Bariatric Surgery

(CP.MP.37)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS)

Policy updates include:

• Added I.A.1.a.xvi Atrial fibrillation
• Added I.A.1.a.xvii. Heart failure
• Removed previous preoperative evaluation and medical clearance requirements in I.B. and I.C. and replaced with consolidated requirements I.B.1. through 3

Gastric Electrical Stimulation

(CP.MP.40)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Changed I.C. to “Chronic intractable (drug refractory) nausea and vomiting”
• Revised verbiage in note at the end of policy/criteria
• Added L8685, L8686, and L8687 and their respective descriptions to HCPCS code table

NICU Apnea Bradycardia Guidelines

(CP.MP.82)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Replaced “Guidelines” section title with “Policy/Criteria” title and added verbiage regarding health plans affiliated with Centene Corporation®
• Updated Criteria I.A.1. to include desaturation as a clinically significant cardiorespiratory event and updated criteria verbiage for clarity
• Removed notation in Criteria I.A.1.b. regarding consideration of using heart rate decrease > 33.3% below baseline for older, more mature infants or those with a lower baseline heart rate
• Updated Criteria I.A.1.d. from bradycardia to isolated bradycardia and updated from < 70 beats per minute to < 80 beats per minute
• Minor rewording for clarity in Criteria I.B. and Criteria I.D
• Updated Note at end of criteria section to state caffeine levels may be therapeutic in preterm infants for as long as ten days after discontinuation
• Removed statement in Note section regarding “caffeine countdown”
• Added car bed and added clarifying language to Note section regarding assessment of cardiorespiratory stability in a car seat

NICU Discharge Guidelines

(CP.MP.81)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Updated Authorization protocol A.5. Apnea or bradycardia monitoring with last dose of caffeine at least seven days prior to discharge
• Updated NICU DC recommended practices B.4. An assessment of cardiorespiratory stability in a car seat or car bed is recommended prior to discharge for infants born at < 37 weeks gestation or for infants with other risk factors for cardiorespiratory compromise (e.g. neuromuscular, orthopedic problems)
• Updated E.1. to reflect car bed recommendations