Updated Clinical Policies - Effective May 1, 2024
Date: 03/27/24
MHS Health Wisconsin continually reviews and updates our clinical policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members.
Updated policies are listed below. All are effective May 1, 2024. The updated policies will be available for review and download on their effective date in the Clinical and Payment Policies section on our website.
| Policy Number | Policy Name | Description | Business Line(s) |
|---|---|---|---|
| CP.MP.22 | Stereotactic Body Radiation Therapy | Annual review. Updated all criteria instances of "blood gas study" to include "or pulse oximetry measurement" and all instances of “arterial oxygen saturation” to include “(or pulse oximetry)”. Changed age requirements in I. and III. from ≥ 21 to ≥ 18 years of age. Changed age requirements in II and IV from <21 to <18 years of age. Minor rewording in Criteria I. Added clarifying language to Criteria I.B.1.a. regarding breathing room air. In I. B.1.b., I.B.1.c., and I.B.2.a., removed the requirement that the measurement is taken after 5 minutes of sleep vs. during sleep. Criteria I.D.2. updated to reflect condition requirements for blood gas study not performed during an inpatient hospital stay. Removed I.E. regarding alternative treatments. Added clarifying language to Criteria II.A.2. for cystic fibrosis complicated by severe chronic hypoxemia. Updated Criteria II.A.4. to state Bronchopulmonary dysplasia (BPD) complicated by chronic hypoxemia. Added Criteria II.A.9. to include pulmonary hypertension without congenital heart disease complicated by chronic hypoxemia. Added Criteria II.A.10. to include interstitial lung disease complicated by severe chronic hypoxemia. Updated Criteria II.B.1. and Criteria II.B.2. to include requirements for SpO2. | Medicaid |
| CP.MP.62 | Hyperhidrosis Treatments | Annual review. Minor rewording of pharmacy policy title (in description). Changed order of criteria. Added criteria point III.I. regarding counseling on risks. Background updated with no clinical significance. Removed CPT codes 64802 through 64823. References reviewed and updated. Reviewed by external specialist. | Medicaid |
| CP.MP.82 | NICU Apnea Bradycardia Guidelines | Annual review. Minor rewording throughout criteria with no impact on criteria. Added clarifying language to Criteria I.A.1.c. and updated oxygen saturation percentage from < 85% to ≤ 85%. Updated wording in Criteria I.A.2.a. for clarity and flow. Updated Criteria I.A.2.b. to include verbiage for significantly reducing the severity and duration of bradycardia or apnea events. Updated Criteria I.A.3.d. to include that parents or caregivers agree with the plan of care. Added Criteria I.A.3.e. regarding the home situation being assessed and deemed adequate. Expanded information on CPR requirement in Note section at end of Criteria. Updated Note section at end of Criteria to include when additional observation days may be needed. Minor rewording in Background with no impact on criteria. References reviewed and updated. Criteria I.A.1.c., Criteria I.A.2.a., and Criteria I.A.2.b. reviewed by internal specialist. Policy reviewed by external specialist. | Medicaid |
| CP.MP.173 | Implantable Intrathecal or Epidural Pain Pump | Annual review. Restructured and reformatted criteria section. In I.B. and II.B. added contraindications to include known allergies to materials in the implant;active alcohol or drug abuse, including but not limited to opioid addiction and intravenous drug abuse, diagnosis of dementia or psychosis; active systemic infection, active infection at the site of implantation. Background updated with no impact to criteria. References reviewed and updated. | Medicaid |
| CP.MP.190 | Outpatient Oxygen Use | Annual review. Updated all criteria instances of "blood gas study" to include "or pulse oximetry measurement" and all instances of “arterial oxygen saturation” to include “(or pulse oximetry)”. Changed age requirements in I. and III. from ≥ 21 to ≥ 18 years of age. Changed age requirements in II and IV from <21 to <18 years of age. Minor rewording in Criteria I. Added clarifying language to Criteria I.B.1.a. regarding breathing room air. In I. B.1.b., I.B.1.c., and I.B.2.a., removed the requirement that the measurement is taken after 5 minutes of sleep vs. during sleep. Criteria I.D.2. updated to reflect condition requirements for blood gas study not performed during an inpatient hospital stay. Removed I.E. regarding alternative treatments. Added clarifying language to Criteria II.A.2. for cystic fibrosis complicated by severe chronic hypoxemia. Updated Criteria II.A.4. to state Bronchopulmonary dysplasia (BPD) complicated by chronic hypoxemia. Added Criteria II.A.9. to include pulmonary hypertension without congenital heart disease complicated by chronic hypoxemia. Added Criteria II.A.10. to include interstitial lung disease complicated by severe chronic hypoxemia. Updated Criteria II.B.1. and Criteria II.B.2. to include requirements for SpO2 | Medicaid |
