Updated Clinical Policies - Effective August 1, 2025
Date: 06/30/25
Updated information as of July 1, 2025.
MHS Health Wisconsin regularly adds new or provides updates to clinical and payment policies to ensure they are designed to comply with industry standards while delivering the best experiences and outcomes for our members.
The following new policies or policy revisions are effective August 1, 2025.
You can view the details of these policies on their effective date by visiting Clinical and Payment Policies.
Policy Number | Policy Name | Policy Description | Product Line(s) |
|---|---|---|---|
CP.MP.58 | Intestinal and Multivisceral Transplant | Annual review. Added clarifying language in Policy/Criteria section and in Criteria II.A.1. Updated Criteria II.A.1.a. to include TPN induced liver injury for clarity and changed “peristomal” to “stomal.” Added hospitalization requirement for clarity in Criteria II.A.1.c. Separated Criteria II.A.1.c. into two criteria points. Clarifying language added to Criteria II.A.1.d. Updated “post-mesenteric” to “portomesenteric” in Criteria II.A.2.5. Updated GFR from < 30 mL/min/1.73m2 to < 40 mL/min/1.73m2 in Criteria II.B.3. Removed information about heart transplant waiting list from Criteria II.B.4.b. Removed Criteria II.B.5. for other GI diseases. Removed Criteria II.B.6. for acute liver failure or cirrhosis…Removed Criteria II.B.12. contraindication regarding absence of an adequate support system. Background updated with no impact on criteria. Reviewed codes and descriptions. References reviewed and updated. Reviewed by internal specialist. | Medicaid; Medicare |
CP.MP.87 | Therapeutic Utilization of Inhaled Nitric Oxide | Annual review. Merged changes and revision log entries from 11/24 and 7/24 policy versions. Under I.A.6. changed oxygen index (OI) >20 to 25. Moved I.A.7. to III.A.1. Removed criteria under III.A.1. Continues to require iNO as evidenced…References reviewed and updated. Reviewed by internal specialist. | Medicaid; Medicare |
CP.MP.132 | Heart-Lung Transplant | Updated criteria I.A.1.h.iv. and I.A.2.h.iv. from, “…could preclude heart failure in the future…” to “…could preclude heart transplant in the future...” | Medicaid; Medicare |
| CP.MP.249 | Therapeutic Utilization of Inhaled Nitric Oxide | Annual review. Merged changes and revision log entries from 11/24 and 7/24 policy versions. Under I.A.6. changed oxygen index (OI) >20 to 25. Moved I.A.7. to III.A.1. Removed criteria under III.A.1. Continues to require iNO as evidenced…References reviewed and updated. Reviewed by internal specialist. | Medicaid |
| CP.MP.127 | Total Artificial Heart | Annual review. Under I.F. added “due to irreversible biventricular heart failure”. References reviewed and updated. Reviewed by internal specialist. | Medicaid |
| CP.MP.137 | Fecal Incontinence Treatments | Annual review. Added criteria I.B.1.d. Member/enrollee demonstrates the ability…and removed I.B.1.e.iii. Inadequate response to test stimulation…and I.B.3.d. Absence of any physical or mental illness… Removed previous criteria I.B.2. for sphincteroplasty. Reworded policy statement II. with no impact on criteria. Added CPT 44320 and HCPCS C1767, C1778 to coding tables. References reviewed and updated. Reviewed by external specialist. | Medicaid |
| CP.MP.51 | Reduction Mammoplasty and Gynecomastia Surgery | Annual review. Added clarifying language to Criteria I.A. Removed “persistent” and “for at least one year” in Criteria I.A.3. Added clarifying language to Criteria I.A.3.c. regarding breast pain. Added clarifying language regarding inframammary folds in Criteria I.A.3.g. Removed criteria II.A.4. requiring adult testicular size to be attained. Coding and descriptions reviewed. References reviewed and updated. Reviewed by internal specialist and external specialist. | Medicaid |
View all Clinical and Payment Policies.
Thank you for being a valued partner in caring for the health and well-being of our members. If you have any questions about the policies listed above or any our Clinical & Payment Policies, please contact your Provider Relations representative or call the Provider Inquiry Line at 1-800-222-9831. If you are unsure who is your representative, please email us at WI_Provider_Relations@mhswi.com.