Get free help in your language with interpreters and other written materials. Get free aids and support if you have a disability. Call 1-833-230-2053 (TTY: 711). Obtenga ayuda gratuita en su idioma a travs de intrpretes y otros materiales en formato escrito. Obtenga ayudas y apoyo gratuitos si tiene una discapacidad. Llame al: 1-833-230-2053 (TTY: 711). Jwenn d gratis nan lang ou ak entprt ansanm ak lt materyl ekri. Jwenn d ak sip gratis si w gen yon andikap. Rele 1-833-230-2053 (TTY: 711). Erhalten Sie kostenlose Hilfe in Ihrer Sprache durch Dolmetscher und andere schriftliche Unterlagen. Beziehen Sie kostenlose Hilfsmittel und Untersttzung, wenn Sie eine Behinderung haben. Rufen Sie folgende Telefonnummer an: 1-833-230-2053 (TTY: 711). Obtenez une aide gratuite dans votre langue grce des interprtes et dautres documents crits. Si vous souffrez dun handicap, vous bnficiez daides et dassistance gratuites. Appelez le 1-833-230-2053 (ATS : 711). Nhn tr gip mi n ph b ng ngn ng ca qu v v i thng d ch vin v cc ti li u b ng vn b n khc. Nh n tr gip v h tr mi n ph nu qu v b khuy t t t. Gi 1-833-230-2053 (TTY: 711). Grick Helfe mitaus Koscht in dei Schprooch mit Iwwersetzer un annere schriftliche Dinge. Grick Aids un Helfe mitaus Koscht wann du en Behinderung hoscht. Ruf 1-833-230-2053 (TTY: 711). . , . 1-833-230-2053 (TTY: 711) . 1-833-230-2053 2053-230-833-1 1-833-230-2053 (TTY: 711) 1-833-230-2053 (TTY 711) Gba rnl wfn d r p l w n gbif ti w n ohun l mrn t a k sl. Gba wn rnl wti tl yn fb o b n lera kan. Pe 1-833-230-2053 (TTY: 711). Makakuha ng libreng tulong sa wika mo gamit ang mga interpreter at mga ibang nakasulat na materyales. Makakuha ng mga libreng pantulong at suporta kung may kapansanan ka. Tumawag sa 1-833-230-2053 (TTY: 711). .. 0-20531-833-23 711):YTT(.Bk jiba ilo an ejjelok wnn ikkijjien kajin eo am ibbn rukok ro im wween ko jet ilo jeje. Bk jerbalin jiba ko ilo an ejjelok wner im jiba ko e ewr am nainmejin utamwe. Kalle 1-833-230-2053 (TTY: 711).MI-MED-M- 3288201 MDH HS Approved: 11/7/2024 1-833-230-2053 1-833-230 – 1-833-230-2053 2053 (TTY: 711) Non-Discrimination Notice We follow all state and federal civil rights laws. We do not discriminate, exclude, or treat people differently based on race, color, national origin, disability, age, religion, sex (which includes pregnancy, gender, gender identity, sexual preference, and sexual orientation), or based on marital, health, or public assistance status. We want all people to have a fair and just chance to be as healthy as they can be. We offer free aids, services, and reasonable modifications if you have a disability. We can get a sign language interpreter. This helps you talk with us or to your providers. Get your printed materials in large print, audio, or braille at no cost. We can also help if you speak a language other than English. We can get an interpreter who speaks your language. Or get printed materials in your language. You can get this all at no cost to you. Call 1-833-230-2053 (TTY: 711) if you need any of this help. You can reach us 24 hours a day, seven days a week. We are here for you. You may file a grievance if we did not provide these services to you or if you think we discriminated in any other way. Mail: HAP CareSource Attn: Civil Rights Coordinator P.O. Box 1947 Dayton, OH 45401 Phone: 1-844-539-1732 (TTY: 711) Fax: 1-844-417-6254 Email: CivilRightsCoordinator@CareSource.com You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. Mail: U.S. Department of Health and Human Services 200 Independence Ave., S.W. Room 509F, HHH Building Washington, D.C. 20201. Mail the complaint form found at www.hhs.gov/sites/default/files/ocr-cr-complaint-form-package.pdf . Phone: 1-800-368-1019 (TTY: 1-800-537-7697) Online: ocrportal.hhs.gov You can find this notice at HAPCareSource.com. MI-M ED-M-3 314789MDHHS Approved: 11/7/2024
