Updated Clinical Policies - Effective May 1, 2025

Date: 03/26/25

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 May 1, 2025.

You can view the details of these policies on their effective date by visiting Clinical and Payment Policies. 

Policy #	Policy Name	Policy Description	Line(s) of Business
CP.MP.81	NICU Discharge Guidelines	Annual review. Updated Authorization protocol A.5. Apnea or bradycardia monitoring with last dose of caffeine at least seven days prior to discharge. Updated NICU DC recommended practices B.4. An assessment of cardiorespiratory stability in a car seat or car bed is recommended prior to discharge for infants born at < 37 weeks gestation or for infants with other risk factors for cardiorespiratory compromise (e.g. neuromuscular, orthopedic problems). Updated E.1. to reflect car bed recommendations. Reference reviewed and updated. External specialist review.	Medicaid, Medicare
CP.MP.82	NICU Apnea Bradycardia Guidelines	Annual review. Replaced “Guidelines” section title with “Policy/Criteria” title and added verbiage regarding health plans affiliated with Centene Corporation®. Updated Criteria I.A.1. to include desaturation as a clinically significant cardiorespiratory event and updated criteria verbiage for clarity. Removed notation in Criteria I.A.1.b. regarding consideration of using heart rate decrease > 33.3% below baseline for older, more mature infants or those with a lower baseline heart rate. Updated Criteria I.A.1.d. from bradycardia to isolated bradycardia and updated from < 70 beats per minute to < 80 beats per minute. Minor rewording for clarity in Criteria I.B. and Criteria I.D. Updated Note at end of criteria section to state caffeine levels may be therapeutic in preterm infants for as long as ten days after discontinuation. Removed statement in Note section regarding “caffeine countdown.” Added car bed and added clarifying language to Note section regarding assessment of cardiorespiratory stability in a car seat. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialists..	Medicaid; Medicare

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.