Policies & Procedures Manual

A

Medical Policies - Prior Authorization*

• Abdominoplasty — Panniculectomy (effective 4/1/17)
• Ankle Replacement, Total (effective 11/1/17)

Pay Policies

• Abdominal Aortic Aneurysm (AAA), Endovascular Stents (effective 6/1/17)
• Acupuncture (effective 12/1/16)
• Angiography, CT of Chest (effective 7/1/17)
• Apnea Monitoring, Home (effective 4/1/17)
• Autism Spectrum Disorders (effective 12/1/16)

B

Medical Policies - Prior Authorization*

• Bariatric/Obesity Surgery (effective 11/1/16)
• Beds – Pediatric Specialty Including Totally Enclosed Bed Systems (effective 6/1/17)
• Beds – Pressure Reducing Support Surfaces (effective 8/1/17)
• Bone Growth Stimulators, Non-Invasive (effective 8/1/17)
• Breast Reduction and Mastectomy for Gynecomastia (effective 4/1/17)

Pay Policies

• Beds, Hospital Beds and Accessories (effective 5/1/17)
• Blepharoplasty (effective 8/1/17)
• Brain and Dorsal Column Stimulators (effective 4/1/17)
• Breast Reconstruction Procedures (effective 9/1/17)
• Breast Pumps (effective 4/1/17)

C

Medical Policies - Prior Authorization*

• Cardiac Defibrillator, Subcutaneous Implantable (effective 5/1/17)
• Cardiac Defibrillator, Wearable (effective 3/1/17)
• Carotid Stents, Extracranial (effective 9/1/17)
• Chest Wall Oscillation Devices (effective 3/1/17)
• Chiropractic, Under 13 Years Old (effective 11/1/16)
• Clinical Trials – Coverage of Routine Care Costs (effective 5/1/17)
• Cochlear Implants and Osseointegrated Bone Conduction Devices (effective 2/1/17)
• Continuous Glucose Monitors (effective 11/1/16)
• Cranial Orthosis/Remolding (effective 9/1/17)

Pay Policies

• Chelation Therapy (effective 5/1/17)
• Chiropractic, 13 Years Old and Over (effective 4/1/17)
• Compression Stockings and Garments (effective 8/1/17)
• Coronary Intravascular Ultrasound (IVUS) (effective 5/1/17)
• Cosmetic versus Reconstructive Services (effective 4/1/17)

D

Medical Policies - Prior Authorization*

• Dental Anesthesia (effective 12/1/16)
• DME, Repair and Replacement (effective 11/1/16)

E

Medical Policies - Prior Authorization*

• Endoscopy, Wireless Capsule (effective 7/1/17)
• Esophagogastroduodenoscopy (EGD), Repeat within 12 Months (effective 9/1/17)
• Experimental and Investigational Services (effective 7/1/17)

Pay Policies

• Endometrial Ablation (effective 2/1/17)
• External Counterpulsation Therapy (effective 5/1/17)
• Eye – Anterior Segment Optical Coherence Tomography (effective 5/1/17)

F

Pay Policies

• Foot Care Services, Routine (effective 5/1/17)

G

Medical Policies - Prior Authorization*

• Gender Confirmation Surgery (effective 1/1/17)
• Genetic Testing – BRCA (effective 1/1/17)
• Genetic Testing – Breast Cancer, Gene Expression Profile (effective 12/1/16)
• Genetic Testing- Chromosomal Microarray (CMA) (effective 9/1/17)
• Genetic Testing – General (effective 2/1/17)
• Genetic Testing – Whole Genome-Exome Sequencing (effective 2/1/17)

Pay Policies

• Genetic Testing – Bladder Tumor (effective 9/1/17)
• Genetic Testing – Cell-Free Fetal DNA (effective 6/1/17)
• Genetic Testing – Colorectal Cancer Treatment (effective 4/1/17)
• Genetic Testing – CYP2D6 (effective 5/1/17)
• Genetic Testing – Cystic Fibrosis (effective 6/1/17)
• Genetic Testing – Inherited Colorectal Cancers (effective 4/1/17)
• Genetic Testing – Lung Cancer (effective 8/1/17)
• Genetic Testing – Melanoma Treatment (effective 7/1/17)
• Genetic Testing – Plavix (Clopidogrel) Metabolism (effective 4/1/17)
• Genetic Testing – Thyroid Nodule (effective 12/1/16)
• Glaucoma, Invasive Procedures (effective 6/1/17)

H

Medical Policies - Prior Authorization*

• Heart Valves, Transcatheter (TAVI/TAVR and Pulmonary) (effective 6/1/17)
• Hip Replacement/Arthroplasty (effective 2/1/17)

Pay Policies

• Human Papilloma Virus (HPV) Testing (effective 5/1/17)
• Hyperbaric Oxygen (effective 5/1/17)

Pharmacy Policies - Prior Authorization

• Hepatitis C Treatment - Medicaid (effective 7/1/17)

I

Medical Policies - Prior Authorization*

• Insulin Pumps (effective 1/1/17)

Pay Policies

• Incontinence – Posterior Tibial Nerve Stimulator (PTNS) (effective 12/17/16)
• Infertility – Diagnosis (effective 9/1/17)
• Infertility – Treatment of (effective 3/1/17)
• Injections – Trigger Point and Transforaminal Epidural (effective 7/1/17)
• Intraoperative Neurophysiological Testing (effective 4/1/17)
• Iontophoresis (effective 4/1/17)

J

K

Medical Policies - Prior Authorization*

• Knee Replacement/Arthroplasty (effective 11/1/17)