Medical Policy Statements are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased, or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage or Certificate of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other plan policies and procedures. Medical Policy Statements do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage or Certificate of Coverage) for the service(s) referenced in the Medical Policy Statement. Except as otherwise required by law, if there is a conflict between the Medical Policy Statement and the plan contract, then the plan contract will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.MEDICAL POLICY STATEMENT Ohio MyCare Policy Name & Number Date Effective Intraosseous Basivertebral Nerve Ablation-MyCare OH FIDE – MM-1827 01/01/2026-03/31/2026 Policy Type MEDICAL Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. Summary of Evidence ……………………………………………………………………………………………. 4 F. Conditions of Coverage ………………………………………………………………………………………….. 6 G. Related Policies/Rules ……………………………………………………………………………………………. 6 H. Review/Revision History …………………………………………………………………………………………. 6 I. References …………………………………………………………………………………………………………… 6 Intraosseous Basivertebral Nerve Ablation-MyCare OH FIDE-MM-1827 Effective Date: 01/01/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 2 A. SubjectIntraosseous Basivertebral Nerve AblationB. Background Interventional procedures for the management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. Chronic low back pain (CLBP) is a common disabling condition, estimated to afflict 80% of adults at some point. Degenerative disc disease (DDD) is an important cause of CLBP. While discs are avascular with limited nerve distribution, vertebral endplates have the potential to trigger a cascade of degenerative events if there is a loss of integrity. Vertebral endplates are a thin interface between bone marrow and discs and contain neural elements. Breakdown of the endplate is believed to cause vertebrogenic chronic low back pain, a type of chronic low back pain. Endplate degeneration can be observed on MRI through Modic changes (MC). Histologically in MC type I (MC I) lesions, the endplate is disrupted as fibrous tissue replaces bone marrow, causing the disc-bone interface to be filled with vascularized granulation tissue. MC I represents bone marrow edema and inflammation. In MC type II (MC II) lesions, there is demonstration of fatty marrow replacement in addition to MC type I findings. MC II represents conversion of hematopoietic marrow into fatty, yellow bone marrow. MC type III (MC III) lesions are related to subchondral bone sclerosis. Analysis of Modic lesions shows that MC I is characterized by high bone turnover, MC II is characterized by decreased bone turnover, and MC III are stable. Radiofrequency ablation (RFA) is a minimally invasive, percutaneous treatment which uses heat to ablate the nerve pathway that conducts the pain signal. The goal of RFA is to interrupt the pain pathway without causing excessive sensory loss, motor dysfunction, or other complications. Intracept is an RFA system designed to ablate the basivertebral nerve of the vertebral endplate. C. Definitions Chronic Low Back Pain Persistent pain in the lumbar region lasting more than 12 weeks. Conservative Therapy A multimodality plan of care including both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen muscle groups and target key spinal structures, including physical therapy, occupationalIntraosseous Basivertebral Nerve Ablation-MyCare OH FIDE-MM-1827 Effective Date: 01/01/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 3 therapy, physician supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS use, and/or pharmacotherapy (prescription or over the counter [eg, non-steroidal anti-inflammatory drugs, acetaminophen]). Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Modic Changes Vertebral bone marrow signal intensity changes that are observable on MRI and are commonly associated with degenerative disc disease.o Modic Change Type I Characterized by hypo-and hyper-intense signal intensities on T1-and T2-weighted spin-echo (T1W1 and T2W1), respectively. o Modic Change Type II Characterized by hyper-intense signal intensities on both T1W1 and T2W1. o Modic Change Type III Characterized by hypo-intense signal intensities on both T1W1 and T2W1. