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Save time each month and keep focused on important Payer medical policy reviews and coverage decisions affecting your business! Policy Alerts takes a client-focused hands-on approach and is constantly working to provide our customers with helpful insights and actionable analytics. We understand what our clients need and are dedicated to providing timely, accurate, and always up-to-date reports.
Health economic and reimbursement information provided by Policy Alerts is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies.
Use of them does not imply any affiliation with or endorsement by them. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Post Views: 1, Stop spending time searching for medical policy changes and let us do it for you! Sign up Now! Sacral neuromodulation SNM or sacral nerve stimulation SNS refers to stimulation of nerves that innervate the bladder and pelvic floor to treat lower urinary tract dysfunction. Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction.
Vagus Nerve Stimulation VNS is performed by an implantable stimulator as a treatment for refractory seizures. A ventricular assist device VAD is surgically attached to one or both intact heart ventricles and used to assist or augment the ability of a damaged or weakened native heart to pump blood. This policy describes the medical necessity of routine eye examination and visual aids for beneficiaries under the age of This policy describes the medical necessity criteria for Wireless Capsule Endoscopy.
The wireless motility capsule WMC assesses gastroparesis or delayed gastric emptying. Attention deficit hyperactivity disorder ADHD is one of the most common neurobehavioral disorders in children, with an increasing prevalence of diagnosis in adults.
Fixed wing FW or rotary wing RW air ambulance are furnished when the medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate.
Ambulatory electroencephalogram EEG testing in the outpatient setting e. Cartilage transfer procedures include autologous chondrocyte implantation, osteochondral allograft transplantation OAG or OCA [i. There are two categories of bariatric surgery: restrictive procedures and malabsorptive procedures. Biofeedback therapy provides visual, auditory or other evidence of the status of certain body functions so that a person can exert voluntary control over the functions.
Johns Hopkins Health Library defines burns as a type of painful wound caused by thermal, electrical, chemical, or electromagnetic energy. This policy will provide general guidelines as to when cosmetic and reconstructive surgery is or is not medically necessary. Medical necessity guidelines for dental anesthesia in the inpatient or ambulatory surgery setting. Electroencephalography EEG is a significant component of epilepsy diagnosis.
DME is defined as equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, and is generally not useful to a person in the absence of an illness or injury. This policy describes the medical necessity requirements for a donor lymphocyte infusion DLI.
Urine drug testing is a key diagnostic and therapeutic tool that is useful for patient care and monitoring of adherence to a controlled substance treatment regimen and to identify drug misuse or addiction prior to starting or during treatment with controlled substances.
This policy describes the medically necessary indications for neurophysiologic evoked potentials. Male and female fertility may be transiently or permanently affected by medical treatments such as gonadotoxic therapy, cytotoxic chemotherapy, or radiation therapy, as well as by other iatrogenic causes. Gastric electrical stimulation GES has been used in patients who are proven refractory to conventional treatment for gastroparesis.
Services for gender affirmation most often include hormone treatment, counseling, psychotherapy, complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate, genital reconstruction, facial hair removal, and certain facial plastic reconstruction. This policy includes criteria for making medical necessity determinations for genetic tests when specific criteria are not available for the requested genetic or pharmacogenetic test.
Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear. Heart-lung transplantation is treatment of choice for patients with both end-stage heart and endstage lung disease.
This policy provides medical necessity guidelines for Holter monitoring up to 48 hours. Hyperbilirubinemia is the most common condition requiring medical attention in newborns. International Normalized Ratio INR or prothrombin time PT is the standard measurement for reporting the blood's clotting time and allows physicians to determine the level of anticoagulation in a patient. Homocysteine is a nonproteinogenic amino acid generated during the conversion of methionine to cysteine. Hyperemesis gravidarum is a term reserved to describe the most severe cases of nausea and vomiting in pregnancy NVP which results in the inability to rehydrate and replenish nutritional reserves.
An implantable, intrathecal drug delivery system consists of an implanted pump and catheter that delivers a drug directly into the spinal fluid. The implanted device measures and monitors daily pulmonary artery PA pressure. The data is used by physicians for heart failure management with the goal of reducing heart failure hospitalizations. Inhaled nitric oxide iNO is a selective pulmonary vasodilator in which its mechanism of action results in smooth muscle relaxation.
Medical necessity criteria for intensity-modulated radiotherapy IMRT. IMRT is an advanced form of 3-dimensional 3-D conformal radiation therapy that delivers a more precise radiation dose. This policy describes the medical necessity criteria for the review of intestinal and multivisceral transplant requests.