L

Medical Policies - Prior Authorization*

• Lumbar Laminectomy/Hemi-laminectomy (effective 3/1/17)
• Lumbar Spinal Fusion (effective 3/1/17)
• Lymphedema Pumps and Appliances (effective 11/1/16)

Pay Policies

• Lenses — PIOLs & A-CIOLs (effective 9/1/17)
• Low Back Pain, Radiofrequency Ablation (effective 7/1/17)
• Low-dose Computed Tomography (CT) Screening for Lung Cancer (effective 9/1/17)

M

Pay Policies

• Magnetic Resonance Spectroscopy (effective 9/1/17)
• Magnetoencephalography (effective 4/1/17)
• Mastectomy, Prophylactic (effective 6/1/17)

N

Medical Policies - Prior Authorization*

• Neuromuscular Electrical Stimulators (Medicare only) (effective 6/1/17)
• Nutrition, Parenteral (effective 2/1/17)
• Nutritional Support (effective 8/1/17)

Pay Policies

• Nerve Block, Paravertebral, Facet Joint, and SI Injections (effective 6/1/17)
• Nerve Conduction Velocity Studies (effective 5/1/17)
• Nerve Stimulators, Sacral (effective 5/1/17)
• Nutrition – Medical Nutrition Therapy (effective 4/1/17)

Clinical Resource Management

• Non-Emergent Ambulance Transportation (effective 12/1/16)

O

Medical Policies - Prior Authorization*

• Outpatient/Mobile Real Time Cardiac Surveillance Systems (effective 11/1/17)

Pay Policies

• Oxygen Therapy, Home (effective 4/1/17)

P

Medical Policies - Prior Authorization*

• Pancreatectomy with Autologous Islet Cell Transplantation (effective 9/1/17)
• Pediatric Extended Care Centers (effective 2/1/17)♦
• Private Duty Nursing – Commercial and CHIP (effective 7/1/17)
• Proton Beam Therapy (PBT) (effective 6/1/17)

Pay Policies

• Physical Therapy, Home (effective 8/1/17)
• Prothrombin Time (INR) Home Testing (effective 3/1/17)
• Pulse Oximetry, Continuous Home (effective 4/1/17)

Q

R

Pay Policies

• Radiation Therapy, Intensity-Modulated (effective 2/1/17)
• Radiation Therapy – SRS and SBRT (effective 10/1/17)

S

Medical Policies - Prior Authorization*

• Skilled Nursing and Personal Care Shift Services – Medical Assistance (effective 8/1/17)

Pay Policies

• Salpingo-Oophorectomy, Prophylactic (effective 5/1/17)
• Septoplasty-Rhinoplasty (effective 10/1/17)
• Shoes and Lower Limb Orthotics (effective 7/1/17)
• Sleep Medicine – C-Pap/BiPap (effective 4/1/17)
• Sleep Medicine - Obstructive Sleep Apnea, Oral Appliances (effective 5/1/17)
• Sleep Medicine - Sleep Study (effective 8/1/17)
• Skin Equivalents (HSE) (effective 3/1/17)
• Speech Generating Devices and Accessories (effective 4/1/17)
• Surgical Dressings (effective 12/1/16)

T

Medical Policies - Prior Authorization*

• Transient Elastography (e.g., FibroScan) (effective 4/1/17)
• Transplant — Adult Heart (effective 3/1/17)
• Transplant: Bone Marrow or Stem Cell Allogeneic (effective 9/1/17)
• Transplant: Bone Marrow or Stem Cell Autologous (effective 9/1/17)
• Transplant: Heart-Lung (effective 9/1/17)
• Transplant — Liver (effective 11/1/17)
• Transplant: Lung or Lung Lobe (effective 9/1/17)
• Transplant — Pancreas Alone and Pancreas-Kidney (effective 1/1/17)
• Transplant — Pediatric Heart (effective 3/1/17)
• Transplant — Renal (effective 5/1/17)
• Transplant — Small Bowel or Multivisceral (effective 4/1/17)

Pay Policies

• Telemedicine (effective 6/1/17)
• Temporomandibular Joint Disorders (effective 8/1/17)
• Transcranial Magnetic Stimulation (effective 7/1/17)
• Transcutaneous Electrical Nerve Stimulators (TENS) (effective 1/1/17)

Clinical Resource Management

• Technology Assessment (effective 8/1/16)

U

Pay Policies

• Ultrasound, Non Vascular Extremity (effective 3/1/17)
• Unlisted Codes (effective 10/1/17)

V

Medical Policies

• Ventricular Assist Devices (effective 5/1/17)
• Vertebral Augmentation (effective 6/1/17)

Pay Policies

• Vaccine - ZOSTAVAX (effective 10/1/17)
• Vagus Nerve Stimulators (effective 7/1/17)
• Varicose Veins (effective 7/1/17)
• Vision Therapy (effective 2/1/17)
• Vocal Cord Augmentation, Laryngeal Injection (effective 12/17/16)

W

Medical Policies - Prior Authorization*

• Wheelchair Options and Accessories (effective 3/1/17)
• Wheelchair Seating Options (effective 12/1/16)
• Wheelchairs, Power and Power Operated Vehicles (effective 12/1/16)
• Wheelchairs, Specialized Manual (effective 2/1/17)
• Wound Therapy, Negative Pressure (effective 1/1/17)

X

Pay Policies

• Xiaflex^® (Collagenase Clostridium Histolyticum) (effective 4/1/17)

Y

Z