Updated Clinical Policies - Effective September 1, 2024
Date: 08/08/24
MHS Health Wisconsin continually adds new or provides updates to clinical and payment policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members.
View all Clinical and Payment Policies.
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.
The following policies are effective September 1, 2024.
Policy | Policy | Policy | Business Line(s) |
CP.BH.124 | Attention Deficit Hyperactivity Disorder Assessment and Treatment | Annual revision, additional codes added | Medicaid; Medicare |
CP.MP.87
| Therapeutic Utilization of Inhaled Nitric Oxide | Annual review. Condensed criteria statement II. to, "while the medical literature predominantly does not support the use of inhaled nitric oxide (iNO) in premature infants < 34 weeks gestational age at birth, requests for initiation of iNO therapy in these infants may be reviewed on a case-by-case basis with consideration of the criteria for premature newborns ≥ 34 weeks gestational age at birth in section I.” References reviewed and updated. Reviewed by external specialist. | Medicaid; Medicare |
CP.MP.107
| Durable Medical Equipment and Orthotics and Prosthetics Guidelines
| Updated verbiage in Newborn Care Equipment, Breast Pumps for inclusivity. Added new criteria section titled Lumbar-Sacral Orthotics (LSO) and included codes L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0643, L0648, L0649, L0650, L0651, L0700, L0710, L0999, L1000, L1001, L1005. Renamed original “Spinal Orthotics” criteria “Other Spinal Orthotics”. Updated manual wheelchair initial request criteria A., A.2. and 4., B.1. and 2., and removed C. Reformatted and updated manual wheelchair replacement request criteria. Deleted codes E1091 and K0009. Reviewed by internal specialist. | Medicaid; Medicare |
CP.MP.114
| Disc Decompression Procedures | Annual review. Removed “unilateral” for radiculopathy in Criteria I.C.1. Updated muscle strength score in Criteria I.C.1.a. from < 3 to ≤ 3. Updated muscle strength score in Criteria I.C.1.b. from 3 or 4 to 4. Added “within the last year” for conservative therapy in Criteria I.C.1.b.ii. Updated physical therapy from ≥ six weeks to ≥ four weeks in Criteria I.C.1.b.ii.a). Updated activity modification from ≥ six weeks to ≥ four weeks in Criteria I.C.1.b.ii.b). Updated Criteria I.C.1.b.ii.c) to specify one of the following: 1) NSAID or acetaminophen ≥ 3 weeks unless contraindicated or not tolerated 2) Epidural steroid injection. Removed “unilateral” for radiculopathy in Criteria I.C.2. Updated physical therapy from ≥ six weeks to ≥ four weeks in Criteria I.C.2.a. Updated activity modification from ≥ six weeks to ≥ four weeks in Criteria I.C.2.b. Updated Criteria I.C.2.c. to specify one of the following: i. NSAID or acetaminophen ≥ 3 weeks unless contraindicated or not tolerated ii. Epidural steroid injection. References reviewed and updated. Reviewed by external specialist. | Medicaid; Medicare |
CP.MP.117
| Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation | Description updated with no impact on criteria. Added Criteria III. stating that there is insufficient evidence to support the efficacy of PENFS for any indication, including irritable bowel syndrome (IBS). Background updated with information to support updated criteria regarding PENFS. Added CPT code 0720T as not covered. References reviewed and updated. | Medicaid; Medicare |
CP.MP.126
| Sacroiliac Joint Fusion
| Annual review. Minor rewording in Criteria I.B. and Criteria I.D. Removed osteopathic or chiropractic manipulation from Criteria II.A.3. Added (sacral sulcus) to criteria II.C. Added clarifying verbiage to Criteria II.B. Updated Criteria II.D. to include a positive response to at least three provocative tests. Added clarifying language to Criteria II.F.2. Removed “at least two weeks apart” in Criteria II.G. regarding image guided, contrast-enhanced intra-articular (diagnostic) SIJ injection on two separate occasions. Added code 27278 to table of codes that do not support coverage. Background updated with no impact on criteria. References reviewed and updated. |
|
CP.MP.184 | Home Ventilators | Annual review. Added note for corresponding Medicare policy. Updated all policy statements to indicate "non-Medicare" health plans. In I.A.1 changed "both" to "one" of the following and added "taken while member/enrollee was stable (not in acute respiratory failure)". Removed criteria for BiPAP failure and contraindications in sections I and II, and replaced with criteria requiring documentation that "member/enrollee could not be appropriately treated with a RAD" and "non-invasive home ventilator will not be used to provide RAD or CPAP therapy...". Removed criteria in I.A.1.a. and b. for members/enrollees < 18 years. In 1.A.1a. updated PaCO2 > to greater than or equal to. In I.C.1 updated BMI > than 30 to greater than or equal to 30. In 1.C.2 added "at baseline". Added criteria I.C.3. "Hypoventilation has been documented by polysomnography and other conditions are not considered the primary cause of hypoventilation..." Removed medical necessity criteria I.D. for home ventilators for treatment failure of BiPAP. In II.B. replaced "medical records document improvement..." with II.B.1. and 2. "Documentation supports: Ongoing benefits... and "non-invasive home ventilator will not be used to provide RAD or CPAP therapy...". Minor rewording throughout policy with no clinical significance. References reviewed and updated. External specialist review. | Medicaid; Medicare
|