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Medical Clinical Policy Updates

The following Medicare Clinical Policies contain changes to their previous versions, have been approved for use by Medicare QIC and will be effective on the date listed below:

May 1, 2024:

  • MC.CP.MP.248 Facility-based Sleep Studies for Obstructive Sleep Apnea
  • January 1, 2024:

  • MC.CP.MP.22 Stereotactic Body Radiation Therapy
  • MC.CP.MP.57 Lung Transplantation
  • MC.CP.MP.69 Intensity-Modulated Radiotherapy
  • MC.CP.MP.101 Donor Lymphocyte Infusion
  • MC.CP.MP.106 Endometrial Ablation
  • MC.CP.MP.108 Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia
  • MC.CP.MP.160 Wireless Pulmonary Artery Monitoring
  • MC.CP.MP.170 Peripheral Nerve Blocks
  • MC.CP.MP.182 Short Inpatient Stay
  • CP.PP.206 Skilled Nursing Facility Leveling
  • MC.CP.MP.246 Pediatric Kidney Transplantation

  • The Concert Genetics Clinical Criteria Support document (PDF) explains the evidence base for the Concert Genetics policies and the balance of the benefits vs. the risks of the criteria. The following policies apply to all Medicare lines of business with the exception of the Texas WellCare by AllWell plan:

  • V2.2023 Concert Genetics Oncology Algorithmic Testing
  • V2.2023 Concert Genetics Genetic Testing Aortopathies and Connective Tissue Disorders
  • V2.2023 Concert Genetics Genetic Testing Cardiac Disorders
  • V2.2023 Concert Genetics Oncology Cancer Screening
  • V2.2023 Concert Genetics Oncology Circulating Tumor DNA and Circulating Tumor Cells Liquid Biopsy
  • V2.2023 Concert Genetics Oncology Cytogenetic Testing
  • V2.2023 Concert Genetics Genetic Testing Dermatologic Conditions 
  • V2.2023 Concert Genetics Genetic Testing Epilepsy, Neurodegenerative, and Neuromuscular Conditions
  • V2.2023 Concert Genetics Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders
  • V2.2023 Concert Genetics Genetic Testing Eye Disorders
  • V2.2023 Concert Genetics Genetic Testing Gastroenterologic Disorders (non-cancerous)
  • V2.2023 Concert Genetics Genetic Testing General Approach to Genetic Testing
  • V2.2023 Concert Genetics Genetic Testing Hearing Loss
  • V2.2023 Concert Genetics Genetic Testing Hematologic Condition (non-cancerous)
  • V2.2023 Concert Genetics Genetic Testing Hereditary Cancer Susceptibility
  • V2.2023 Concert Genetics Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders
  • V2.2023 Concert Genetics Genetic Testing Kidney Disorders
  • V2.2023 Concert Genetics Genetic Testing Lung Disorders
  • V2.2023 Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies
  • V2.2023 Concert Genetics Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders
  • V2.2023 Concert Genetics Genetic Testing Non-Invasive Prenatal Screening (NIPS)
  • V2.2023 Concert Genetics Genetic Testing Pharmacogenetics
  • V2.2023 Concert Genetics Genetic Testing Preimplantation Genetic Testing
  • V2.2023 Concert Genetics Genetic Testing Prenatal and Preconception Carrier Screening
  • V2.2023 Concert Genetics Genetic Testing Prenatal Diagnosis via Amniocentesis, CVS or PUBS and Pregnancy Loss
  • V2.2023 Concert Genetics Genetic Testing Skeletal Dysplasia and Rare Bone Disorders
  • V2.2023 Concert Genetics Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, & Developmental Delay
  • Policies Retired for Medicare

