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Highmark Wholecare Policy Updates

Published Date: 2024-10-23

Highmark Wholecare regularly reviews and updates our policies and procedures. To help you know when policies have been amended, we post a Provider Notice to our website one month (30 days) prior to the effective date. You can find these Provider Notices on the first of each month at the following links:

Medicaid Provider Updates

Medicare Provider Updates

Policy Updates Effective September 1, 2024

As a reminder, we have updated or reviewed the following Medical Policies, with changes effective September 1. These updates were previously posted on the Highmark Wholecare provider website August 1, 2024.

Medicaid Policies:

MP-118-MD-PA Experimental/Investigational Services - No changes to clinical criteria. Added the several experimental/investigational procedure codes. Removed the following procedure codes as they are currently listed on the PA Fee Schedule: 30469 & 69728. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
MP-001-MD-PA Wearable Cardioverter Defibrillators in the Home Setting - Added diagnosis code I21.B to the ‘Coding Requirements’ section. Removed PA DHS TAG determination for HCPCS code K0606 - this code no longer requires a Program Exception for approval.
MP-123-MD-PA Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease - No changes to clinical criteria. Revised ‘Procedures’ section, Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
MP-122-MD-PA Selected Tests for Rheumatic Diseases - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
MP-069-MD-PA Home Oxygen Therapy (HOT) - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
MP-101-MD-PA Repetitive Transcranial Magnetic Stimulation - No change to E/I determination. Updated ‘Reference Sources’ and ‘Summary of Literature’ sections.
MP-121-MD-PA Experimental/Investigational Laboratory Services - No changes to criteria. Updated ‘Reference Sources’ section.
MP-066-MD-PA Fecal Microbiota Transplant - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.

Medicare Policies:

MP-100-MC-PA Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) - No changes to clinical criteria. There are several ICD-10-CM coding updates. Updated ‘Reference Sources’ section.
MP-072-MC-PA Ambulatory Blood Pressure Monitor (NCD 20.19) - No changes to clinical criteria. Updated ‘Reference Sources’ section.
MP-019-MC-PA Bronchial Thermoplasty - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.