Policy Number

Policy Name

Policy Description

Lines of Business

CP.MP.242

Pulmonary Function Testing

Pulmonary function tests (PFTs), also known as lung function tests, include a variety of tests to check how well the lungs are working. This policy describes the medical necessity guidelines for pulmonary function testing.

It is the policy of health plans affiliated with Centene Corporation^® that pulmonary function testing (PFT) is medically necessary for members/enrollees aged three years and above when meeting the criteria for one of the following tests:

· Spirometry

· Lung Volume Tests

· Diffusion capacity of the lungs for Carbon monoxide (DLCO) tests

· Lung compliance studies when all other PFTs give equivocal results or results which must be confirmed by additional lung compliance testing

· Pulmonary studies during exercise testing

Marketplace

Commercial

CP.MP.97

Testing for Select Genitourinary Conditions

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. This policy also defines unspecified amplified DNA probe testing for genitourinary conditions.

Note: Although Trichomonas vaginalis is a common cause of vaginitis, testing for it is not restricted with medical necessity criteria, and, thus, it is not included in the scope of this policy.

Marketplace

Commercial

CP.VP.14

Scanning Computerized Ophthalmic Diagnostic Imaging

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) is a non-invasive, non-contact imaging technique that produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of anterior segment and posterior segment diseases. This policy describes the medical necessity indications for SCODI.

It is the policy of health plans affiliated with Centene Corporation® (Centene) and Envolve Vision, Inc.® (Envolve) that SCODI is medically necessary for the following indications:

· Anterior SCODI

· Posterior Optic nerve SCODI

· Posterior retinal SCODI, and posterior retinal SCODI including OCT angiography

It is the policy of health plans affiliated with Centene and Envolve that SCODI is not medically necessary for the following indications:

· Advanced glaucomatous damage

· Screening for glaucoma

Marketplace

Commercial