Intradiscal steroid injections involve injecting glucocorticoids directly into the spinal disc that has been identified as the source of pain. Nursing home care includes both long term residential care and short-term post-acute or rehabilitative care. This policy addresses long term care LTC placement ranging from basic custodial care to more intense care needed due to dementia or other complex medical needs.
Low-frequency ultrasound debridement is a noncontact debridement method that provides simultaneous cleansing and debridement of wounds. Medical necessity criteria for the review of lung transplantation requests. This policy addresses when measurement of 1,25 OH 2D is appropriate and medically necessary.
Mechanical stretching devices are used for the prevention and treatment of joint contractures of the extremities, with the goal to maintain or restore range of motion ROM to the joint. Clinically important neonatal withdrawal most commonly results from intrauterine opioid exposure.
Through the increased incidence of intra-partum antibiotics, early-onset neonatal sepsis is occurring less frequently. Allogeneic hematopoietic stem cell transplants that do not destroy all of the hematopoietic cells in the bone marrow are termed reduced-intensity or nonmyeloablative conditioning regimens.
This policy will provide general guidelines as to when non-invasive home ventilators are or are not medically necessary. Medical necessity criteria for obstetrical home health programs offered by vendors such as Optum. Cell-free circulating tumor DNA ctDNA originates directly from the tumor tissue primary or metastasis ; as tumor cells die the contents are released into the bloodstream.
This policy describes the medical necessity requirements for orthognathic surgery. Of the estimated 5. Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air This policy describes the medical necessity requirements for pancreas transplantation procedures. An insulin pump is a device that delivers a continuous subcutaneous infusion of a rapid- or short-acting insulin, supplemented by boluses before each meal or snack.
Amplification with hearing instruments should be considered for a child who demonstrates a significant hearing loss, including sensorineural, conductive, or mixed hearing losses of any degree. Pediatric heart disease may be a progressive disease, affecting cardiac structure and function in infants and children.
End stage liver disease presents unique clinical considerations in the pediatric population. Posterior tibial nerve stimulation PTNS , also known as peripheral tibial nerve stimulation2 , is a minimally invasive form of electrical neuromodulation used to treat overactive bladder OAB syndrome and associated symptoms of urinary urgency, urinary frequency, and urge urinary incontinence.
Atrial fibrillation AF is the most commonly encountered sustained tachyarrhythmia and is associated with a 5-fold increased risk of stroke, and stroke risk increases with age. Proton beam therapy PBT is a form of external beam radiation therapy EBRT that utilizes protons positively charged subatomic particles to precisely target a specific tissue mass. Post—acute care refers to a wide range of services, which include skilled nursing facilities, inpatient rehabilitation facilities, home health aides, outpatient physical and occupational therapy, and longterm care facilities.
Reduction mammoplasty is the surgical reduction of breast size. It was developed as a means of alleviating physical and emotional symptoms associated with excessive breast size and breast ptosis. Sacroiliac joint SIJ fusion, or arthrodesis, is a surgical technique that fuses the iliac bone to the sacrum for stabilization. Description Treatment for sacroiliac joint SIJ dysfunction is usually conservative non-surgical and focuses on trying to restore normal motion in the joint. Selective dorsal rhizotomy SDR is a neurosurgical technique developed to reduce spasticity and improve mobility in children with cerebral palsy CP and lower extremity spasticity.
Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure.
Peripheral nerve stimulation PNS is intended to decrease chronic and acute pain by stimulating peripheral nerves with leads placed adjacent or parallel to the affected nerve. A tandem transplant, also known as a sequential or double transplant , refers to a planned second course of high-dose therapy and stem cell transplant SCT within 6 months.
DiGeorge syndrome DGS is a disorder in which there is a defect in the development of the pharyngeal pouch system. The syndrome is most commonly caused by a chromosomal deletion at 22q Numerous essential metabolic functions are mitigated by hormones produced by, and affecting the thyroid.
This policy describes the medical necessity requirements for two types of PN, A total parenteral nutrition TPN , in which all of the necessary macronutrients and micronutrients are supplied to the patient, and B intradialytic parenteral nutrition IDPN , in which nutrition is supplied to end-stage renal disease ESRD patients undergoing dialysis as an alternative to regularly scheduled TPN.
Trigger points cause pain at their physical location as well as referred pain to other areas in a specific pattern. Lymphedema is an accumulation of lymphatic fluid in the interstitial tissue, principally in the subcutaneous fatty issues. This policy outlines the medical necessity criteria for ultrasound use in pregnancy.
