23-1339m Medical Policies - October 2023
Date:
11/14/23
Check out the new policies and 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 The Plan’s Medical Advisory Council (MAC) for October 2023. For a complete description of the medical policies, go to the California Health & Wellness Plan (CHWP) website at Clinical 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. This 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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Inactive policies
The following policies have been retired:
Policy number
| Policy name
|
|---|
HNCA.CP.MP.203/ CA.CP.MP.203
| Cardiac Risk Lab Tests
|
Updated Policies
Policy number and name
| Change
|
|---|
CP.MP.113 –
Holter Monitor
| - Criteria I. updated to specify a U.S. Food and Drug Administration (FDA)-approved Holter monitor device, and age in Criteria I. changed from > 18 years old to ≥ 18 years old.
- Criteria I.D. updated to include arrhythmogenic right ventricular cardiomyopathy (ARVC), hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy, or a first degree relative with HCM.
- Added Criteria I.O. for baseline or periodic screening for those with adult congenital heart disease.
- Criteria II. updated to specify an FDA approved Holter monitor device, and age in Criteria II. changed from ≤ 18 years old to < 18 years old.
|
CP.MP.146 –
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins
| Removed criterion I.B. regarding positioning during ultrasound.
|
CP. MP.97 –
Testing for Select Genitourinary Conditions
| - Description, Policy, and Background updated to increase age at which criteria restrictions apply to ≥ 16 years of age and note added in description for Trichomonas vaginalis, vaginal pH testing and potassium hydroxide (KOH).
- Policy/Criteria updated to include specified amplified deoxyribonucleic acid (DNA) probe testing as medically necessary.
- Updated criteria I. to include amplified DNA probe testing for symptomatic members/enrollees ≥ 16 years of age.
- Updated criteria III. for specific testing not medically necessary in asymptomatic individuals during routine exams, contraceptive management care, or pregnancy care to include unspecified amplified DNA probe testing, amplified DNA probe Candida testing, and SureSwab (CPT Code 81513), BD MAX Vaginal Panel (CPT Code 81514), and Xpert Xpress MVP (CPT Code 0352U) nucleic acid amplification testing (NAAT) panels for vaginitis.
- Updated criteria V. to include CPT code 0330U as not medically necessary.
- Background updated to include Megasphaera phylotype 1 and 2, BV-associated bacteria (BVAB)1, and 3 which allows for payment for CPT codes 81513 and 81514 and Sensitivity of Clinical and Nucleic Acid Amplification Testing (NAAT) table.
- Background information related to pediatric patients updated to address puberty and increase in age to ≥ 16 years of age. Moved CPT codes 81513, 81514, 87511, and 0352U codes to Table 1 (medically necessary CPT codes) from Table 3 (CPT codes considered not medically necessary).
- Added CPT codes O23.0 through O23.03, O23.1 through O23.13, O23.2 through O23.23, and O23.3 through O23.43 to Table 2 (ICD-10-CM diagnosis codes that support medical necessity).
- Table 5 updated to include screening ICD-10 codes Z11.2 and Z13.9 as not medically necessary.
- CPT Code 0353U removed from Table 6 and Table 7 header as gonorrhea and chlamydia are not in scope for this policy.
- Table 7 updated to remove ICD-10 codes B37.31, B37.32, L29.2, L29.3, N76.0 through N76.3, N77.1, N89.8, O23.511 through O23.93, Z72.51 through Z72.53, and Z86.19 allowing for payment of CPT code 87481 for vaginitis.
- Added ICD-10 codes Z11.2 and Z13.9 to Table 7.
|
CP.MP.152 –
Vitamin D, Measurement of Serum
| - Added criteria I.G. Hyperparathyroidism.
- Added ICD-10 codes E89.2, M83.8, and M83.9.
|
Additional information
If you have questions regarding the information contained in this update, contact CHWP at 877 658 0305.
This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, and Ancillary Providers.
