Updated Clinical Policies - Effective November 17, 2023

Date: 10/17/23

MHS Health Wisconsin continually reviews and updates our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members.

The following policies will take effect on November 17, 2023.

Policy Number	Policy Name	Policy Description	Business Line(s)
CP.MP.129	Fetal Surgery in Utero for Prenatally Diagnosed Malformations	This policy describes the medical necessity requirements for performing fetal surgery. This becomes an option when it is predicted that there will be severe disability, or if it is predicted that the fetus will not live long enough to survive delivery or after birth.1 Therefore, surgical intervention during pregnancy on the fetus is meant to correct problems that would be too advanced to correct after birth. Annual review and revision. Criteria I.G.3. updated to include confirmation on fetal MRI. Added clarifying language to Criteria I.G.4. Added CPT code 59072. ICD-10 codes removed.	Medicaid; Medicare
CP.MP.48	Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES)	This policy describes the medical necessity requirements for the use of neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES). Annual review and revision. Combined criteria applicable to LE units into section II.G. Additional contraindications added to Section F. ICD-10-CM Diagnosis Code table removed.	Medicaid; Medicare

Policy Number

Policy Name

Policy Description

Business Line(s)

CP.MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

This policy describes the medical necessity requirements for performing fetal surgery. This becomes an option when it is predicted that there will be severe disability, or if it is predicted that the fetus will not live long enough to survive delivery or after birth.1 Therefore, surgical intervention during pregnancy on the fetus is meant to correct problems that would be too advanced to correct after birth.

Annual review and revision. Criteria I.G.3. updated to include confirmation on fetal MRI. Added clarifying language to Criteria I.G.4. Added CPT code 59072. ICD-10 codes removed.

Medicaid; Medicare

CP.MP.48

Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES)

This policy describes the medical necessity requirements for the use of neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES).

Annual review and revision. Combined criteria applicable to LE units into section II.G. Additional contraindications added to Section F. ICD-10-CM Diagnosis Code table removed.

Medicaid; Medicare

Thank you for being a valued partner in caring for the health and well-being of our members. If you have any questions about the policies listed above or any our Clinical & Payment Policies, please contact your Provider Relations representative or call the Provider Inquiry Line at 1-800-222-9831. If you are unsure who your representative is, please email us at WI_Provider_Relations@mhswi.com.