New or Updated Policies - Effective June 1, 2026

Policy #

Policy Name

 Description

Line(s) of Business

CP.MP.252

Immobilized Lipase Cartridges (Relizorb)

New policy developed. Reviewed by internal and external specialist.

Medicaid; Medicare

CP.MP.132

Heart-Lung Transplant

Annual review. Removed indication I.A.2.d., pulmonary alveolar proteinosis. Removed serial blood and urine testing details in Criteria I.C.16. Updated Table 2 regarding heart failure stages for clarity. Coding and descriptions reviewed. References reviewed and updated.

Medicaid; Medicare

CP.MP.184

Home Ventilators

Annual review. Revision of section of I.B. including rewording of I.B.1. and 2. with no impact on criteria, addition of new I.B.3.a.-c. regarding ventilation requirements and restructuring with previous I.B.3.a.-b. becoming I.B.4.a.-b. Removed three-month specification in Criteria II. Coding and descriptions reviewed. References reviewed and updated. Reviewed by external specialist.

Medicaid; Medicare

CP.MP.57

Lung Transplantation

Annual review. Updated adult and pediatric interstitial lung disease criteria to include end-stage or refractory pulmonary alveolar proteinosis as criteria I.D.1.c.vii.a)-b) and I.D.2.c.vii.a)-b) respectively. Reviewed codes and descriptions. References reviewed and updated.

Medicaid; Medicare

CP.BH.200

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression

Annual review. Removed all references of "Centene Advanced Behavioral Health". In I.C. added current course of "psychopharmacologic and psychotherapeutic" treatment. In. I.C.1. and I.C.2. added trials of "evidenced based" antidepressants. In. I.D. added ... (such as "weekly" cognitive behavioral therapy...)". Removed former I.E “The member/enrollee has failed a trial of electroconvulsive therapy (ECT)….” In. I.F.2. clarified Psychiatric "Mental Health" Nurse Practitioner (PMHNP). Removed "concomitant esketamine intranasal, ketamine infusion or other infusion therapy" from the contraindication list in I.J. Added I.K. "No changes to psychotropic treatment during the course of TMS treatment unless clinical documentation justifies the change...". In II.D. added throughout the current course of "psychopharmacologic and psychotherapeutic" treatment. In. II.D.1. and II.D.2. added trials of "evidenced based" antidepressants. Removed former II.E. “The member/enrollee has failed a trial of electroconvulsive therapy (ECT)….”  In II.E. added ... (such as "weekly" cognitive behavioral therapy...)". In. II.G.2. clarified Psychiatric "Mental Health" Nurse Practitioner (PMHNP). In. II.J. 4. removed "concomitant esketamine intranasal, ketamine infusion or other infusion therapy" from the contraindication list. Added II.K. "No changes to psychotropic treatment during the course of TMS treatment unless clinical documentation justifies the change (such as administration of concomitant ketamine, esketamine or other infusion therapy)". In III.F.2 added "Psychiatric Mental Health". In III.G added "(such as weekly cognitive behavioral therapy...). in III.K. Removed "concomitant esketamine intranasal, ketamine infusion or other infusion therapy". Added III.L “No changes to psychotropic treatment during the course of TMS...". In IV.G.2. added "Psychiatric Mental Health". In IV.H. added "(such as weekly cognitive behavioral therapy...). In IV.K. removed "concomitant esketamine intranasal, ketamine infusion or other infusion therapy". In IV.L added "No changes to psychotropic treatment during the course of TMS...". Background updated. Referenced reviewed and updated. External review completed by AMR.

Medicaid; Medicare

CP.BH.201

Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder

Annual review. Description updated. Removed all references of "Centene Advanced Behavioral Health". Added I.E., " Member/enrollee is referred for TMS...". Added I.F. "Planned use of Y-BOCS...". Added I.H.5. "Apollo TMS Therapy System". Added I.J.1.g. Vagus nerve

Medicaid; Medicare

CC.PI.08

Prepay DRG Validation

Prepay DRG Validation: This program was put in place to comply with provisions set forth in the contract with the state in which they operate and meet or exceed all requirements and timeframes outlined in the contract.  To comply with these provisions, Centene has the right to audit facility claim/medical records to ensure claims were billed in compliance with all state and federal clinical and coding guidelines.

Medicaid; Medicare

CP.BH.124

Attention Deficit Hyperactivity Disorder Assessment and Treatment

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders in children, with an increasing prevalence of diagnosis in adults. ADHD affects the cognitive, academic, emotional, and social well-being of individuals and can persist throughout life. While there is no single test to diagnose ADHD, a clinical assessment based on defined clinical parameters establishes criteria for diagnosis in children and adults.

Medicaid

CP.MP.38

Ultrasound in Pregnancy

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today. Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented.

Medicaid

CP.MP.247

Transplant Service Documentation Requirements

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.102

Pancreas Transplantation

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.108

Allogeneic Hemapoietic Cell Transplants for SCA and Beta Thalassemia

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.141

Nonmyeloablative Allogeneic Stem Cell Transplants

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.162

Tandem Transplant

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.249

Allogeneic Hematopoietic Progenitor Cell Therapy

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.49

Physical, Occupational and Speech Therapy Services(Birth to 3 months-PT,OT, SLP)

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.24

Multiple Sleep Latency Testing

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.BH.500

Behavioral Health Treatment Documentation Requirements

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.50

Drugs of Abuse: Definitive Testing

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.175

Air Ambulance

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

V2025.2

Concert Genetic Testing

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare

CP.MP.120

Liver Transplant

Policy reviewed off cycle for Medicaid Navigator and InterQual Custom Content.

Medicaid; Medicare