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Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Ambetter of Tennessee Clinical Policy Manual apply to Ambetter of Tennessee members. Policies in the Ambetter of Tennessee Clinical Policy Manual may have either a Ambetter of Tennessee or a “Centene” heading. Ambetter of Tennessee utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter of Tennessee clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Ambetter of Tennessee. In addition, Ambetter of Tennessee may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Ambetter of Tennessee.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Clinical Policy List
A-G H-O P-Z
25-hydroxyvitamin D testing in children and adolescents (PDF)
Effective Date: 12/29/2017		 H. Pylori serology testing (PDF)
Effective Date: 12/29/2017		 Pancreas transplant (PDF)
Effective Date: 2/28/2018
ADHD Assessment and Treatment (PDF)
Effective Date: 5/31/2018		 Heart-Lung Transplant (PDF)
Effective Date: 4/30/2018		 Pediatric heart transplant (PDF)
Effective Date: 1/31/2018
Allergy Testing and Therapy (PDF)
Effective Date: 1/31/2018		 Holter Monitors (PDF)
Effective Date: 6/30/2018		 Pediatric Liver Transplant (PDF)
Effective Date: 4/30/2018
Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF)
Effective Date: 2/28/2018		 Home phototherapy for neonatal hyperbilirubinemia (PDF)
Effective Date: 10/31/2018		 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
Effective Date: 5/31/2018
Ambulatory EEG (PDF)
Effective Date: 8/31/2018		 Homocysteine testing (PDF)
Effective Date: 5/31/2018		 Posterior tibial nerve stimulation for voiding dysfunction (PDF)
Effective Date: 8/31/2018
Ambulatory Surgery Center Optimization (PDF)
Effective Date: 2/16/2018		 Hospice Services (PDF)
Effective Date: 4/30/2018		 Preventive Health and Clinical Practice Guideline Policy (PDF)
Effective Date: 9/19/2018
Applied Behavioral Analysis for Autism (PDF)
Effective Date: 1/31/2018		 Hyperbaric Oxygen Therapy (PDF)
Effective Date: 10/31/2018		 Radial Head Implant (PDF)
Effective Date: 10/19/2018
Articular Cartilage Defect Repairs (PDF)
Effective Date: 4/30/2018		 Hyperemesis gravidarum treatment (PDF)
Effective Date: 3/30/2018		 Reduction mammoplasty and gynecomastia surgery (PDF)
Effective Date: 7/31/2018
Balloon sinus ostial dilation (PDF)
Effective Date: 9/30/2018		 Hyperhidrosis treatments (PDF)
Effective Date: 2/28/2018		 Sacroiliac joint fusion (PDF)
Effective Date: 6/30/2018
Bone-anchored hearing aid (PDF)
Effective Date: 10/31/2018		 Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
Effective Date: 4/30/2018		 Sacroiliac Joint Interventions for Pain Management (PDF)
Effective: 8/31/2018
Bronchial Thermoplasty (PDF)
Effective Date: 3/31/2018		 Infusion Therapy Site of Care Optimization (PDF)
Effective Date: 10/31/2018		 Sclerotherapy for Varicose Veins (PDF)
Effective Date: 4/30/2018
Cardiac biomarker testing (PDF)
Effective Date: 3/30/2018		 Inhaled nitric oxide (PDF)
Effective Date: 9/30/2018		 Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
Effective Date: 8/31/2018
Carrier Screening in Pregnancy (PDF)
Effective Date: 5/31/2018		 Intensity-Modulated Radiotherapy (PDF)
Effective Date: 2/28/2018		 Sickle cell disease observation (PDF)
Effective Date: 7/31/2018
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)
Effective Date: 8/31/2018		 Intestinal and multivisceral transplant (PDF)
Effective Date: 6/30/2018		 Spinal Cord Stimulation (PDF)
Effective Date: 9/30/2018
Cell-free Fetal DNA Testing (PDF)
Effective Date: 4/30/2018		 Intradiscal Steroid Injections for Pain Management (PDF)