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial or lateral branches of the dorsal spinal nerves. D. Policy I. Intraosseous basivertebral nerve ablation is considered medically necessary when ALL the following clinical criteria are met: A. Member has a diagnosis and documentation of chronic low back pain of at least 6 months duration that causes functional deficit measured on a pain or disability scale. B. Failure of conservative therapy, as evidenced by ALL the following: 1. documentation in the medical record of at least 6 weeks of active conservative therapy (see definition above) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance 2. documentation in the medical record of at least 6 weeks of inactive conservative therapy (see definition above) within the past 6 months Intraosseous Basivertebral Nerve Ablation-MyCare OH FIDE-MM-1827 Effective Date: 01/01/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 4 C. MRI demonstrates Type I or Type II modic changes at one or more vertebral endplates from level L3 to S1, as demonstrated by 1. hypointense T1-weighted signal and hyperintense T2-weighted signal (ie, bone marrow edema and inflammation), or 2. hyperintense T1-weighted signal and hyperintense T2-weighted signal (ie, bone marrow ischemia) D. Device is FDA-approved (eg, Intracept System). E. Member does not have any of the following contraindications: 1. severe cardiac or pulmonary compromise 2. targeted ablation zone less than 10mm from a sensitive structure not intended to be ablated (including vertebral foramen) 3. active systemic infection or localized infection in the area to be treated 4. current pregnancy 5. skeletal immaturity 6. implantable pulse generator (eg, pacemaker, defibrillator) or other electronic implant 7. scoliosis 8. spinal instability II. Repeat or additional intraosseous basivertebral nerve ablation is not considered medically necessary, as it has not been adequately studied in peer-reviewed medical literature. III. Monitored anesthesia and conscious sedation during intraosseous basivertebral nerve ablation are considered not medically necessary and will, therefore, not be reimbursed. IV. Coverage is limited to the above criteria. Intraosseous basivertebral nerve ablation is considered not medically necessary for all other indications.E. Summary of EvidenceFischgrund et al (2018) conducted a prospective randomized double-blind sham-controlled Food and Drug Administration (FDA) Investigational Device Exemption (IDE) clinical trial to evaluate the safety and efficacy of radiofrequency ablation (RFA) of the basivertebral nerve (BVN) for the treatment of chronic low back pain. The trial involved 225 patients diagnosed with chronic low back pain at 18 sites across the United States and Europe. Patients were skeletally mature, experienced chronic, isolated lumbar pain, had failed at least 6 months of conservative management, and demonstrated Type 1 or Type 2 Modic changes at 3 or fewer contiguous levels between L3 and S1 on MRI. At the start of the clinical trial, patients had a minimum Oswestry Disability Index (ODI) of 30 points (100-point scale) and a minimum visual analog scale (VAS) of 4cm (10cm scale). The primary endpoint was the comparative change in ODI from baseline to 3 months. At 3 months, the average ODI in the treatment arm decreased 20.5 points, compared to a 15.2 decrease in the sham control arm. Responder analysis demonstrated that 75.6% of patients in the treatment arm compared to 55.3% in the Intraosseous Basivertebral Nerve Ablation-MyCare OH FIDE-MM-1827 Effective Date: 01/01/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 5 sham control arm exhibited a clinically meaningful improvement at 3 months. Out of the 147 participants treated with RFA of the BVN, the procedure was deemed successful by imaging in 129 of 145 patients (89%) and in 300 of 317 treated vertebral bodies (94.6%). Fischgrund et al (2019) reported on the 2-year follow up from the SMART Trial. Following the 1-year mark, participants in the sham arm were allowed to cross over; 57 (73%) chose to receive the Intracept intervention. Intra-patient comparison of patient-reported measures from baseline to each follow-up visit were used to evaluated long-term efficacy and treatment durability in RFA arm participants with 24-month data. 106 patients completed a 24-month follow-up visit. Patients exhibited a durable ODI mean improvement of 23.4 points at 24 months compared to the mean improvements observed during the first year of follow up (20.3, 20.8, and 19.8 points at 3, 6, and 12 months, respectively). Using a 10-point improvement in ODI as a commonly accepted minimum clinically important difference in the treatment of chronic low back pain, 75.6% of treated patients existed a successful response at 3 months, which was sustained at 24 months (76.4% of treated patients). VAS improvement was also maintained at 24 months, starting with a baseline of 6.73 cm and improving by 2.76 and 3.59 cm at 12 and 24-months follow-up, respectively. No device or procedure-related patient deaths, unanticipated adverse device effects, or device related serious adverse events were reported. Fischgrund et al (2020) reported on the 5-year outcome for patients in the SMART Trial. Primary outcome was mean change in ODI. 100 patients of the original 117 US participants were available for review at a minimum of 5-years post BVN ablation. Mean ODI score improved from 42.81 to 16.86 at 5-year follow-up, a reduction of 25.95 points. Mean reduction of VAS pain score was 4.38 points. 66% of patients reported more than a 50% reduction in pain, 47% reported more than 75% reduction in pain, and 34% of patients reported complete pain resolution. 5-year results indicate a sustained improvement in patients treated with RFA of the BVN for chronic low back pain. Khalil et al (2019) reported on the INTRACEPT Trial, a prospective, randomized, multicenter study at 20 US cites which compared the effectiveness of intraosseous basivertebral nerve ablation to standard of care for the treatment of chronic low back pain. The trial involved 140 patients experiencing chronic low back pain for at least 6 months, with Modic Type 1 or 2 vertebral endplate changes between L3 and S1, who had failed to respond to conservative therapy. Similar to the SMART Trial, patients were skeletally mature, with a minimum ODI of 30 points and a minimum VAS of 4cm. Patients had a baseline average ODI of 46.1 and VAS of 6.67. Comparing the RFA arm to the standard of care arm, the mean changes in ODI at 3 months were-25.3 points versus-4.4 points, respectively, resulting in an adjusted difference of 20.9 points (p
Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.MEDICAL POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Neonatal Discharge Criteria-OH MCD-MM-1229 06/01/2025-03/31/2026 Policy Type MEDICAL Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 4 F. Related Policies/Rules ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 4 Neonatal Discharge Criteria-OH MCD-MM-1229 Effective Date: 06/01/2025 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 2 A. SubjectNeonatal Discharge CriteriaB. Background Infants who require neonatal admission remain at increased risk for morbidity and mortality following discharge. These infants require comprehensive discharge planning to ensure a smooth transition from the neonatal intensive care unit (NICU) and reduce morbidity and mortality after discharge. Despite the inability to predict the exact timing of a NICU discharge, discharge planning should begin at NICU admission in an effort to avoid overwhelming parents and hospital staff. This planning will aid in minimizing discharge delays and will promote safe and healthy discharges to home. Discharge may be appropriate when the establishment of physiologic competencies, including, but not limited to, thermoregulation, feeding, respiratory control, and