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Sunflower August Policy Updates

Fecha: 14/07/20

Thank you for your continued partnership with Sunflower Health Plan. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you that the below policies have been revised or changed. Sunflower Health Plan will be implementing effective August 14, 2020.

NUMBERPOLICY NAMEPOLICY REVISIONS/CHANGESLINE OF BUSINESS (LOB)
CP.MP.121Homocysteine Testing
  • More restrictive: During the May 2020 annual review of homocysteine testing, it was determined to make the policy significantly more restrictive than it has previously been for all lines of business.
  • Changed borderline B12 deficiency and idiopathic VTE/thromboembolism indications from medically necessary to investigational.
  • Removed from the list of ICD-10 codes supporting coverage criteria: D51.0-D51.9, E53.8, I26.01-I26.99, I81, I82.0-I82.91, Z86.711, Z86.718.”
MARKETPLACE
CP.MP.124ADHD
  • More restrictive: During the May 2020 ADHD annual review, it was determined to make the policy more restrictive than it has previously been for all lines of business
  • Add the following CPT codes as not payable when billed with only a diagnosis of ADHD (F90.0, F90.1, F90.2, F90.8, F90.9): 78803, 81171, 81172, 92547, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726, 96121, 97129, 97130
  • Remove the following CPT codes as not payable when billed with only a diagnosis of ADHD (F90.0, F90.1, F90.2, F90.8, F90.9): 78607, 95827, 97127
  • Add the following HCPCS code as not payable when billed with only a diagnosis of ADHD (F90.0, F90.1, F90.2, F90.8, F90.9): G0176
MEDICARE
MARKETPLACE

For more detailed information about these policies, please refer to the Clinical and Payment Policies page. And for questions about this or any of our payment policies, please don’t hesitate to reach out to our Provider Services teams:

  • Allwell (Medicare): 1-855-565-9519
  • Ambetter (Marketplace): 844-518-9505