Updated Payment and Utilization Policies

Date: 12/22/20

Thank you for your continued partnership with Trillium Community Health Plan. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of new policies Trillium Community Health Plan will be implementing effective 04/01/2021.

Number	Policy Name	Policy Description	Line of Business (LOB)
CP.MP.38	Ultrasound in Pregnancy	Ultrasounds during pregnancy are considered medically necessary when the conditions and frequency outlined in the policy are met.	Medicaid Medicare
CP.MP.97	Testing for Select GU Conditions	Certain diagnostic tests for symptomatic women for the evaluation of vaginitis are medically necessary for members age ≥ 13 based on the indications outlined in the policy.	Medicaid Medicare
CP.MP.106	Endometrial Ablation	The treatment for endometrial ablation is considered experimental or investigational if it is photodynamic endometrial ablation or for treatment for all other conditions than those specified in the policy.	Medicaid Medicare
CP.MP.113	Holter Monitors	Holter Monitoring (CPT codes 93224, 93225, 93226, and 93227) is considered medically necessary for adult and pediatric members who require 24 to 48 hours of cardiac activity monitoring with any of the indications listed in the policy.	Medicaid Medicare
CP.MP.121	Homocysteine Testing	Homocysteine testing is considered medically necessary for the following indications: borderline vitamin B12 deficiency, homocystinuria caused by cystathionine beta-synthase deficiency, or Idiopathic venous thromboembolism, recurrent venous thromboembolism, thrombosis occurring at less than 45 years of age, or thrombosis at an unusual site	Medicaid
CP.MP.125	DNA Analysis of Stool to Screen for Colorectal Cancer	Code 81528 is considered medically necessary every three years if member is 50-85 years old, asymptomatic and at average risk of colon cancer, and is not within the standard interval of another screening test for colon cancer.	Medicaid Medicare
CP.MP.149	Testing for Rupture of Fetal Membranes	AmniSure, Actim PROM and the ROM Plus Fetal Membranes Rupture Test (tests billed with CPT® code 84112) are not medically necessary for members as they have not been shown to improve clinical outcomes over standard methods of diagnosis.	Medicaid Medicare
CP.MP.152	Measurement of Serum 1,25-dihydroxyvitamin D	Measurement of serum 1,25-dihydroxyvitamin D is considered medically necessary when submitted with diagnosis codes for certain inherited disorders of vitamin D and phosphate metabolism.	Medicaid Medicare
CP.MP.153	H Pylori Serology Testing	Code 86677 will not be paid because it is not medically necessary.	Medicaid Medicare
CP.MP.154	Thyroid Hormones and Insulin Testing in Pediatrics	Deny thyroid function tests and insulin level testing in healthy, or obese but otherwise healthy, children 1-18 years of age. This is because slightly elevated levels of TSH in obesity are more likely a consequence of obesity than true hypothyroidism and there are significant limitations in the use of insulin levels as a marker of insulin resistance.	Medicaid Medicare
CP.MP.156	Cardiac Biomarker Testing for Acute Myocardial Infarction	Troponin I or T testing is medically necessary and appropriate for evaluating acute myocardial infarctions. It is the policy that creatin kinase myocardial isoenzyme (CK-MB) and myoglobin testing are not medically necessary in the evaluation for suspected acute myocardial infarctions because troponin is the recommended biomarker due to its superior sensitivity and accuracy.	Medicaid Medicare
CP.MP.157	25-hydroxyvitamin D Testing in Children and Adolescents	It is the policy that although a 25-hydroxyvitamin D concentration, reflecting both vitamin D synthesis and intake, is the correct screening lab to monitor for vitamin D deficiency, is not necessary or safe because current evidence when testing otherwise healthy children who are overweight or obese is not sufficient.	Medicaid Medicare

For more detailed information about these policies, please refer to our website at https://www.trilliumohp.com/providers/resources/clinical-payment-policies2.html.

For questions about this or any of our payment policies, please don’t hesitate to reach out to our Trillium Provider Services team at 1-877-600-5472 (OHP/Medicaid) or 1-844-867-1156 (Medicare).