Medical Policies - 2nd Quarter

New Policies

Policy Reference Number

Policy Name

Description

CP.MP.158

Implantable Wireless PAP Monitoring

Implantable wireless pulmonary artery pressure monitoring (PAP) (for example, CardioMEMS^™) is considered not medically necessary for all indications, including management of heart failure

CP.MP.156

Pediatric Liver Transplant

Clinical indications and contraindications are included

Updated Policies

Policy Reference Number

Policy Name

Description

CP.MP.124

ADHD Assessment and Treatment

Attention Deficit Hyperactivity Disorder (ADHD): Added evaluation of iron status (for example measurement of serum iron and ferritin levels) as not medically necessary. Codes reviewed and updated 

Policy Reference Number

Policy Name

Change

CP.MP.104

Applied Behavioral Analysis

Specified which Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and DSM-5 diagnoses apply, and broke these into separate criteria points. Added pediatric psychiatrist, neurologist or developmental pediatrician as clinicians that can validate the autism spectrum disorder (ASD) diagnosis

CP.MP.26

Articular Cartilage Defect Repairs

Osteochondral implants: added requirement for absent or minimal changes in surrounding articular cartilage

CP.MP.119

Balloon Sinus Ostial Dilation

Clarified in >18 chronic rhinosinusitis (CRS) section that computed tomography (CT) findings of opacification should be in the sinuses, and removed statement that CT findings should be radiographic

CP.MP.156

Cardiac Biomarker Testing

Deleted Table 2, diagnosis code list. Clarified in criteria point II that creatine kinase myocardial isoenzyme (CK-MB) and myoglobin are not medically necessary when billed with CPT code 84484 for troponin

CP.MP.84

Cell-free Fetal DNA Testing

Added III. Cell-free fetal DNA testing for additional chromosomal abnormalities other than trisomy 21, 18 or 13 are considered not medically necessary, including, but not limited to, other trisomies, aneuploidies or microdeletions. Background information updated

CP.MP.114

Disc Decompression Procedures

Revised I.C.1.a. from a score of <2 on the Medical Research Council 0 to 5 muscle strength scale to a score of <3 per 2017 IQ criteria. Codes updated

CP.MP.89

Genetic Testing

References reviewed and updated. Added I.D: member has not previously undergone genetic testing for the disorder. Added statement that direct-to-consumer genetic testing is not medically necessary

CP.MP.153

H. Pylori Serology Testing

Removed from background of policy the statement, Serology testing is useful in screening and epidemiological studies and indications for testing in individuals without alarm symptoms

CP.MP.34

Hyperemesis Gravidarum Treatment

Removed step therapy approach in I.C because it is redundant. Removed information about symptoms, food intake, urinary ketones, urine specific gravity, and daily weights

CP.MP.118

Injections for Pain Management

Removed criteria addressing selective nerve root block (SNRB) from section I. Renamed section I, Cervical/Thoracic/Lumbar/Caudal, Interlaminar ESI. Added section II, Selective Nerve Root Blocks/Transforaminal Epidural Steroid Injections (TFESI) that includes criteria for SNRB/TFESI. All subsequent sections have been renumbered accordingly. Under section IIIB, removed #2 and #3, as the criteria are already addressed in section III C. Added medically necessary criteria to section III, Transforaminal Epidural Steroid Injections, regarding initial injections

Policy Reference Number

Policy Name

Change

CP.MP.82

NICU Apnea Bradycardia Discharge Guidelines

Revised statement in section I, clarifying possibly longer to up to 7 days.           Changed <28 weeks gestation to <32 weeks gestation. References reviewed and updated. Replaced in background, “A target level of 10-20ug/ml is sought” with “The therapeutic trough serum concentration is 5 to 25 mg/L” as per UpToDate. Clarified statement under II. Caffeine, that discontinuation of caffeine often occurs before discharge

CP.MP.109

Panniculectomy

Changed wording in I.D for clarification that weight should be stable after bariatric surgery

CP.MP.138

Pediatric Heart Transplant

Specified for each indication the stage of heart failure required, and removed general criteria stating that patient is in stage C or D heart failure. Removed severely limited functional status with poor rehab potential, as it is included in criteria requiring adequate functional status with the ability for rehabilitation

CP.MP.147

Percutaneous LAAD Stroke Prevention

Percutaneous Left Atrial Appendage Closure Device (LAAC) for Stroke Prevention: Clarified in I.A and I.B that the anticoagulation therapy recommended is for long-term use. Updated background information to include possible complication associated with the device. Revised information under section American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) for clarification purposes 

CP.MP.142

Urinary Incontinence Devices and Treatments

Reworded investigational statement in III for clarity

CP.MP.46

Ventricular Assist Devices

Clarified in section I.B.3.a. that the phrase “failure to respond to” only applied to optimal medical management, and not balloon or inotrope dependence. Specified that balloon pump and inotrope requirements are ≥, and not exact. Changed cardiac transplantation to heart transplant for consistency

CP.MP.111

Zika Virus testing

Simplified definition of possible Zika exposure. Numerous changes that are noted in the policy under Reviews, Revisions and Approvals