stability regardless of weight or corrected gestational age, have been achieved. C. Definitions Acceptable Bilirubin Level Defined per American Academy of Pediatrics (AAP) guidelines. Bilirubin Blood test to measure liver function. Car Seat Test Eligibility An infant tolerance test for sitting usually occurring 36.4 Caxillary while clothed in an open bed/crib. D. Policy I. CareSource considers neonatal discharge medically appropriate for non-technology dependent infants when ALL of the following clinical criteria are met: A. Thermoregulation Stability 1. Infant demonstrates the ability to maintain normal body temperature while clothed in an open crib. Up to 48 hours of stable body temperature is typically adequate for infants born
12016 CareSource. All Rights Reserved.Save the Date! Thursday, April 16, 2026 11:00 a.m. Eastern Time (ET) / 10:00 a.m. Central Time (CT) Indiana Live Provider OrientationRegister for the Event here . Agenda: Medical Provider Orientation Time Topic11:00 a.m. ET / 10:00 p.m. CT Live Provider OrientationThis orientation is tailored towards newly contracted medical providers and healthcare facilities. Please provide your Health Partner Engagemetn Specialist with any topics, discussions, or questions you would like to see highlighted within this presentation. We look forward to your attendance! IN-Multi-P -3865880-v.2 ; Issued Date: 5/19/2025 OMPP Approved: 5/19/2025
12016 CareSource. All Rights Reserved.Save the Date! Thursday, April 23, 2026 11:00 a.m. Eastern Time (ET) / 10:00 a.m. Central Time (CT) Indiana Live Provider OrientationRegister for the Event here . Agenda: Behavioral Health Live Orientation Time Topic11:00 a.m.ET / 10:00 p.m. CT Behavioral Health Live OrientationThis orientation is tailored towards newly contracted behavioral health providers and care facilities. Please provide your Behavioral Health Resolution Specialists with any topics, discussions, or questions you would like to see highlighted within this presentation. We look forward to your attendance! IN-Multi-P -3865880; Issued Date: 5/19/2025 OMPP Approved: 5/19/2025
__________________________________________________________________ ___________________________ Georgia Medicaid2026 Transparency Act Prior Authorization Report Monthly Outpatient Prior Authorizations by StatusJAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC YTDApproved 17,885 17,885Denied 3,191 3,191 Monthly Outpatient Prior Authorization Denial Reasons (Medical Benefit)JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC YTDAdministrative Denial60 60 Benefit Limit Exceeded 0 0 Exceeds Notification Limits 198 198 Medical Necessity Not Established 1,851 1,851 Non – Participating Provider 1,031 1,031 Not a Covered Benefit 45 45 Other 6 6 Total 3,191 3,191 Percentage of Outpatient Prior Authorization Turnaround TimesJAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC YTDExpedited 98.7% 98.7%Standard 97.9% 97. 9% GA-MED-P-3541262-v.9 DCH Approved: 3/13/25
Georgia Marketplace2026 Pharmacy Transparency Act Prior Authorization Report Monthly Outpatient Drug Prior Authorizations by Status JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC YTDTotal 1,215 1,131 2,346Approved 737 655 1,392 Medical Benefit 98 90 188 Pharmacy Benefit 639 565 1,204 Denied 478 476 954 Medical Benefit 35 23 58 Pharmacy Benefit 443 453 896 Monthly Outpatient Drug Prior Authorizations by Denial & Denial Status ReasonJAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC YTDDenied 478 476 954Medical Benefit 35 23 58 Medical Necessity 35 23 58 Non-Formulary 0 0 0 Off Label 0 0 0 Retro Untimely 0 0 0 Pharmacy Benefit 443 453 896 Excluded Benefit 2 1 3 Medical Necessity 116 127 243 Non-Formulary 268 278 546 Off Label 24 21 45 Quantity Label 5 4 9 Step Therapy 28 22 50 Percentage of Outpatient Drug Prior Authorizations Met Turnaround Time by Benefit Type & Priority Type JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC YTDOverall 99. 92% 99.91% 99. 91%Medical Benefit 99.25% 99.12% 99.19% Expedited 100 % 98.15% 99.21% Standard 98.36 % 100% 99.17% Pharmacy Benefit 100% 100% 100 % Expedited 100% 100% 100 % Standard 100% 100% 100% GA-EXC-P -2841155-v. 11
Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.MEDICAL POLICY STATEMENT Nevada Marketplace Policy Name & Number Date Effective Trigger Point Injections-NV MP-MM-1760 01/01/2026-03/31/2026 Policy Type MEDICAL Table of ContentsA. Subject ………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………. 2 E. Conditions of Coverage ……………………………………………………………………………………. 4 F. Related Policies/Rules ……………………………………………………………………………………… 4 G. Review/Revision History …………………………………………………………………………………… 4 H. References …………………………………………………………………………………………………….. 5Trigger Point Injections-NV MP-MM-1760 Effective Date: 01/01/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 2 A. SubjectTrigger Point InjectionsB. Background Myofascial trigger points are self-sustaining hyper-irritative foci in any skeletal muscle, often occurring in response to strain produced by acute or chronic overload. There is no associated neurologic deficit, and the pain may be aggravated by hyperextension of the spine, standing, and walking. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS) which is responsive to appropriate treatment. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor. The purpose of a trigger point injection (TPI) is to treat not only the symptom but also the cause through the injection of a single substance (eg, a local anesthetic) or a mixture of substances (eg, a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Interventional procedures for management of pain should be part of a comprehensive pain management care plan that incorporates an initial trial of conservative treatment utilizing appropriate medications, physical therapy modalities and behavioral support, as needed. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers acting within their scope of practice who are qualified to deliver these health services. C. Definitions Acute Pain Pain that lasts less than 4 weeks. Physician Supervised Home Exercise Program (HEP) A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Member inconvenience or noncompliance without explanation does not constitute an inability to complete. Subacute Pain Pain that has lasted between 4 weeks and 12 weeks. Trigger Point A hyper excitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. D. Policy I. Trigger Point Injections Initial Injections A. Trigger point injections of anesthetic and/or corticosteroid for back pain, neck pain, or myofascial pain syndrome are considered medically necessary when pain has persisted despite appropriate medical management and ALL the following criteria are met: Trigger Point Injections-NV MP-MM-1760 Effective Date: 01/01/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 3 1. Member presents with new (acute or subacute) localized pain, occurring in the last 3 months. 2. Member has been refractory or intolerant of conservative therapies for at least 1 month, including at least 1 of the following: a. bed rest b. active exercise c. ultrasound d. range of motion e. heating or cooling treatments f. massage 3. TPIs are being given as a part of an overall conservative management (usually short term) plan, including at least 1 of the following: a. physical therapy b. occupational therapy c. physician supervised home exercise program (HEP) d. manipulative therapy 4. Pharmacotherapies are being administered, including at least 1 of the following: a. non-steroidal anti-inflammatory drugs (NSAIDS) b. muscle relaxants c. non-narcotic analgesics d. anti-depressants 5. The member must have a diagnosis for which the trigger point injection is an appropriate treatment; ALL the following information must be documented in the medical record: a. proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point b. reason(s) for selecting this therapeutic option c. affected muscle or muscles d. muscle or muscles injected and the number of injections e. frequency of injections required f. name of the medication