Updated Clinical Policies - Effective June 1, 2025

Policy Number

Policy Name

Policy Description

Product Line(s)

CP.MP.133

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

Posterior tibial nerve stimulation (PTNS), also known as peripheral tibial nerve stimulation, is a minimally invasive form of electrical neuromodulation used to treat overactive bladder (OAB) syndrome and associated symptoms of urinary urgency, urinary frequency, and urge urinary incontinence.1 This policy describes the medical necessity requirements for posterior tibial nerve stimulation.

Medicaid; Medicare

CP.CPC.03

Preventive Health and Clinical Practice Guidelines

Annual review. Updated Corporate Clinical Policy Committee (CPC) to Physical Health Clinical Policy Committee (PH CPC) throughout policy. Added “plan websites” under I.C.6.e. Reviewed and updated Clinical Practice Guidelines Grid, including Behavioral Health guidelines Updated plan addenda for Meridian MI.

Medicaid; Medicare

CPG Grid

CPG Grid

Annual review. Reviewed and updated all links and guideline versions as appropriate. Added the following Physical Health guidelines: Combined Coronary Artery Disease section and Congenital Disorders to Cardiovascular Disease, Added ISTH- clinical practice guideline for treatment of congenital hemophilia A and B based on the Grading of Recommendations Assessment, Development, and Evaluation methodology; Updated Hyperlipidemia section to Dyslipidemia and added VA/DoD Clinical Practice Guidelines Management of Dyslipidemia for Cardiovascular Risk Reduction (2020); AAFP- Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP (2022), VA/DoD- Clinical Practice Guidelines Diagnosis and Management of Hypertension (HTN) in Primary Care (2020); ACOG Clinical Practice Guideline No. 2. Management of Postmenopausal Osteoporosis (April 2022); Women’s Preventive Services Initiative (WPSI), American College of Obstetricians and Gynecologists (ACOG)- Recommendations for Well-Woman Care; WHO clinical treatment guideline for tobacco cessation in adults; NCCN Clinical Practice Guidelines in Oncology, Smoking Cessation, Version 3.2022; Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline; American Association of Clinical Endocrinologists (AACE), The Obesity Society, American Society of Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists- Clinical Practice Guidelines For The Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update; IFSO-WGO GUIDELINES ON OBESITY (2023). Updated the following Physical Health guidelines with new publication revision dates: 2024 GINA Report, Global Strategy for Asthma Management and Prevention; Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2025 Report); IDSA Guidelines of the Treatment and Management of Patients with COVID-19 (Updated August 2024); USPSTF- Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis (2023); ACOG- Routine Human Immunodeficiency Virus Screening (2014- reaffirmed 2024); CDC- Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the ACIP United States, 2024-2025 Influenza Season; CDC- Adult Immunization Schedule. Recommendations for Ages 19 years or older, United States, 2025; CDC- Child and Adolescent Immunization Schedule. Recommendations for Ages 18 years or younger, United States, 2025; Bright Futures/American Academy of Pediatrics- Periodicity Schedule: Recommendations for Preventive Pediatric Health Care (2024); Final Recommendation Statement High Body Mass Index in Children and Adolescents: Interventions; CDC- Clinical Testing and Diagnosis for Zika Virus Disease For Healthcare Providers: New Zika and Dengue Testing Guidance (May 15, 2024). Removed the following guidelines: HHS, NIH and NHLBI Asthma Care Quick Reference: Diagnosing and Managing Asthma. Guidelines from the National Asthma Education and Prevention Program. Expert Panel Report 3. (Revised 2012); Journal of Orthopaedic and Sports Physical Therapy- Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health (2012); NIH- Coronavirus Disease 2019 Treatment Guidelines; NICE Managing Medicines for Adults Receiving Social Care in the Community (2017); General Evidence Based Medicine- Choosing Wisely; HHS/HRSA- Guide for HIV/AIDS Program Clinical Care (2014); 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults; U.S. Department of Health and Human Services, NIH, NHLBI - Managing Overweight and Obesity in Adults: Systematic Evidence Review from the Obesity Expert Panel (2013). Added the following Behavioral Health guidelines: Added the following Behavioral Health guidelines: AAFP Generalized Anxiety disorder and Panic disorder.

Medicaid; Medicare

CP.MP.160

Implantable Wireless Pulmonary Artery Presure Monitoring

Annual review. References reviewed and updated. Reviewed by external specialist.

