Medical Clinical Policy Updates
The following Medicare Clinical Policies contain changes to their previous versions, have been approved for use by Medicare QIC and will be effective on the date listed below:
February 1, 2025:
CC.PP.206 Skilled Nursing Facility Leveling
MC.CP.MP.108 Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia
MC.CP.MP.166 Sacroiliac Joint Interventions for Pain Management
MC.CP.MP.249 Omisirge (omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy
MC.CP.MP.250 Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy
MC.CP.MP.31 Cosmetic and Reconstructive Procedures
November 11, 2024:
CPG Grid Adopted Clinical Practice and Preventive Health Guidelines
MC.CP.MP.101 Donor Lymphocyte Infusion
MC.CP.MP.160 Implantable Wireless Pulmonary Artery Pressure Monitoring
MC.CP.MP.170 Peripheral Nerve Blocks
MC.CP.MP.182 Short Inpatient Hospital Stay
MC.CP.MP.185 Skin Substitutes for Chronic Wounds of the Lower Extremities
MC.CP.MP.246 Pediatric Kidney Transplant
MC.CP.MP.248 Facility-based Sleep Studies for Obstructive Sleep Apnea
MC.CP.MP.250 Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy
MC.CP.MP.57 Lung Transplantation
MC.CP.MP.69 Intensity Modulated Radiation Therapy (IMRT)
August 1, 2024:
MC.CP.MP.106 Endometrial Ablation
MC.CP.MP.170 Peripheral Nerve Blocks
MC.CP.MP.184 Home Ventilators
MC.CP.MP.190 Outpatient Oxygen Use
MC.CP.MP.247 Transplant Service Documentation Requirements
MC.CP.MP.249 Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy
V1.2024 Concert Genetics Genetic Testing Aortopathies and Connective Tissue Disorders
V1.2024 Concert Genetics Genetic Testing Cardiac Disorders
V1.2024 Concert Genetics Genetic Testing Dermatologic Conditions
V1.2024 Concert Genetics Genetic Testing Epilepsy, Neurodegenerative, and Neuromuscular Conditions
V1.2024 Concert Genetics Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders
V1.2024 Concert Genetics Genetic Testing Eye Disorders
V1.2024 Concert Genetics Genetic Testing Gastroenterologic Disorders (non-cancerous)
V1.2024 Concert Genetics Genetic Testing General Approach to Genetic Testing
V1.2024 Concert Genetics Genetic Testing Hearing Loss
V1.2024 Concert Genetics Genetic Testing Hematologic Condition (non-cancerous)
V1.2024 Concert Genetics Genetic Testing Hereditary Cancer Susceptibility
V1.2024 Concert Genetics Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders
V1.2024 Concert Genetics Genetic Testing Kidney Disorders
V1.2024 Concert Genetics Genetic Testing Lung Disorders
V1.2024 Concert Genetics Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders
V1.2024 Concert Genetics Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, & Developmental Delay
V1.2024 Concert Genetics Genetic Testing Non-Invasive Prenatal Screening (NIPS)
V1.2024 Concert Genetics Genetic Testing Pharmacogenetics
V1.2024 Concert Genetics Genetic Testing Preimplantation Genetic Testing
V1.2024 Concert Genetics Genetic Testing Prenatal and Preconception Carrier Screening
V1.2024 Concert Genetics Genetic Testing Prenatal Diagnosis via Amniocentesis, CVS or PUBS and Pregnancy Loss
V1.2024 Concert Genetics Genetic Testing Skeletal Dysplasia and Rare Bone Disorders
V1.2024 Concert Genetics Oncology Algorithmic Testing
V1.2024 Concert Genetics Oncology Cancer Screening
V1.2024 Concert Genetics Oncology Circulating Tumor DNA and Circulating Tumor Cells Liquid Biopsy
V1.2024 Concert Genetics Oncology Cytogenetic Testing
V1.2024 Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies
May 1, 2024:
MC.CP.MP.248 Facility-based Sleep Studies for Obstructive Sleep Apnea
January 1, 2024:
MC.CP.MP.22 Stereotactic Body Radiation Therapy
MC.CP.MP.57 Lung Transplantation
MC.CP.MP.69 Intensity-Modulated Radiotherapy
MC.CP.MP.101 Donor Lymphocyte Infusion
MC.CP.MP.106 Endometrial Ablation
MC.CP.MP.108 Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia
MC.CP.MP.160 Wireless Pulmonary Artery Monitoring
MC.CP.MP.170 Peripheral Nerve Blocks
MC.CP.MP.182 Short Inpatient Stay
