Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Applied Behavioral Analysis Documentation Requirements

(CP.BH.105)

Ambetter

Policy updates include:

• Policy restructured and reformatted
• Removed medical necessity criteria noted in former I.A-D and provide clarity in documentation requirements throughout
• Added I.A. " Prior authorization approval for ABA services has been obtained, if required”
• Added I.B. "Clinical documentation is reviewed and updated at regular intervals and includes the signature and printed names of the member/enrollee, legal guardian, rendering clinician/technician and supervising practitioner (as applicable)”
• Added I.C. "Documentation and data collection supports that active treatment was delivered throughout the duration of billed services as evidenced by both of the following”
• In I.D.1-7 combined service note requirements for all services rendered by RBT and QHP
• In I.D.8.a-e added new criteria to expand requirements for a detailed summary of treatment activity
• I.D.8.f.and g. added documentation guidance when services associated with CPT codes 0373T, 97155, 97158, 97156 and 97157 are rendered
• Added I.D.8.h. regarding telehealth requirements
• Added I.D.8.i. "Progress, or lack of, towards the identified treatment goals (includes cumulative graphs of goals and objectives and baseline data, as applicable)”
• Added I.D.8.j. "Member/enrollee’s response to treatment, and the outcome of the interventions”
• Added I.D.9. "Addenda created to include additional documentation after the initial submission of a clinical note, include all the following (as applicable)”
• Added I.D.10. "Discharge planning is documented in all treatment plans and upon termination of services”
• Added II.C. ”Signature of qualified rendering provider”
• Added I.D. “Signature of caregiver”

Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

( CP.MP.180)

Ambetter

Policy updates include:

• Updated verbiage in Criteria I.A. to specify that criteria is for the Inspire® Upper Airway Stimulation system
• Added Criteria I.A.2. “Polysomnography (PSG) performed within 24 months of first consultation for the hypoglossal nerve stimulator implant”
• Removed Criteria I.A.3.b.ii. and I.A.3.c.ii. regarding absence of complete concentric collapse at the soft palate level since this is addressed in Criteria I.A.4.b
• Changed Criteria I.A.3.c.i. from apnea-hypopnea index (AHI) ≥ 10 and ≤ 50 to AHI > 10 and < 50
• Added Criteria I.B. for criteria for the Genio® System

Outpatient Oxygen Use

(CP.MP.190)

CHIP and Ambetter

Policy updates include:

• Updated verbiage in Criteria I.B. regarding Group I and Group II hypoxemia for clarity
• Updated verbiage in Criteria I.B.1.c. regarding symptoms and signs and examples for clarity
• Updated verbiage to include “supplemental” oxygen in Criteria I.B.1.d. for clarity
• Removed parenthetical note in Criteria II. and Criteria IV. regarding medically fragile members/enrollees and those covered under EPSDT
• Updated Criteria III.A.3.a. to no longer include information regarding home oxygen companies being permitted to coordinate with an independent diagnostic testing facility (IDTF)
• Criteria IV.A. updated from 30 days to 90 days prior to the date of recertification
• Updated verbiage in Criteria IV.B.2.b. regarding oxygen levels obtained by DME providers

Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation

(CP.MP.117)

Ambetter

Policy updates include:

• Added percutaneous electrical nerve stimulation (PENS) to Criteria I. for insufficient evidence to support efficacy
• Removed medically necessary criteria II. for PENS
• Removed “for a minimum of 60 days prior to request, as confirmed by lab testing” in Criteria IV.A.7., IV.B.7., IV.C.5., IV.D.7., and IV.E.9
• Background updated to align with criteria updates