Effective Date: 8/31/2018		 Stereotactic Body Radiation Therapy (PDF)
Effective Date: 1/31/2018
Clinical Policy Committee (PDF)
Effective Date: 7/31/2018		 Laser therapy for skin conditions (PDF)
Effective Date: 6/30/2018		 Tandem Transplant (PDF)
Effective Date: 7/31/2018
Clinical Policy Web Posting (PDF)
Effective Date: 8/24/2018		 Long Term Care Placement Criteria (PDF)
Effective Date: 4/30/2018		 Testing for rupture of fetal membranes (PDF)
Effective Date: 6/30/2018
Cochlear Implant Replacements (PDF)
Effective Date: 10/31/2018		 Low-frequency ultrasound therapy for wound management (PDF)
Effective Date: 1/31/2018		 Testing for select genitourinary conditions (PDF)
Effective Date: 8/31/2018
Dental Anesthesia (PDF)
Effective Date: 4/30/2018		 Lung Transplantation (PDF)
Effective Date: 10/31/2018		 Therapy Services (PT/OT/ST) (PDF)
Effective Date: 6/22/2018
Digital electroencephalography spike analysis (PDF)
Effective Date: 1/31/2018		 Lysis of Epidural Lesions (PDF)
Effective Date: 5/31/2018		 Thyroid hormones and insulin testing in pediatrics (PDF)
Effective Date: 12/29/2017
Disc Decompression Procedures (PDF)
Effective Date: 5/31/2018		 Measurement of serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: 12/29/2017		 Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Effective Date: 4/30/2018
Discography (PDF)
Effective Date: 6/30/2018		 Medical Necessity Criteria (PDF)
Effective Date: 6/30/2018		 Transcatheter closure of patent foramen ovale (PDF)
Effective Date: 12/29/2017
DNA analysis of stool to screen for colorectal cancer (PDF)
Effective Date: 7/31/2018		 Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
Effective Date: 5/31/2018		 Trigger Point Injections for Pain Management (PDF)
Effective Date: 8/31/2018
Durable Medical Equipment (DME) (PDF)
Effective Date: 7/31/2018		 Multiple Sleep Latency Testing (PDF)
Effective Date: 4/30/2018
 Ultrasound in Pregnancy (PDF)
Effective Date: 6/30/2018
Electroencephalography in the evaluation of headache (PDF)
Effective Date: 12/29/2017		 Neonatal abstinence syndrome guidelines (PDF)
Effective Date: 9/30/2018
 Urinary Incontinence Devices and Treatments (PDF)
Effective Date: 9/24/2018
Endometrial ablation (PDF)
Effective Date: 7/31/2018		 Neonatal sepsis management (PDF)
Effective Date: 7/31/2018		 Urodynamic testing (PDF)
Effective Date: 9/30/2018
Evoked Potential Testing (PDF)
Effective Date: 10/31/2018		 Nerve Blocks for Pain Management (PDF)
Effective Date: 8/31/2018		 Vagus Nerve Stimulation (PDF)
Effective Date: 8/31/2018
Facet Joint Interventions for pain management (PDF)
Effective Date: 9/14/2018		 NICU Apnea Bradycardia Guidelines (PDF)
Effective Date: 5/31/2018		 Ventricular Assist Devices (PDF)
Effective Date: 2/28/2018
Fecal calprotectin assay (PDF)
Effective Date: 11/30/2017		 NICU discharge guidelines (PDF)
Effective Date: 8/31/2018		 Ventriculectomy and cardiomyoplasty (PDF)
Effective Date: 2/28/2018
Fecal incontinence treatments (PDF)
Effective Date: 12/29/2017		 Non-myeloablative allogeneic stem cell transplants (PDF)
Effective Date: 2/28/2018		 Wheelchair seating (PDF)
Effective Date: 9/30/2018
Fractional exhaled nitric oxide (PDF)
Effective Date: 12/29/2017		 Optic nerve decompression surgery (PDF)
Effective Date: 8/31/2018
 Zika Virus Testing (PDF)
Effective Date: 5/31/2018
Functional MRI (PDF)
Effective Date: 9/30/2018		 Outpatient testing for drugs of abuse (PDF)
Effective Date: 7/31/2018		  
Gastric electrical stimulation (PDF)
Effective Date: 9/30/2018		    
Genetic Testing (PDF)
Effective Date: 4/30/2018