| CP.MP.243 | Implantable Loop Recorder | Annual review. Added criteria III. to include requests for replacement implantable loop recorders. Background updated with no impact to criteria. References reviewed and updated. Reviewed by external specialist. | Medicaid |
| CP.MP.248 | Facility-based Sleep Studies for Obstructive Sleep Apnea | Annual review. Updated description and included “Notes”. Added non-Medicare to all policy statements. Added superscript citations throughout policy. In I.B.8.a. added "documentation". Updated I.B.8.a.i. to "Moderate to severe, chronic pulmonary disease". Removed criteria I.B.8.a.i.a) and b). Updated I.B.8.a.ii. to "Congestive heart failure...". Updated I.B.8.a.v. to "Concern for significant non-respiratory sleep disorder(s)...". Added I.B.8.a.vi "Hypoventilation syndrome". Updated I.B.8.b.ii to "Daytime sleepiness...". Added I.B.8.b.ii.a "Habitual loud snoring". Removed I.B.8.b.iv. "Significant oxygen desaturation...". Updated III.A. to "Meets criteria in section I...". Removed III.C and D. for central sleep apnea. References reviewed and updated. Internal and external specialist reviewed. | Medicaid |
| CP.BH.104 | Applied Behavioral Analysis | Annual review. Replaced all instances of “DSM-5” with “DSM-5 TR”. Added requirement for a comprehensive diagnostic evaluation to have been conducted within the past five years in I.A.1. Added Social Skills Improvement System (SSIS) as an additional skill assessment option in I.E.1.b.ii.e. In I.E.,2.b. deleted “comprehensive.” Deleted I.E.,2.b.ii.e). and replaced it as a “note” under I.2.b.ii.d). In I.E.2.c.vi. deleted “in the home or community activities.” Added I.E.2.f.i. “Behavioral health outpatient services” to the list. Added statement to I.E.3.b. “Assessments are performed consistent with criteria in I.E.1. b.” Rearranged criteria point in I.E.3 for clarity. In II.A. added statement “… and generally involve a gradual step-down in services.” In II.C. Removed the statements “Services may be appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care.” Removed ICD 10 chart. Updated description and background with no clinical significance. References reviewed and updated. Annual review. Replaced all instances of “DSM-5” with “DSM-5 TR”. Added requirement for a comprehensive diagnostic evaluation to have been conducted within the past five years in I.A.1. Added Social Skills Improvement System (SSIS) as an additional skill assessment option in I.E.1.b.ii.e. In I.E.,2.b. deleted “comprehensive.” Deleted I.E.,2.b.ii.e). and replaced it as a “note” under I.2.b.ii.d). In I.E.2.c.vi. deleted “in the home or community activities.” Added I.E.2.f.i. “Behavioral health outpatient services” to the list. Added statement to I.E.3.b. “Assessments are performed consistent with criteria in I.E.1. b.” Rearranged criteria point in I.E.3 for clarity. In II.A. added statement “… and generally involve a gradual step-down in services.” In II.C. Removed the statements “Services may be appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care.” Removed ICD 10 chart. Updated description and background with no clinical significance. References reviewed and updated. | Medicaid |
| V1.2024 | CG Hereditary Cancer Susceptibility | In hereditary breast cancer susceptibility panel criteria, changed the “or” after I.B.2. to “and.” In PTCH1 and SUFU Sequencing and/or Deletion/Duplication Analysis criteria, moved indication I.1.f)1)- 9) to I.A.2.a)-i); after criteria newly numbered as I.A.3)e), changed the “or” to “and”; moved indications previously listed as I.A.3.f)1)-9) to new number I.A.4.a)-i). | Medicaid |
| V1.2024 | CG Metabolic, Endocrine, and Mitochondrial Disorders | Updated table, criteria section labels, and background for maturity onset diabetes of the young to state “Monogenic diabetes of the young (including maturity-onset diabetes of the young (MODY))”. Updated monogenic diabetes of the young criteria: In I.A., changed from requiring the diabetes diagnosis within the first six months of life to the first 12 months of life; in I.B., changed requirement for the member to have the diagnosis before age 35 years to age 30 years; reworded option for autoantibodies; reworded C-peptide criteria to remove specific values and the requirement for hypoglycemia; replaced criteria for specific features of atypical type 2 diabetes with “diagnosis of diabetes not characteristic of type 1 or type 2 diabetes”; removed requirement for inclusion of specific genes in the panel. Background for monogenic diabetes updated. | Medicaid |
| V1.2024 | CG Prenatal and Preconception Carrier Screening | In the criteria for CFTR Sequencing, Deletion/Duplication Analysis, or Mutation Panel, changed the number of tested variants from 23 to 100 and updated background accordingly, consistent with the 2023 ACMG statement on CFTR variant testing. | Medicaid |
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.