CurrentKaiser PermanentePolicy N/A

Kaiser Foundation Health Plan of Washington Clinical Review Criteria

An index/listing of Kaiser Foundation Health Plan of Washington Clinical Review Criteria, mapping many medical policy topics (DME, radiology, laboratory, surgical procedures, etc.) to their coverage location (NCD, LCD, LCA, Decision Memo, Manuals) and noting revision history. It is an administrative/reference index rather than a single-issue coverage policy.

Policy Summary

PayerKaiser Permanente

PolicyKaiser Foundation Health Plan of Washington Clinical Review Criteria

Policy CodePolicy N/A

Change TypeRevision history (additions/removals)

Effective Date

Next Review Date

Key ActionProviders must consult the patient's Evidence of Coverage or call Kaiser Permanente Member Services to determine coverage for a specific medical service before proceeding.

POLICY UPDATE CHANGES

Multiple NCDs, LCDs, LCAs and Decision Memos were added over time and specific items were added or retired per the revision history (entries list dates and added/removed items).

Policy index entries and locations updated (e.g., removed items that have individual criteria pages).

40+Referenced policies/articles

2009-2025Revision history range (years)

multipleCoverage locations referenced

Policy Index Summary

This document is an index of Kaiser Foundation Health Plan of Washington Clinical Review Criteria that maps many topic-specific policies (DME, radiology, laboratory, surgical procedures, etc.) to their governing Medicare coverage documents (NCD, LCD, LCA), Decision Memos, Policy Articles, and Manuals. It is intended as an administrative/reference index for members and providers and does not itself serve as a single-issue coverage policy.

Status: CURRENT. Subject: Kaiser Permanente Clinical Review Criteria index (KPWA). Last review date: 2024-12-03.

PayerKaiser Permanente

PolicyKaiser Foundation Health Plan of Washington Clinical Review Criteria

StatusCURRENT

Last review2024-12-03

Revision range2009-2025

Referenced NCDs / LCDs / LCAs / Decision Memos (Index)

This section is an index mapping topic-specific clinical review criteria to their governing Medicare coverage documents (NCD, LCD, LCA), Decision Memos, Policy Articles, and Manuals for Kaiser Foundation Health Plan of Washington.

Referenced NCD/LCD/LCA/Decision Memo/Policy Article topics (index)mixed

20.19	Ambulatory Blood Pressure Monitoring (NCD location referenced)
160.22	Ambulatory EEG Monitoring - Retired
280.1	Durable Medical Equipment Reference List NCD
280.7	Hospital Beds (NCD)
230.13	Peridex CAPD Filter Set (NCD)
L33686	Ankle-Foot/Knee-Ankle-Foot Orthosis (LCD)
L36267	Bowel Management Devices (LCD)
L33733	Canes and Crutches (LCD)
L33823	Cervical Traction Devices (LCD)
L33735	Cold Therapy (LCD)

1–10 of 83

1/9

Provider Guidance & Required Actions

Documentation Required

Consult member Evidence of Coverage

Providers must consult the patient's Evidence of Coverage or call Kaiser Permanente Member Services to determine coverage for a specific medical service before proceeding.

Note for providers: This index is provided as a reference only. Providers must consult the patient’s Evidence of Coverage or call Kaiser Permanente Member Services to determine coverage for a specific medical service before proceeding.

Medicare Determinations (Notable Entries)

Selected Medicare determinations referenced in this index are highlighted below; the index notes added and retired NCDs/LCDs/LCAs and Decision Memos over time (for example, additions such as MTWA 20.3 on 12/21/2023 and numerous DME LCDs added 06/04/2024, and retirements such as Ambulatory EEG Monitoring 160.22).

Number	Name	Type	Status/Effective
160.22	Ambulatory EEG Monitoring	NCD	Retired (as noted)
20.3	Microvolt T-Wave Alternans (MTWA)	NCD	Added 12/21/2023
240.1	Lung Volume Reduction Surgery (Reduction Pneumoplasty)	NCD

Document Revision Timeline

04/30/2015added

12/21/2023added

Multiple NCDs, LCDs, LCAs and Decision Memos were added over time and specific items were added or retired per the revision history (entries list dates and added/removed items). Example: 12/21/2023 added NCD Microvolt T-Wave Alternans and others (Lung Volume Reduction Surgery, Partial Ventriculectomy, Percutaneous Transluminal Angioplasty).

06/04/2024addedLatest

Multiple NCDs, LCDs, LCAs and Decision Memos were added over time and specific items were added or retired per the revision history (entries list dates and added/removed items). Example: 06/04/2024 added NCD for Capsule pH Monitoring System and several DME LCDs and Policy Articles (Ankle-foot/knee-ankle-foot orthosis; Bowel Management Devices; Canes and Crutches; Cervical Traction Devices; Cold Therapy; Commodes; Heating Pads and Heat Lamps; Infrared Heating Pad systems; Knee Orthosis; Nebulizers; Orthopedic Footwear; Spinal Orthosis: TLSO and LSO; Therapeutic Shoes for Persons with Diabetes; Tracheostomy Care Supplies; Urological Supplies; Vacuum Erection Devices; Walkers).

revised

Policy index entries and locations updated (e.g., removed items that have individual criteria pages). Examples include removal of Leadless Pacemakers and Cardiac Pacemakers from index when they had independent criteria pages.

The document-level changes list is populated from the revision history component and includes additions and removals of index items and movement of items to separate, independent criteria pages (examples in the revision history include adding Transcatheter Mitral Valve Repair on 04/30/2015, retiring Ambulatory EEG Monitoring 160.22, and removing items that now have individual criteria pages).

Policy Summary

PayerKaiser Permanente

PolicyKaiser Foundation Health Plan of Washington Clinical Review Criteria

Policy CodePolicy N/A

Change TypeRevision history (additions/removals)

Effective Date

Next Review Date

Key ActionProviders must consult the patient's Evidence of Coverage or call Kaiser Permanente Member Services to determine coverage for a specific medical service before proceeding.

On This Page

OpenPayer

Kaiser Foundation Health Plan of Washington Clinical Review Criteria

Policy Index Summary

Referenced NCDs / LCDs / LCAs / Decision Memos (Index)

Provider Guidance & Required Actions

Key Definitions

Medicare Determinations (Notable Entries)

Document Revision Timeline