CLINICAL COVERAGE/MEDICAL POLICY UPDATES

Date: 08/29/24

Ambetter Health of Delaware reviews all clinical policies at least annually. This review is done to ensure medical necessity review criteria is current and appropriate for members and the scope of the services. On a bi-monthly basis, prior to updates, clinical policies are reviewed and approved by the National Marketplace Quality Improvement Committee (QIC).

This page reflects all clinical and policy changes. The full list of policies are on the Clinical and Payment Policies section under Provider Resources.  

For questions or additional information, please contact your Provider Engagement Administrator (PDF).

Policy Updates: Effective: October 30, 2024

NEW POLICIES

• Behavioral Health Treatment Documentation Requirements HIM.CP.BH.500
• Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy CP.MP.250

POLICIES WITH CHANGES

• Acupuncture CP.MP.92
• Air Ambulance CP.MP.175
• Bariatric Surgery CP.MP.37
• Behavioral Health Treatment Documentation Requirements   HIM.CP.BH.500
• Biofeedback    CP.MP.168
• Bone-Anchored Hearing Aid    CP.MP.93
• Burn Surgery   CP.MP.186
• Caudal or Interlaminar Epidural Steroid Injections   CP.MP.164
• Clinical Trials CP.MP.94
• Cochlear Implant Replacements   CP.MP.14
• Concert Genetic Testing: Aortopathies and Connective Tissue Disorders   V2.2024
• Concert Genetic Testing: Cardiac Disorders   V2.2024
• Concert Genetic Testing: Dermatologic Conditions   V2.2024
• Concert Genetic Testing: Epilepsy, Neurodegenerative and Neuromuscular Conditions   V2.2024
• Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders V2.2024
• Concert Genetic Testing: Eye Disorders   V2.2024
• Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) V2.2024
• Concert Genetic Testing: General Approach to Genetic Testing   V2.2024
• Concert Genetic Testing: Hearing Loss   V2.2024
• Concert Genetic Testing: Hematologic Conditions (non-cancerous) V2.2024
• Concert Genetic Testing: Hereditary Cancer Susceptibility   V2.2024
• Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders   V2.2024
• Concert Genetic Testing: Kidney Disorders   V2.2024
• Concert Genetic Testing: Lung Disorders   V2.2024
• Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders   V2.2024
• Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay V2.2024
• Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS)  V2.2024
• Concert Genetic Testing: Pharmacogenetics   V2.2024
• Concert Genetic Testing: Prenatal and Preconception Carrier Screening   V2.2024
• Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss V2.2024
• Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders V2.2024
• Concert Genetics Oncology: Algorithmic Testing V2.2024
• Concert Genetics Oncology: Cancer Screening V2.2024
• Concert Genetics Oncology: Circulating Tumor Cells (Liquid Biopsy)  V2.2024
• Concert Genetics Oncology: Cytogenetic Testing V2.2024
• Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies V2.2024
• Disc Decompression Procedures   CP.MP.114
• Discography   CP.MP.115
• Electric Tumor Treating Fields (Optune)  CP.MP.145
• Facet Joint Interventions   CP.MP.171
• Facility-based Sleep Studies for Obstructive Sleep Apnea   CP.MP.248
• Fecal Incontinence Treatments   CP.MP.137
• Fetal Surgery in Utero for Prenatally Diagnosed Malformations    CP.MP.129
• Gastric Electrical Stimulation   CP.MP.40
• Heart-Lung Transplant   CP.MP.132
• Home Ventilators   CP.MP.184
• Hospice Services   CP.MP.54
• Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea   CP.MP.180
• Implantable Intrathecal or Epidural Pain Pump   CP.MP.173
• Implantable Loop Recorder   CP.MP.243
• Intestinal and Multivisceral Transplant   CP.MP.58
• Intensity-Modulated Radiotherapy   CP.MP.69
• Lantidra   CP.MP.250
• Liposuction for Lipedema   CP.MP.244
• Lung Transplantation   CP.MP.57
• Lysis of Epidural Lesions   CP.MP.116
• Mechanical Stretching Devices for Joint Stiffness and Contracture   CP.MP.144
• Multiple Sleep Latency Testing   CP.MP.24
• Neonatal Sepsis Management   CP.MP.85
• Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) CP.MP.48
• NICU Apnea Bradycardia Guidelines CP.MP.82
• Nonmyeloablative Allogeneic Stem Cell Transplants   CP.MP.141
• Obstetrical Home Care Programs   CP.MP.91
• Omisirge (Omidubicel): Nicotinamide-modified Allogeneic Hematopoietic Progenitor Cell Therapy CP.MP.249
• Outpatient Cardiac Rehabilitation   CP.MP.176
• Outpatient Oxygen Use   CP.MP.190
• Pancreas Transplantation   CP.MP.102
• Pediatric Kidney Transplant   CP.MP.246
• Pediatric Liver Transplant   CP.MP.120
• Pediatric Oral Function Therapy   CP.MP.188
• Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention   CP.MP.147
• Physical, Occupational and Speech Therapy Services   CP.MP.49
• Proton and Neutron Beam Therapies   CP.MP.70
• Reduction Mammoplasty and Gynecomastia Surgery   CP.MP.51
• Repair of Nasal Valve Compromise   CP.MP.210
• Sacroiliac Joint Fusion   CP.MP.126
• Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders   CP.MP.146
• Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy   CP.MP.174
• Skin and Soft Tissue Substitutes for Chronic Wounds   CP.MP.185
• Stereotactic Body Radiation Therapy   CP.MP.22
• Tandem Transplant   CP.MP.162
• Therapeutic Utilization of Inhaled Nitric Oxide   CP.MP.87
• Total Artificial Heart   CP.MP.127
• Transcatheter Closure of Patent Foramen Ovale   CP.MP.151
• Urinary Incontinence Devices and Treatments   CP.MP.142
• Applied Behavior Analysis   CP.BH.104
• Behavioral Health Clinical Policy Committee   BH.CPC.01
• Biofeedback for Behavioral Health Diagnosis   CP.BH.300
• Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive-Compulsive Disorder CP.BH.201
• Transcranial Magnetic Stimulation for Treatment Resistant Major Depression   CP.BH.200