  • CP.MP.100 Allergy Testing and Therapy
  • CP.MP.101 Donor Lymphocyte Infusion
  • CP.MP.102 Pancreas Transplant
  • CP.MP.105 Digital EEG Analysis
  • CP.MP.106 Endometrial Ablation
  • CP.MP.107 Durable Medical Equipment and Orthotics and Prosthetics Guidelines
  • CP.MP.108 Allogeneic Hematopoietic Cell Transplants For Sickle Cell Anemia and Beta-thalassemia
  • CP.MP.109 Panniculectomy
  • CP.MP.110 Bronchial Thermoplasty
  • CP.MP.113 Holter Monitors
  • CP.MP.114 Disc Decompression Procedures
  • CP.MP.115 Discography
  • CP.MP.116 Lysis of Epidural Lesions
  • CP.MP.117 Spinal Cord Stimulation
  • CP.MP.12 Vagus Nerve Stimulation
  • CP.MP.120 Pediatric Liver Transplant
  • CP.MP.121 Homocysteine Testing
  • CP.MP.123 Laser Therapy for Skin Conditions
  • CP.MP.126 Sacroiliac Joint Infusion
  • CP.MP.127 Total Artificial Heart
  • CP.MP.128 Optic Nerve Decompression Surgery
  • CP.MP.129 Fetal Surgery in Utero for Prenatally Diagnosed Malfunctions
  • CP.MP.130 Fertility Preservation
  • CP.MP.132 Heart-Lung Transplant
  • CP.MP.133 Posterior Tibial Nerve Stimulation for Voiding Dysfunction
  • CP.MP.134 Evoked Potential Testing
  • CP.MP.136 Home Births
  • CP.MP.137 Fecal Incontinence Treatments
  • CP.MP.138 Pediatric Heart Transplant
  • CP.MP.139 Low-frequency Ultrasound and Noncontact Wound Therapy
  • CP.MP.14 Cochlear Implant Replacements
  • CP.MP.141 Non-myeloablative Allogeneic Stem Cell Transplants
  • CP.MP.142 Urinary Incontinence Devices and Treatments
  • CP.MP.143 Wireless Motility Capsule
  • CP.MP.144 Mechanical Stretching Devices for Joint Stiffness and Contracture
  • CP.MP.145 Electric Tumor Treating Fields (Optune)
  • CP.MP.146 Sclerotherapy for Chemical Endovenous Ablation for Varicose Veins
  • CP.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention
  • CP.MP.148 Radial Head Implant
  • CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia
  • CP.MP.151 Transcatheter Closure of Patent Foramen Ovale
  • CP.MP.152 Measurement of Serum 1,25-dihydroxyvitamin D
  • CP.MP.153 Helicobacter Pylori (H Pylori) Serology Testing
  • CP.MP.154 Thyroid Hormones and Insulin in Pediatrics
  • CP.MP.155 EEG Headache
  • CP.MP.156 Cardiac Biomarker Testing
  • CP.MP.157 25-hydroxyvitamin D Testing in Children and Adolescents
  • CP.MP.158 Ambulatory Surgery Center Optimization
  • CP.MP.160 Implantable Wireless Pulmonary Artery Pressure Monitoring
  • CP.MP.162 Tandem Transplant
  • CP.MP.163 Total Parenteral Nutrition and Intradialytic Parenteral Nutrition
  • CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections
  • CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Injections
  • CP.MP.166 Sacroiliac Joint Interventions for Pain Management
  • CP.MP.167 Intradiscal Steroid Injections for Pain Management
  • CP.MP.168 Biofeedback
  • CP.MP.169 Trigger Point Injections for Pain Management
  • CP.MP.170 Nerve Blocks for Pain
  • CP.MP.171 Facet Joint Interventions
  • CP.MP.173 Implantable Intrathecal or Pain Pump
  • CP.MP.174 Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy
  • CP.MP.175 Air Ambulance
  • CP.MP.176 Outpatient Cardiac Rehabilitation
  • CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
  • CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing
  • CP.MP.182 Short Inpatient Hospital Stay
  • CP.MP.184 Home Ventilators
  • CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds
  • CP.MP.186 Burn Surgery
  • CP.MP.188 Pediatric Oral Function Therapy
  • CP.MP.190 Outpatient Oxygen Use
  • CP.MP.194 Osteogenic Stimulation
  • CP.MP.202 Orthognathic Surgery
  • CP.MP.203 Diaphragmatic Phrenic Nerve Stimulation
  • CP.MP.206 Skilled Nursing Facility Leveling
  • CP.MP.209 Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing
  • CP.MP.210 Repair of Nasal Valve Compromise
  • CP.MP.22 Stereotactic Body Radiation Therapy
  • CP.MP.24 Multiple Sleep Latency Testing
  • CP.MP.242 Pulmonary Function Testing
  • CP.MP.243 Implantable Loop Recorder
  • CP.MP.244 Liposuction for Lipedema
  • CP.MP.246 Pediatric Kidney Transplant
  • CP.MP.247 Transplant Service Documentation Requirements
  • CP.MP.248 Facility Based Sleep Studies for OSA
  • CP.MP.26 Articular Cartilage Defect Repair
  • CP.MP.31 Cosmetic and Reconstructive Surgery
  • CP.MP.36 Experimental Technologies
  • CP.MP.37 Bariatric Surgery
  • CP.MP.38 Ultrasound in Pregnancy
  • CP.MP.40 Gastric Electrical Stimulation
  • CP.MP.43 Functional MRI
  • CP.MP.46 Ventricular Assist Devices
  • CP.MP.48 Neuromuscular and Peroneal Nerve Electric Stimulation
  • CP.MP.49 Physical Occupational and Speech Therapy Services
  • CP.MP.50 Drugs of Abuse Definitive Testing
  • CP.MP.51 Reduction Mammoplasty and Gynecomastia Surgery
  • CP.MP.53 Ferriscan R2-MRI
  • CP.MP.54 Hospice
  • CP.MP.55 Assisted Reproductive Technology
  • CP.MP.57 Lung Transplantation
  • CP.MP.58 Intestinal and Multivisceral Transplant
  • CP.MP.61 IV Moderate Sedation IVE Deep Sedation and General Anesthesia for Dental Procedures
  • CP.MP.62 Hyperhidrosis Treatments
  • CP.MP.69 Intensity Modulated Radiotherapy
  • CP.MP.70 Proton and Neutron Beam Therapies
  • CP.MP.71 Long Term Care Placement Criteria
  • CP.MP.81 NICU Discharge Guidelines
  • CP.MP.82 NICU Apnea Bradycardia
  • CP.MP.85 Neonatal Sepsis Management
  • CP.MP.86 Neonatal Abstinence Syndrome Guidelines
  • CP.MP.87 Therapeutic Utilization of Inhaled Nitric Oxide
  • CP.MP.91 Obstetrical Home Care Programs
  • CP.MP.92 Acupuncture
  • CP.MP.93 Bone-Anchored Hearing Aid
  • CP.MP.94 Clinical Trials
  • CP.MP.95 Gender-Affirming Procedures
  • CP.MP.97 Testing for Select Genitourinary Conditions
  • CP.MP.98 Urodynamic Testing
  • CP.MP.99 Wheelchair Seating
  • CP.BH.100 Substance Use Disorders and Treatment Services
  • CP.BH.104 Applied Behavioral Analysis
  • CP.BH.124 ADHD
  • CP.BH.200 TMS for Treatment Resistant Major Depression
  • CP.BH.201 Deep Transcranial Magnetic Stimulation for Treatment of Obsessive-Compulsive Disorder
  • CP.BH.300 Biofeedback for BH Disorders
  • CP.BH.500 BH Treatment Documentation Requirements
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    Y0020_WCM_134133E Last Updated On: 1/9/2024