used in the injectiong. results of any prior treatment h. corroborating evidence that the injection is medically necessary B. Localization techniques to image or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. II. Trigger Point Injections Subsequent Injections A. Trigger point injections should be repeated only if doing so is reasonable and medically necessary. No more than 8 dates of service per calendar year per member may be reimbursed. B. Injections may be repeated only with documented positive results to the most recent trigger point injection of the same anatomic site. Documentation should include at least 50% improvement in pain, functioning, and activity tolerance.Trigger Point Injections-NV MP-MM-1760 Effective Date: 01/01/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 4 III. There is no laboratory or imaging test for establishing the diagnosis of trigger points. Diagnosis is dependent upon a detailed history and a thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis: A. history of onset and its cause (injury, sprain, etc.) B. distribution of pain C. restriction of movement D. mild muscle specific weakness E. focal tenderness of a trigger point F. palpable taut band of muscle in which trigger point is located G. local taut response to snapping palpitation H. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point IV. Payment Information A. Certain trigger point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. B. Payment may be made for 1 unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a particular date. C. A trigger point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (eg, in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. D. Dry needling is not an acceptable alternative to trigger point injections by an appropriately licensed clinician.E. Conditions of CoverageN/A F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 05/21/2025 New market, approved at Committee. Date Revised Date Effective 01/01/2026 Date Archived 03/31/2026 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. Trigger Point Injections-NV MP-MM-1760 Effective Date: 01/01/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 5 H. References1. Appasamy M, Lam C, Alm J, Chadwick AL. Trigger point injections. Phys Med Rehabil Clin NAm . 2022;33(2):307-333. doi:10.1016/j.pmr.2022.01.011 2. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated May 15, 2024. Accessed April 21, 2025. www.uptodate.com 3. Gerwin R. Myofascial trigger point pain syndromes. Semin Neurol . 2016;36(5):469-473. doi:10.1055/s-0036-1586262 4. Hammi C, Schroader JD, Yeung B. Trigger point injection. StatPearls . StatPearls Publishing; 2024. Updated July 24, 2023. Accessed April 21, 2025. www.ncbi.nlm.nih.gov 5. Hamzoian H, Zograbyan V. Trigger point injections versus medical management for acute myofascial pain: a systematic review and meta-analysis. Cureus. 2023;15(8):e43424. doi:10.7759/cureus.43424 6. Isaac Z. Management of non-radicular neck pain in adults. UpToDate. Updated November 14, 2024. Accessed April 21, 2025. www.uptodate.com 7. Khoury AL, Keane H, Varghese F, et al. Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief. NPJ Breast Cancer. 2021;7:123. doi:10.1038/s41523-021-00321-w 8. Meyer GW. Anterior cutaneous nerve entrapment syndrome. UpToDate. Updated December 31, 2024. Accessed April 21, 2025. www.uptodate.com 9. Moynihan LK, Elkadry E. Myofascial pelvic pain syndrome in females: treatment. UpToDate. Updated January 11, 2023. Accessed April 21, 2025. www.uptodate.com 10. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate. Updated August 16, 2024. Accessed April 21, 2025. www.uptodate.com Independent Medical Review January 2025