Ultrasound is the most common fetal imaging tool used today. Vagus nerve stimulation VNS has been used in the treatment of epilepsy and has been studied for the treatment of refractory depression and other indications. A ventricular assist device VAD is a mechanical pump that helps the heart when it is too weak to pump blood through the body. VADs are designed to enhance blood flow to the bodily organs, either in conjunction with, or as a replacement for, a damaged or diseased heart. Video electroencephalographic VEEG monitoring is the synchronous recording and display of EEG patterns and video-recorded clinical behavior.
A global consensus statement recommends against universal screening for vitamin D deficiency in healthy children as there is insufficient evidence that the potential benefits of testing outweigh the potential harms. Medicaid Overview Secure Login. Corporate Information Company Overview Careers. Newsroom Newsroom. Who are you? Go to Login. Register for an Account. Medicaid Policies. Download English. Allergy Immunotherapy: WNC.
Allergy Testing: WNC. Ambulance Services: WNC. Art Therapy: WNC. Breast Surgeries: WNC. Bronchial Thermoplasty: WNC. Craniofacial Surgery: WNC. Diagnostic Assessment: WNC.
Discography: WNC. Experimental Technologies: WNC. Extended Ophthalmoscopy: WNC. Endometrial Ablation: WNC. Fetal Surveillance: WNC. Fluorescein Angiography: WNC. Genetic Testing: WNC. Gonioscopy: WNC. Heart Transplantation: WNC. Homocysteine Testing: WNC. Hospice Services: WNC. Hyperhidrosis Treatments WNC. Hysterectomy: WNC. Home Births: WNC. Liver Transplantation: WNC. Lung Transplantation: WNC. Orthotics Prosthetics: WNC. Pancreas Transplant: WNC.
Rhinoplasty and or Septoplasty: WNC. Skin Substitutes: WNC. Stereotactic Pallidotomy: WNC. Sterilization Procedures: WNC. Urodynamic Testing: WNC. Vision Under WNC. Medicare Policies. Acupuncture: CP. Air Ambulance: CP. Assisted Reproductive Technology: CP. Bariatric Surgery: CP. Biofeedback: CP. Burn Surgery: CP. Cardiac Biomarker Testing: CP. Clinical Trials: CP. Cochlear Implant Replacements: CP. Cosmetic and Reconstructive Procedures: CP.
Dental Anesthesia: CP. Disc Decompression Procedures: CP. Donor Lymphocyte Infusion: CP. Evoked Potentials: CP.
Experimental Technologies: CP. Essure Removal: CP. Facet Joint Interventions: CP. Fecal Incontinence Treatments: CP. Fertility Preservation: CP. Fetal Surgery in Utero: CP. Gastric Electrical Stimulation: CP. Gender Affirming Procedures: CP. Genetic and Pharmacogenetic Testing: CP.
Hearing Aids-Adult: CP.
|Accenture call center project||Testing for select genitourinary conditions: CP. Attention deficit hyperactivity disorder ADHD is one of the most common neurobehavioral disorders in children, with an increasing prevalence of diagnosis in adults. Ambulatory electroencephalogram EEG testing in the outpatient setting e. Home Health Services include medically bulletni skilled nursing services, specialized therapies, home health aide services, and medical supplies provided to beneficiaries in any setting, other than a hospital, or nursing facility. Gonioscopy: WNC.|
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|Horizon webmail change healthcare||Child First Services is centsne intensive, early childhood, two-generation, home visiting intervention that works with the most vulnerable young children prenatal through age five years and their families. An electroencephalogram Https://andypickfordmusic.com/rebuilt-59-cummins-for-sale/6994-emblemhealth-wikipedia.php is a non-invasive method for assessing neurophysiological function. This policy describes the medical necessity guidelines for an endometrial ablation. Homocysteine is a nonproteinogenic amino acid generated during the conversion of methionine to cysteine. Bulletij electroencephalographic VEEG monitoring is the synchronous recording and display of EEG patterns and video-recorded clinical https://andypickfordmusic.com/richard-cummins/5452-cigna-prior-authorization-for-medication-form.php. Services for gender affirmation most often include hormone treatment, counseling, psychotherapy, complete hysterectomy, bilateral mastectomy, chest centene florida clinical policy bulletin alcon activefocus augmentation as appropriate, genital reconstruction, facial hair removal, and certain facial plastic reconstruction. Breast Surgeries: WNC.|
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WebClinical & Payment Policies Clinical Policies Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or . WebThis policy should only be used if there is no relevant clinical decision support criteria. Policy/Criteria I. Initial Authorization. It is the policy of health plans affiliated with . WebCentene is the largest Medicaid managed care organization in the U.S., and a leader in California, Florida, New York and Texas, four of the largest Medicaid states. Centene is .