Bariatric Surgery

(CP.MP.37)

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

Policy updates include:

• In Section III, added indication for SG to RYGB or BPD-DS DS as a bridging procedure for BMI ≥ 50 kg/m² in III.4

Reduction Mammoplasty and Gynecomastia Surgery

(CP.MP.51)

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

Policy updates include:

• Changed “women” to “members/enrollees” in I.A.5.c
• Added I.B.5. to gigantomastia of pregnancy criteria
• Language references in the criteria, description and background sections changed from “male” and/or “female” to “those with a male reproductive system” and/or “those with a female reproductive system”

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression

(CP.BH.200)

Ambetter

Policy updates include:

• In Policy/Criteria Section I, changed the initial number of sessions from 20 to 30 authorizations reviewed on a case-by-case basis
• Section II.A was changed from an additional 10 to additional 6 sessions of TMS reviewed on a case-by-case basis

Trigger Point Injections for Pain Management

(CP.MP.169)

Ambetter

Policy updates include:

• In I.B. updated criteria from 2 additional injections to 4
• In I.B.1 added pain relief with functional improvement
• In I.B.2. added “≥” 6 weeks
• In I.B.4:
  • Added “from initial injection”
  • Changed maximum of 4 total sessions to 6

Vagus Nerve Stimulation

(CP.MP.12)

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

Policy updates include:

• Added opposition to surgery as a possibility
• Removed “resective” in I.C