Provider Communication Policy Update

Number

Policy Name

Policy Description

Line of Business (LOB)

CC.MP.96

Ambulatory Electroencephalography

This policy defines the scenarios where ambulatory electroencephalogram would be medically necessary.

Medicare,
Medicaid

CC.MP.98

Urodynamic Testing

The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies.

Medicare,
Medicaid

CP.MP.70

Proton and Neutron Beam Therapy

This policy outlines medical necessity parameters for Proton Bean and Neutron Beam Radiotherapy.  The goal of this policy is to divert utilization to Intensity Modulated Radiation Therapy (IMRT).

Medicare,
Medicaid

CP.MP.105

Digital Analysis of EEG

The purpose of this policy is to define criteria for medical necessity of digital EEG spike analysis

Medicare,
Medicaid

CP.MP.103

FeNo Testing

Fractionated exhaled nitric oxide (FeNO) measurement is a quantitative, noninvasive, and simple method of measuring airway inflammation.  While measurement of FeNO is standardized, there are currently no reference guidelines available to aid practitioners in appropriately applying test results in practice.

Medicare,
Medicaid

CP.MP.110

Bronchial Thermoplasty

This policy describes the medical necessity requirements for bronchial thermoplasty (BT). BT is a bronchoscopic procedure that utilizes radiofrequency ablation to reduce airway smooth muscle cells. It is designed to serve as a therapeutic option to reduce severe bronchoconstriction for severe persistent asthma.

Medicare,
Medicaid

CP.MP.113

Holter Monitors

This policy defines the medically necessary indications for continuous ambulatory ECG monitoring.

Medicare,
Medicaid

CP.MP.121

Homocysteine Testing

This policy defines the medically necessary indications for homocysteine testing.

Medicare,
Medicaid

CC.PP.049

Status “P” Bundled Services

The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another physician’s procedure or service to be used in making payment decisions and administering benefits.

Medicare,
Medicaid

CP.MP.125

DNA Analysis of Stool

Cologuard is a non-invasive screening test for colon cancer.  This test comprises a multi-target screen for several aberrant DNA markers of colon cancer, as well as a hemoglobin immunoassay.  This policy describes the medical necessity requirements for DNA analysis of stool with the Cologuard.

Medicare,
Medicaid

CP.MP.134

Evoked Potentials

Evoked potentials evaluate electrical activity in the nervous system in response to stimulation of specific nerve pathways.  Types of evoked potentials include somatosensory, brainstem auditory, visual and motor.  Monitoring of neurophysiologic evoked potentials intraoperatively helps prevent neurologic injury during neurological, orthopedic, and other types of surgeries.  This policy describes the medically necessary indications for neurophysiologic evoked potentials.

Medicare,
Medicaid

CP.MP.135

Fecal Calprotectin Assay

Calprotectin is a calcium binding protein that is excreted in stool in patients with inflammatory bowel disease (IBD) and other gastrointestinal conditions.  Fecal calprotectin (FC), used as a noninvasive marker of intestinal inflammation, has been proposed to aid in the diagnosis and as a predictor of relapse in IBD including Crohn’s disease (CD) and ulcerative colitis (UC), rather than relying solely on clinical symptoms.  The policy provides a statement of medical necessity for FC assay testingFeNO Testing

Medicare,
Medicaid

CC.MP.139

Low-Frequency Ultrasound Therapy for Wound Management

The policy provides a statement of medical necessity for low-frequency ultrasound wound therapy.

Medicare,
Medicaid

CP.MP.140

EpiFix Wound Treatment

This policy describes the medically necessary indications for EpiFix wound treatment.

Medicare,
Medicaid

CP.MP.143

Wireless Motility Capsule

The policy provides a statement of medical necessity for wireless motility capsule (WMC).

Medicare,
Medicaid

CC.PP.050

Robotic Surgery

This policy defines payment criteria for robotic surgeries to be used in making payment decisions and administering benefits.

Medicare,
Medicaid

CP.MP.153

Helicobacter Pylori (H. Pylori) Serology Testing

This policy outlines why serologic antibody testing cannot distinguish between an active infection and a past infection, and why alternative, non-invasive testing methods (e.g., the urea breath test and stool antigen test) exist for detecting the presence of H. pylori.

Medicare,
Medicaid

CP.MP.155

EEG in the Evaluation of a Headache

This policy addresses the use of EEG in the diagnostic evaluation of headache.

Medicare,
Medicaid

CP.MP.156

Cardiac Biomarker Testing for Acute Myocadial

​This policy discusses the medical necessity requirements for testing of cardiac biomarkers.

Medicare,
Medicaid

CP.MP.143

Place of Service Mismatch

The purpose of this policy is to identify instances in which a procedure code is billed with an inappropriate place of service per CPT/HCPCS guidelines.

Medicare,
Medicaid