Medicaid; Medicare

CP.MP.170

Nerve Blocks and Neurolysis for Pain Management

Annual review. Added note in Description to refer to CP.MP.171 Facet Joint Interventions for facet joint injections and radiofrequency neurotomy and added note for Medicare plans to refer to MC.CP.MP.170 Peripheral Nerve Blocks and Ablation of Peripheral Nerves for Pain Management. Added clarifying verbiage regarding non-Medicare health plans in Policy/Criteria with no impact to criteria. Added clarifying language to Criteria I.A.2. Updated Criteria II.A.1.c. to include application of lidocaine and minor grammatical change made. Grammatical update made in Criteria II.B.1. for clarity. Grammatical update made in Criteria VI.B.2.b. for clarity. References reviewed and updated. Reviewed by internal specialist and external specialist.

Medicaid; Medicare

CP.MP.176

Outpatient Cardiac Rehabilitation

Annual review. Removed I.A.2. History of unstable angina pectoria within last 12 months. Removed I.D. If diabetic, documentation supports that it is adequately controlled. Removed I.E.2. Uncontrolled hypertension- resting systolic blood pressure (SBP) >180 mmHg and/or resting diastolic (DBP) >110 mmHg. Under I.D.3. replaced “Significant” with “Symptomatic severe”. Added “with hemodynamic compromise” to I.D.4. Removed previous I.E.6. and I.E.8. Under new I.E.8. replaced “Recent” with “Active pulmonary” and added “pulmonary infarction or deep vein thrombosis. Removed I.E.13. Other metabolic conditions, such as acute thyroiditis, hypokalemia, hyperkalemia, or hypovolemia (until adequately treated). Added I.E.13. Active endocarditis and I.E.14. Acute aortic dissection. Under II.C. removed “a total of”. Minor rewording in background with no clinical significance. References reviewed and updated.

Medicaid; Medicare

CP.BH.200

Transcranial Magnetic Stimulation for Treatment of Major Depression

Annual review. Policy restructured and reformatted for clarity. Description updated. Criteria restructuring in policy statements I and III which apply to adults ≥ 18 years of age only. Added new policy statements II and IV, which apply to adolescents 15-17 years of age only. In policy statements I and III, added deep TMS (dTMS) as a form of TMS for adults ≥ 18 years of age. In I.A. removed the psychosis exclusion from the diagnosis criteria. In I.B. removed criteria statement “the major depressive disorder diagnosis is not part of a presentation with multiple psychiatric comorbidities and there is no evidence of psychosis or substance use” and replaced it with “The member/enrollee does not have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder. In I.C.1. replaced the term “psychopharmacologic agents” with “antidepressants” and removed the statement "during the current depressive episode (and within if the current episode exceeds 24 months of duration)”. In I.C.2. combined subpoints for clarity. In I.D. removed requirement for PHQ-9 scores to be documented throughout treatment and added a broader statement referencing evidenced based treatment “ The member/enrollee has participated in an adequate trial of evidence-based psychotherapy (such as cognitive behavioral therapy and/or interpersonal therapy) during the current episode of illness, without significant improvement”;  in the note associated, replaced “medication trials” with “antidepressant trials”. In. I.F. added criteria statement “The member/enrollee is referred for TMS treatment by the provider treating the member/enrollee's MDD". In I.G. added criteria indicating that a comprehensive psychiatric evaluation has been completed by a qualified licensed provider (MD, DO or MBBS). In I.I added frequency of services “up to 36 sessions" and added a note indicating a schedule recommendation "Recommended schedule is for five days a week for six weeks, with an optional six sessions for tapering”. In I.K. removed the following relative contraindications: “history of seizures, severe cardiovascular disease,” acute psychotic disorders in the current depressive episode, dementia, and active suicidal ideation with intent. In I.L. added new criteria statement “Documentation of rTMS, iTBS or dTMS protocol used” In III. D. added the statement "with a documented 6-month duration of response". Added policy statement VI. which states that MRI guided theta burst is considered experimental and investigational. Background and references reviewed and updated.

Medicaid; Medicare

CP.BH.201

Deep Transcranial Megnetic Stimulation for Treatment of Obsessive Compulsive Disorder

Annual review. Updated description with no clinical significance. Minor rewording throughout the policy for clarity with no clinical significance. Removed verbiage indicating that the request must be reviewed by a medical director. In I.E., changed the frequency of services from 30 to 36 approved sessions “Request is for up to 36 sessions (Note: Recommended schedule is for five days a week for six weeks, with an optional six sessions for tapering)”. In I.H. removed the following relative contraindications: history of seizures, severe dementia, severe cardiovascular disease, and active suicidal ideation with intent. Deleted what was policy statement II. referencing tapering criteria. In III. C. added statement indicating documented 6-month duration of response. Background section updated. References reviewed and updated.

Medicaid; Medicare