CP.PP.206 Skilled Nursing Facility Leveling
MC.CP.MP.246 Pediatric Kidney Transplantation
The Concert Genetics Clinical Criteria Support document (PDF) explains the evidence base for the Concert Genetics policies and the balance of the benefits vs. the risks of the criteria. The following policies apply to all Medicare lines of business with the exception of the Texas WellCare by AllWell plan:
V2.2023 Concert Genetics Oncology Algorithmic Testing
V2.2023 Concert Genetics Genetic Testing Aortopathies and Connective Tissue Disorders
V2.2023 Concert Genetics Genetic Testing Cardiac Disorders
V2.2023 Concert Genetics Oncology Cancer Screening
V2.2023 Concert Genetics Oncology Circulating Tumor DNA and Circulating Tumor Cells Liquid Biopsy
V2.2023 Concert Genetics Oncology Cytogenetic Testing
V2.2023 Concert Genetics Genetic Testing Dermatologic Conditions
V2.2023 Concert Genetics Genetic Testing Epilepsy, Neurodegenerative, and Neuromuscular Conditions
V2.2023 Concert Genetics Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders
V2.2023 Concert Genetics Genetic Testing Eye Disorders
V2.2023 Concert Genetics Genetic Testing Gastroenterologic Disorders (non-cancerous)
V2.2023 Concert Genetics Genetic Testing General Approach to Genetic Testing
V2.2023 Concert Genetics Genetic Testing Hearing Loss
V2.2023 Concert Genetics Genetic Testing Hematologic Condition (non-cancerous)
V2.2023 Concert Genetics Genetic Testing Hereditary Cancer Susceptibility
V2.2023 Concert Genetics Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders
V2.2023 Concert Genetics Genetic Testing Kidney Disorders
V2.2023 Concert Genetics Genetic Testing Lung Disorders
V2.2023 Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies
V2.2023 Concert Genetics Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders
V2.2023 Concert Genetics Genetic Testing Non-Invasive Prenatal Screening (NIPS)
V2.2023 Concert Genetics Genetic Testing Pharmacogenetics
V2.2023 Concert Genetics Genetic Testing Preimplantation Genetic Testing
V2.2023 Concert Genetics Genetic Testing Prenatal and Preconception Carrier Screening
V2.2023 Concert Genetics Genetic Testing Prenatal Diagnosis via Amniocentesis, CVS or PUBS and Pregnancy Loss
V2.2023 Concert Genetics Genetic Testing Skeletal Dysplasia and Rare Bone Disorders
V2.2023 Concert Genetics Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, & Developmental Delay
Policies Retired for Medicare
CP.MP.100 Allergy Testing and Therapy
CP.MP.101 Donor Lymphocyte Infusion
CP.MP.102 Pancreas Transplant
CP.MP.105 Digital EEG Analysis
CP.MP.106 Endometrial Ablation
CP.MP.107 Durable Medical Equipment and Orthotics and Prosthetics Guidelines
CP.MP.108 Allogeneic Hematopoietic Cell Transplants For Sickle Cell Anemia and Beta-thalassemia
CP.MP.109 Panniculectomy
CP.MP.110 Bronchial Thermoplasty
CP.MP.113 Holter Monitors
CP.MP.114 Disc Decompression Procedures
CP.MP.115 Discography
CP.MP.116 Lysis of Epidural Lesions
CP.MP.117 Spinal Cord Stimulation
CP.MP.12 Vagus Nerve Stimulation
CP.MP.120 Pediatric Liver Transplant
CP.MP.121 Homocysteine Testing
CP.MP.123 Laser Therapy for Skin Conditions
CP.MP.126 Sacroiliac Joint Infusion
CP.MP.127 Total Artificial Heart
CP.MP.128 Optic Nerve Decompression Surgery
CP.MP.129 Fetal Surgery in Utero for Prenatally Diagnosed Malfunctions
CP.MP.130 Fertility Preservation
CP.MP.132 Heart-Lung Transplant
CP.MP.133 Posterior Tibial Nerve Stimulation for Voiding Dysfunction
CP.MP.134 Evoked Potential Testing
CP.MP.136 Home Births
CP.MP.137 Fecal Incontinence Treatments
CP.MP.138 Pediatric Heart Transplant
CP.MP.139 Low-frequency Ultrasound and Noncontact Wound Therapy
CP.MP.14 Cochlear Implant Replacements
CP.MP.141 Non-myeloablative Allogeneic Stem Cell Transplants
CP.MP.142 Urinary Incontinence Devices and Treatments
CP.MP.143 Wireless Motility Capsule
CP.MP.144 Mechanical Stretching Devices for Joint Stiffness and Contracture
CP.MP.145 Electric Tumor Treating Fields (Optune)
