Updated Payment Policies - Effective October 1, 2024

Policy Number

Policy Name

Description

Business Line(s)

CP.MP.51

Reduction Mammoplasty and Gynecomastia Surgery

Annual review. Verbiage updated in criteria I.A.4.b. Removed criteria I.A.4.c. and d. Criteria updated to include mammogram requirement for members/enrollees < 40 years of age with symptoms of breast cancer or high-risk factors for breast cancer in what is now I.A.4.c.i.through iii. Clarifying language added to Criteria II.A.2. Criteria II.B.3. updated to include clarifying language and to include gynecomastia that persists for more than three months after unsuccessful medical treatment for pathological gynecomastia. Criteria II.B.4. updated to include clarifying language. References reviewed and updated.

Medicaid; Medicare

CP.MP.54

Hospice

Annual review. Revised criteria II.D.3.c. added “after bronchodilator (if able to obtain); under II.E.2.b. added “or upper urinary tract infection; under II.E.2.f. removed “over” and updated with “during the previous”; under II.G. removed “Failure” and replaced with “Disease”; under II.I.2.a. removed “up to” and replaced with “the last”. References reviewed and updated. Reviewed by external specialist.

Medicaid; Medicare

CP.MP.93

Bone-Anchored Hearing Aid

Annual review. Updated criteria in I.C. to specify “is consistent with the FDA indications for the requested device”. Added “(provided that the nerve is functional)” to I.F.1. Minor updates made to I.F4. and the policy statements in II. and III. Reference reviewed and updated.

Medicaid; Medicare

CP.MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Annual review. Description updated with no impact to criteria. Under I.A. added “with treatment including”. Added criteria to I.A.1.-I.A.2. to include: Correction via a minimally invasive approach; SCT resection when meeting all of the following: Fetuses with high-risk SCT and hydrops developing at a gestational age earlier than appropriate for delivery and neonatal care (eg. 28-32 weeks gestation); Does not have the following contraindications: Type III or IV Altman-type tumors; Severe placentomegaly; Maternal cervical shortening. Removed indication I.F.5. Normal fetal karyotype. Quantified criteria I.F.5.c. to include (≥30 degrees). Added criteria I.G. Fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) when all of the following criteria are met: Severe left-sided CDH; Severe pulmonary hypoplasia defined as a quotient of the observed-to-expected lung-to-head ratios of less than 25%; Gestational age ≤ 30 weeks. Removed III.A. Open or endoscopic fetal surgery for congenital diaphragmatic hernia (CDH), including temporary tracheal occlusion. References reviewed and updated. Reviewed by external specialist.

Medicaid; Medicare

CP.MP.171

Facet Joint Interventions

Annual review. Clarifying language added to Criteria I.A. to specify diagnostic facet joint injections. Minor rewording in Criteria I.A.1.a. Updated to include ≥ four weeks of physical therapy or prescribed home exercise program and ≥ four weeks activity modification. Removed Criteria I.A.1.c. regarding ≥ six weeks chiropractic, physical therapy, or prescribed home exercise program. Removed Criteria I.A.1.d. and added to Criteria I.A.1.b. Removed Criteria I.A.1.e. regarding ≥ six weeks activity modification. Criteria I.A.1.c. updated to replace disc herniation, radiculitis, discogenic or sacroiliac pain with fracture, tumor, infection, and extraspinal lesion and updated to include pain not associated with radiculopathy or myelopathy and removed pain worse at night. Pain relief updated from > 75% to ≥ 80 % in Criteria I.A.1.e. Note at end of Criteria I. updated to pain relief of < 80% instead of < 75% and updated to specify a second block at the same level is not medically necessary. Criteria I.B. updated to specify neck or back pain present for ≥ three months. Pain relief updated from > 75% to ≥ 80 % in Criteria I.B.1.b. and removed ability to perform prior painful movements without significant pain. Criteria I.B.2.b. updated from at least four months to at least six months. Criteria I.D. updated to include medical necessity for therapeutic facet joint injections when meeting criteria I.D.1 through I.D.4. References reviewed and updated. Reviewed by internal specialist.

Medicaid; Medicare