Policy Description Notification of Updates and Changes to Policies

Policy Name

Description

Bevacizumab Policy

The intent of the criteria is to ensure that patients follow selection elements established by Centene^® clinical policy for bevacizumab (Avastin^®).

Upon review of 2018 ICD-10 code changes diagnosis codes H44.2A1, H44.2A2, H44.2A3 have been added to the list of codes that support coverage.

Evoked Potentials Policy

Holter Monitors Policy

Ultrasound in Pregnancy Policy

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today. Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location; and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented.

Upon review of 2018 ICD-10 changes diagnosis codes O36.8310-O36.8319, O36.8320-O36.8329, O36.8330-O36.8339, O36.8390-O36.8399 have been added to the list of codes that support coverage

Urodynamic Testing Policy

Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction. The clinician must exercise clinical judgment in the appropriate selection of urodynamic tests following an appropriate evaluation and symptom characterization.  The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies.   

Annual review of the policy by our Medical Affairs team resulted in the addition of ICD-10 diagnosis codes E10.69, E11.69 and S34.0 – S34.9XXs codes as covered and payable.

Vaginitis Policy

Various diagnostic methods are available to identify the etiology of the signs and symptoms of vaginitis. The purpose of this policy is to define medical necessity criteria for the diagnostic evaluation of vaginitis in members’ ≥ 13 years of age. This policy also defines unnecessary amplified DNA- (deoxyribonucleic acid) probe testing for genitourinary conditions.

Annual review of the policy by our Medical Affairs team resulted in the following changes:

• Re-naming the policy to Testing for Select Genitourinary Conditions from Diagnosis of Vaginitis
• Removal of CPT code 87761 from the not medically necessary table as of 10/1/2017
• Addition of CPT code 87798 as not medically necessary for specific diagnosis

Wheelchair Seating Policy

The intent of this policy is to outline appropriate coding and clinical criteria for the payment of wheelchair seating and accessories.

Upon review of 2018 ICD-10 code changes diagnosis codes G12.23, G12.24 and G12.25 have been added to the list of codes that support coverage.