CP.MP.146 Sclerotherapy for Chemical Endovenous Ablation for Varicose Veins
CP.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention
CP.MP.148 Radial Head Implant
CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia
CP.MP.151 Transcatheter Closure of Patent Foramen Ovale
CP.MP.152 Measurement of Serum 1,25-dihydroxyvitamin D
CP.MP.153 Helicobacter Pylori (H Pylori) Serology Testing
CP.MP.154 Thyroid Hormones and Insulin in Pediatrics
CP.MP.155 EEG Headache
CP.MP.156 Cardiac Biomarker Testing
CP.MP.157 25-hydroxyvitamin D Testing in Children and Adolescents
CP.MP.158 Ambulatory Surgery Center Optimization
CP.MP.160 Implantable Wireless Pulmonary Artery Pressure Monitoring
CP.MP.162 Tandem Transplant
CP.MP.163 Total Parenteral Nutrition and Intradialytic Parenteral Nutrition
CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections
CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Injections
CP.MP.166 Sacroiliac Joint Interventions for Pain Management
CP.MP.167 Intradiscal Steroid Injections for Pain Management
CP.MP.168 Biofeedback
CP.MP.169 Trigger Point Injections for Pain Management
CP.MP.170 Nerve Blocks for Pain
CP.MP.171 Facet Joint Interventions
CP.MP.173 Implantable Intrathecal or Pain Pump
CP.MP.174 Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy
CP.MP.175 Air Ambulance
CP.MP.176 Outpatient Cardiac Rehabilitation
CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing
CP.MP.182 Short Inpatient Hospital Stay
CP.MP.184 Home Ventilators
CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds
CP.MP.186 Burn Surgery
CP.MP.188 Pediatric Oral Function Therapy
CP.MP.190 Outpatient Oxygen Use
CP.MP.194 Osteogenic Stimulation
CP.MP.202 Orthognathic Surgery
CP.MP.203 Diaphragmatic Phrenic Nerve Stimulation
CP.MP.206 Skilled Nursing Facility Leveling
CP.MP.209 Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing
CP.MP.210 Repair of Nasal Valve Compromise
CP.MP.22 Stereotactic Body Radiation Therapy
CP.MP.24 Multiple Sleep Latency Testing
CP.MP.242 Pulmonary Function Testing
CP.MP.243 Implantable Loop Recorder
CP.MP.244 Liposuction for Lipedema
CP.MP.246 Pediatric Kidney Transplant
CP.MP.247 Transplant Service Documentation Requirements
CP.MP.248 Facility Based Sleep Studies for OSA
CP.MP.26 Articular Cartilage Defect Repair
CP.MP.31 Cosmetic and Reconstructive Surgery
CP.MP.36 Experimental Technologies
CP.MP.37 Bariatric Surgery
CP.MP.38 Ultrasound in Pregnancy
CP.MP.40 Gastric Electrical Stimulation
CP.MP.43 Functional MRI
CP.MP.46 Ventricular Assist Devices
CP.MP.48 Neuromuscular and Peroneal Nerve Electric Stimulation
CP.MP.49 Physical Occupational and Speech Therapy Services
CP.MP.50 Drugs of Abuse Definitive Testing
CP.MP.51 Reduction Mammoplasty and Gynecomastia Surgery
CP.MP.53 Ferriscan R2-MRI
CP.MP.54 Hospice
CP.MP.55 Assisted Reproductive Technology
CP.MP.57 Lung Transplantation
CP.MP.58 Intestinal and Multivisceral Transplant
CP.MP.61 IV Moderate Sedation IVE Deep Sedation and General Anesthesia for Dental Procedures
CP.MP.62 Hyperhidrosis Treatments
CP.MP.69 Intensity Modulated Radiotherapy
CP.MP.70 Proton and Neutron Beam Therapies
CP.MP.71 Long Term Care Placement Criteria
CP.MP.81 NICU Discharge Guidelines
CP.MP.82 NICU Apnea Bradycardia
CP.MP.85 Neonatal Sepsis Management
CP.MP.86 Neonatal Abstinence Syndrome Guidelines
CP.MP.87 Therapeutic Utilization of Inhaled Nitric Oxide
CP.MP.91 Obstetrical Home Care Programs
CP.MP.92 Acupuncture
CP.MP.93 Bone-Anchored Hearing Aid
CP.MP.94 Clinical Trials
CP.MP.95 Gender-Affirming Procedures
CP.MP.97 Testing for Select Genitourinary Conditions
CP.MP.98 Urodynamic Testing
CP.MP.99 Wheelchair Seating
CP.BH.100 Substance Use Disorders and Treatment Services
CP.BH.104 Applied Behavioral Analysis
CP.BH.124 ADHD
CP.BH.200 TMS for Treatment Resistant Major Depression
CP.BH.201 Deep Transcranial Magnetic Stimulation for Treatment of Obsessive-Compulsive Disorder
CP.BH.300 Biofeedback for BH Disorders
CP.BH.500 BH Treatment Documentation Requirements
