21-140 Medical Policies - 4th Quarter 2020

Date: 02/16/21

Review new and updated policies to stay current on clinical criteria for procedures and services

The medical policies listed in this update were approved by Centene’s Corporate Clinical Policy Committee in the fourth quarter of 2020. A complete description of the medical policies is on the California Health & Wellness Plan (CHWP) website.

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 Medi-Cal Member Handbook describes 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.

New Policies:

Medical policy	Policy statement
Oxygen Use and Concentrators	In Section II, specified that the diagnosis list is not all-inclusive, and that there must be a cause of severe lung disease or hypoxia; edited diagnosis list Added polysomnography as a qualifying lab results option Revised reauthorization criteria for adults and those aged < 21 Portable oxygen systems: Added that criteria in Section I must be met and specified that portable oxygen system criteria applies to adults Added “shortness of breath or dyspnea in a pediatric patient without evidence of hypoxemia” to the list of not medically necessary indications for oxygen concentrators Clarified in I.2.a that the oxygen saturation should be 89% or less, instead of 89% For reauthorization of oxygen concentrators and stationary oxygen systems in adults in Section III, added an option for a letter of medical necessity documenting a chronic condition not expected to improve or expected to worsen, when provided in addition to a physician evaluation within 90 days Specified that Section I applies to oxygen concentrators and stationary oxygen systems for indications other than cluster headaches, and referred to Section VII for stationary oxygen systems for cluster headaches

Medical policy

Policy statement

Oxygen Use and Concentrators

In Section II, specified that the diagnosis list is not all-inclusive, and that there must be a cause of severe lung disease or hypoxia; edited diagnosis list
Added polysomnography as a qualifying lab results option
Revised reauthorization criteria for adults and those aged < 21

Portable oxygen systems:

Added that criteria in Section I must be met and specified that portable oxygen system criteria applies to adults
Added “shortness of breath or dyspnea in a pediatric patient without evidence of hypoxemia” to the list of not medically necessary indications for oxygen concentrators
Clarified in I.2.a that the oxygen saturation should be 89% or less, instead of 89%
For reauthorization of oxygen concentrators and stationary oxygen systems in adults in Section III, added an option for a letter of medical necessity documenting a chronic condition not expected to improve or expected to worsen, when provided in addition to a physician evaluation within 90 days
Specified that Section I applies to oxygen concentrators and stationary oxygen systems for indications other than cluster headaches, and referred to Section VII for stationary oxygen systems for cluster headaches

Updated Policies:

Medical policy	Change
Allergy Testing	I.C.1, added “(scratch, puncture, prick)” to description III.B, added several not medically necessary tests Background, added section on sublingual immunotherapy CPT Code Table 2, added CPT codes to not medically necessary
Ambulatory Surgery Center Optimization	I.C, added reference to procedures in Table 1 and added MCG as an additional option for conducting medical necessity reviews of the procedure Added table of CPT codes that will be redirected to an ambulatory surgery center (ASC) from an outpatient hospital when criteria are met
Balloon Sinus Ostial Sinuplasty for Treatment of Chronic Sinusitis	I.B.2, gave an option for when corticosteroids are contraindicated
Bariatric Surgery	II.I, specified that H. Pylori screening should be conducted using a urea breath test or stool antigen test Added the following ICD-10 code ranges: M17.0–M17.9, M19.171–M19.179 and M19.271–M19.279
Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Stem Cell Transplantation	I.B, added that donor lymphocyte infusion (DLI) is intended to convert recipient cells from mixed to full chimerism, if there is a risk of relapse II.C and II.D, added “higher than grade 2 acute graft-versus-host-disease (GvHD)” and “total host chimerism” Removed not medically necessary indication from section II of a second DLI when benefits were not noted from the first
Durable Medical Equipment	Under Wound Care, removed HCPC’s code Q4111, GammaGraft, as code is included in CP.MP.185 Skin Substitutes for Chronic Wounds
Evoked Potential Testing	IV.B, added indications when visually evoked potentials are not medically necessary IV.C, revised “Treatment of all other conditions than those specified above” to “evaluation/assessment of all other conditions…” Added additional ICD 10 codes A39.82, H35.54, R44.1 and R48.3 as supporting medical necessity. Removed code H54.7 from list of medically necessary codes
Home Phototherapy for Neonatal Hyperbilirubinemia	I.C, added criterion that “if the mother is breastfeeding, she has been offered lactation support from a qualified professional”
Intraperitoneal Hyperthermic Chemotherapy for Abdominopelvic Cancers	Added I.F Ovarian cancer following neoadjuvant chemotherapy
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy	Renamed policy to Low Frequency Ultrasound Therapy and Noncontact Normothermic Wound Therapy Added criteria and background for noncontact normothermic wound therapy
Neonatal Abstinence Syndrome Guidelines	I.A.1, in asymptomatic infants section, specified that transitional care or newborn level 1 is appropriate if being assessed with modified Finnegan’s scoring I.A.2, added an alternative option for Level 2 nursery if being assessed and treated using ESC
Physical, Occupational and Speech Therapy	IV, Reevaluation: Added 1. New clinical findings or a significant change in the patient’s condition that was not anticipated in the plan of care (POC); added 2. Failure to respond to therapeutic interventions outlined in the POC
Proton and Neutron Beam Therapy	Removed Esophageal and Esophagogastric Junction Cancers as an indication for proton beam therapy (PBT) Added Hodgkin Lymphoma, Thymomas and Thymic carcinoma as indications. Added language for clarity to I.L, I.M ICD -10 Code updates: Removed C15.3–C15.9, added C37. Revised description of codes C71.0–C71.9 and C72.0–C72.9
Thyroid and Insulin Testing in Pediatrics	ICD-10 code updates
Total Artificial Heart	In I.G, removed specifications about chest size related to the device, and added that the requested device is FDA approved and used according to FDA indications
Ultrafiltration for Heart Failure	II, Added peritoneal ultrafiltration as investigational
Urodynamic Testing	Code update: ICD-10 N40.1 and R35.1, no longer specific to CPT 51798 and moved to list of codes that support medical necessity Added ICD-10 codes that support medical necessity
Wheelchair Seating	Coding revisions as noted in the Policy section

Clinical Practice Guideline:

Guideline	New Guideline Links
Clinical Practice Guidelines Grid	Updated the grid for a number of guidelines (too numerous to list here) with new publication/revision dates related to: early detection of cancer, asthma management, postmenopausal osteoarthritis, Rheumatoid Arthritis; tobacco use cessation, opioid use disorders, diabetes, HIV in pregnant women, sickle cell disease, Zika and Dengue Testing and added guideline for Coronavirus Disease 2019 (Covid-19)

Guideline

New Guideline Links

Clinical Practice Guidelines Grid

Updated the grid for a number of guidelines (too numerous to list here) with new publication/revision dates related to: early detection of cancer, asthma management, postmenopausal osteoarthritis, Rheumatoid Arthritis; tobacco use cessation, opioid use disorders, diabetes, HIV in pregnant women, sickle cell disease, Zika and Dengue Testing and added guideline for Coronavirus Disease 2019 (Covid-19)

If you have questions regarding the information contained in this update, contact California Health & Wellness Plan at
1-877-658-0305.