/min-1 to GFR < 60 mL/min-1.
  • Added Criteria I.B.1.b.vii. to include unstable angina.
  • Added Criteria I.B.1.b.viii. to include recent myocardial infarction (within the past 60 days).
  • Updated Criteria I.B.4. to include thiamine, calcium and fat-soluble vitamins.
  • In I.B.5., removed requirement for monthly nutritional counseling.
  • Updated verbiage to Criteria I.B.9. to “state gastrointestinal (GI) screening and evaluation for clinically significant GI symptoms with documentation of needed treatment prior to bariatric surgery.”
  • Removed Criteria I.B.10. for Helicobacter pylori screening.
  • Minor rewording in Criteria I.B.11.
  • Updated Criteria III.B. to include other names of procedure for clarification.
  • Minor rewording in Criteria III.K.
  • Removed one-anastomosis gastric bypass in Criteria III.L. since duplicative.

CP.BH.201 –

Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder

  • Separated former criteria point I.A into two sub points (A and B).
  • Criteria point I. D. reworded for clarity “Direct supervision of treatment is provided by a licensed psychiatrist except where state scope of practice acts allows for other provider types to supervise.”
  • Removed I.G.3. “Vagus nerve stimulator leads in the carotid sheath” as this is captured in I.G.2.h.
  • In criteria point I.G.4. Replaced “substance abuse at time of treatment” with “less than three months of substantiated remission from a substance use disorder.”
  • Removed “Neurological disease or head injury” and “pregnancy” from the contraindication list.
  • Added new CPT/HCPCS codes: 97014: Application of a modality to 1 or more areas; electrical stimulation (unattended); 97032: Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.

CP.MP.185 –

Skin and Soft Tissue Substitutes for Chronic Wounds

  • In note and policy statements I and II, specified that this policy applies to non-Medicare plans.
  • Removed language related to venous stasis ulcers.
  • Removed criteria 1.A “Age ≥ 18 years, or diabetic (Type 1 or Type 2).”
  • Removed “including silver dressings” in I.C.1. Replaced I.C2 “wound has increased in size or depth or has not changed…” with “Wound area has reduced <50% in four weeks.”
  • Removed the following codes from HCPCS codes that do not support medical necessity criteria and added to table for HCPCS codes that support medical necessity criteria: A2002, Q4236, and Q4262.
  • Added HCPCS code Q4278 to table for HCPCS codes that support medical necessity criteria.
  • Added the following codes to table for HCPCS codes that do not support medical necessity criteria: Q4279 and Q4287 through Q4304.

CP.BH.200 –

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression

  • Minor rewording throughout the policy for clarity with no clinical significance.
  • Criteria point I.D. added that the pre-TMS score should be documented in order to measure progress more effectively “Planned use of a depression severity standardized rating scale by the TMS provider to monitor response during treatment, with pre-TMS score documented.”
  • Removed prior Criteria I.G. and reworded criteria regarding trial and failure of psychopharmacologic therapy and psychotherapy in new I.G and I.H. to include the requirement for a standardized scale to indicate moderate to severe depression throughout treatment.
  • In I.G., clarified that the member/enrollee must present with the “failure or intolerance to two trials of psychopharmacologic agents from at least two different agent classes.”
  • In I.G.2, required that both criteria a. and b. be met for intolerance.
  • In G.2.b, specified that “at least four antidepressants representing at least two different drug classes” must have been attempted.
  • In I.H., added a note that the therapy should overlap with medication trials.
  • In I.J.6., added contraindication “concomitant esketamine intranasal, ketamine infusion or other infusion therapies.”
  • Removed HCPCS coding table including G0295.

Additional Information

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141. Behavioral Health providers can call 844-966-0298.

 


This information applies to Physicians, Participating Physician Groups (PPGs), and Behavioral Health Providers.

This information applies to Medi-Cal in Imperial county.



Last Updated: 05/21/2024