19-926 Medical Policies 3rd Quarter 2019

Updated Policies

Policy number

Policy name

Change

CP.MP.96

Ambulatory Electroencephalography (EEG)

·      Added last sentence, “Ambulatory EEG monitoring….” to the description.  Within criteria, removed “for classification of seizure type” from “B.” and updated “D.” with “To characterize seizure type…..”, also removed “To adjust antiepileptic medication levels”

·      Removed “F. To identify and medicate absence seizures”

·      Removed “G. To differentiate between epileptic and sleep disorder related episodes”

Updated Policies, continued

Policy number

Policy name

Change

CP.MP.96, continued

Ambulatory Electroencephalography (EEG)

·      Removed paragraph in Background section on psychogenic nonepileptic spells and the paragraph on analysis

CP.MP.119

Balloon Ostial Dilation

Added CPT 31298

CP.MP.37

Bariatric Surgery

·      Revised and reorganized section I.A.1. by BMI and type of procedures considered medically necessary

·      I.A.1.c., added medically necessary BMI category of ≥ 30 and < 35 kg/m2 when criteria is met

·      Revised I.A.2, a. and b., clarifying weight parameters to reflect current terminology

·      I.A.2.a., removed requirement for comorbidities, I.A.2.b., added comorbidities to this section

·      Removed II.D, requirement that Tanner stage, or bone age should be completed

·      Section V, added single anastomosis duodenoileal bypass (SADI); gastric plication/endoluminal vertical gastroplasty; and endoscopic gastrointestinal bypass devices (EGIBD) (barrier devices) as investigational

CP.MP.164

Caudal or Interlaminar Epidural Steroid Injections

·      In section D regarding second or subsequent epidural steroid injection (ESI) for chronic pain that improved from the diagnostic injections

·      Changed requirement for 3 months having passed from the previous injection to 2 months

·      Anticoagulation indication moved to policy/criteria section as it is applicable to all injections in this policy

CP.MP.84

Cell-free Fetal DNA Testing

·      Moved 81422 and 81479 to a table for codes that do not support medical necessity

·      Clarified that between “10 and 22 weeks gestation” is ≥ 10 weeks and
< 23 weeks gestation

CP.MP.114

Disc Decompression Procedures

Specified that CPT 0275T is a code that does not support coverage criteria

CP.MP.107

DME and O&P Criteria

·      Added E1399 miscellaneous component code criteria under Gait Trainers

·      Added E1399, K0108, and K0739 as miscellaneous equipment codes requiring physician or therapy advisor review under Specialized Supply or Equipment

·      Removed E1811, E1815, and E1818 for flexion/extension devices, as they are included in CP.MP.144 Mechanical Stretch devices

CP.MP.106

Endometrial Ablation

Added additional FDA approved devices (i.e., Mara™, Minerva^®) to table 1

CP.MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformation

Sacrococcygeal teratoma (SCT) under I.A.: removed requirement for hydrops and included option for minimally invasive approach

Updated Policies, continued

Policy number

Policy name

Change

CP.MP.89

Genetic Testing

Added note that this policy should only be used if there is no specific clinical decision support criteria available

CP.MP.173

Implantable Intrathecal Pain Pump

Added CPT codes: 62320, 62321, 62351, 62361

CP.MP.144

Mechanical Stretching Devices for Joint Stiffness and Contracture

Added code E1399 (miscellaneous DME) as not medically necessary

CP.MP.170

Nerve Blocks for Pain Management

·      Removed CPT 64508 as code was inactive 1/1/2019.

·      Added CPT 64620 for intercostal neurolysis

·      Specified that the following codes DO NOT support medical necessity: 64400, 64402, 64408, 64410, 64413, 64415, 64417, 64418, 64425, 64430, 64435, 64445, 64447, 64450, 64505

CP.MP.81

Neonatal Intensive Care Unit (NICU) Guidelines

·      Removed “support and training” criteria in nutrition section as it is contained in general discharge guidelines

·      Changed informational note that home nursing support will usually be needed for home ventilation to criteria requiring its arrangement

·      Added to home nutrition and home respiratory needs sections that caregiver and provider agree to home management and removed “may be considered” language

·      Moved home antibiotic infusion criteria from authorization protocol to physiologic competency section

·      Added the following general discharge recommendations: follow-up care planned, medication reconciled, transportation needs identified and addressed

CP.MP.133

Posterior Nerve Stimulation for Voiding Dysfunction

Revised I.B, examples of pharmacotherapy, to include oral anti-muscarinics or β3-adrenoceptor agonists

CP.MP.165

Selective Nerve Root Blocks and Transformational Epidural Steroid Injections

·      Revised frequency interval of transforaminal epidural steroid injections (TFESI) in II.D.3 to at least 2 months apart

·      Anticoagulation indication moved to policy/criteria section as it is applicable to all injections in this policy

CP.MP.97

Testing for Select Genitourinary Conditions

·      Removed direct probe for trichomonas vaginalis from the policy (CPT 87660) to allow trichomonas testing to be performed without symptoms

·      Added ICD-10 N89.8 as medically necessary for testing

CP.MP.12

Vagus Nerve Stimulation

·      Added CPT code 61888 (revision or removal of cranial neurostimulator..)

·      Added ICD-10 code, G40.311 (..epilepsy..)