Pharmacy Policy Updates March 2026The following policies are effective May 1, 2026Indiana Medicaid 2 Policy Updates Network Notification | March 2026AT CARESOURCE, WE LISTEN TO OUR PROVIDERS, AND WE STREAMLINE OUR BUSINESS PRACTICES TO MAKE IT EASIER FOR YOU TO WORK WITH US. We have worked to create a predictable cycle for releasing administrative, pharmacy, and reimbursement policies, so you know wha t to expect.Check back each month for a consolidated network notification of policy updates from CareSource.HOW TO USE THIS NETWORK NOTIFICATION Reference the list of policy updates. Note the effective date and impacted plans for each policy. Click the hyperlinked policy title to open the webpage containing the policy location. FIND OUR POLICIES ONLINETo access all CareSource policies, visit CareSource.com > Providers > Tools & Resources > Provider Policies . Select your plan and state, then Pharmacy, Reimbursement, or Administrative. Each policy page has an archive where you can find previous versions of policies. PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT BENLYSTA (BELIMUMAB) 05/01/2026INDIANA MEDICAID REVISED POLICYBERINERT (C1 ESTERASE INHIBITOR (HUMAN)) 05/01/2026 INDIANA MEDICAID ANNUAL REVIEW; NO UPDATESBRINSUPRI(BRENSOCATIB ) 05/01/2026INDIANA MEDICAID NEW POLICYESBRIET (PIRFENIDONE) 05/01/2026 INDIANA MEDICAID ANNUAL REVIEW; NO UPDATESFORZINITY (ELAMIPRETIDE ) 05/01/2026INDIANA MEDICAID NEW POLICYGAZYVA (OBINUTUZUMAB) 05/01/2026 INDIANA MEDICAID NEW POLICYIMMUNE GLOBULIN (IVIG AND SCIG) 05/01/2026 INDIANA MEDICAID REVISED POLICYJASCAYD (NERANDOMILAST )05/01/2026INDIANA MEDICAID NEW POLICYKALBITOR (ECALLANTIDE )05/01/2026INDIANA MEDICAID ANNUAL REVIEW; NO UPDATES3 Policy Updates Network Notification | March 2026 | IN-MED-P -5210500 IN-MED-P -1045664; Issue Date: 03/01/2026 OMPP Approval Date: 1/19/2022 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACTKOSELUGO (SELUMETINIB) 05/01/2026 INDIANA MEDICAID REVISED POLICYLUPKYNIS (VOCLOSPORIN) 05/01/2026 INDIANA MEDICAID REVISED POLICYNITISINONE(ORFADIN , NITYR, HARLIKU) 05/01/2026INDIANA MEDICAID REVISED POLICYNOVANTRONE (MITOXANTRONE) 05/01/2026 INDIANA MEDICAID ANNUAL REVIEW; NO UPDATESNPLATE(ROMIPLOSTIM) 05/01/2026INDIANA MEDICAID REVISED POLICYOFEV(NINTEDANIB) 05/01/2026INDIANA MEDICAID ANNUAL REVIEW; NO UPDATESOXLUMO(LUMASIRAN) 05/01/2026INDIANA MEDICAID ANNUAL REVIEW; NO UPDATESPAPZIMEOS (IMADENOVEC-DRBA ) 05/01/2026INDIANA MEDICAID NEW POLICYQALSODY (TOFERSEN ) 05/01/2026INDIANA MEDICAID REVISED POLICY4 Policy Updates Network Notification | March 2026 | IN-MED-P -5210500 IN-MED-P -1045664; Issue Date: 03/01/2026 OMPP Approval Date: 1/19/2022 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT RUCONEST (C1 ESTERASE INHIBITOR (RECOMBINANT)) 05/01/2026 INDIANA MEDICAID ANNUAL REVIEW; NO UPDATESSAPHNELO (ANIFROLUMAB-FNIA ) 05/01/2026INDIANA MEDICAID REVISED POLICY5 Policy Updates Network Notification | March 2026 | IN-MED-P -5210500 IN-MED-P -1045664; Issue Date: 03/01/2026 OMPP Approval Date: 1/19/2022
Pharmacy Policy Updates March 2026The following policies are effective April 1, 2026Ohio Medicaid 2 Policy Updates Network Notification | March 2026 | OH-MED-P -5210200AT CARESOURCE, WE LISTEN TO OUR PROVIDERS, AND WE STREAMLINE OUR BUSINESS PRACTICES TO MAKE IT EASIER FOR YOU TO WORK WITH US. We have worked to create a predictable cycle for releasing administrative, pharmacy, and reimbursement policies, so you know wha t to expect.Check back each month for a consolidated network notification of policy updates from CareSource.HOW TO USE THIS NETWORK NOTIFICATION Reference the list of policy updates. Note the effective date and impacted plans for each policy. Click the hyperlinked policy title to open the webpage containing the policy location. FIND OUR POLICIES ONLINETo access all CareSource policies, visit CareSource.com > Providers > Tools & Resources > Provider Policies . Select your plan and state, then Pharmacy, Reimbursement, or Administrative. Each policy page has an archive where you can find previous versions of policies. PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT BENLYSTA (BELIMUMAB) 04/01/2026OHIO MEDICAID REVISED POLICYEVKEEZA ( EVINACUMAB-DGNB) 04/01/2026OHIO MEDICAID REVISED POLICYGAZYVA(OBINUTUZUMAB) 04/01/2026 OHIO MEDICAID NEW POLICYIMMUNE GLOBULIN (IVIG AND SCIG) 04/01/2026 OHIO MEDICAID REVISED POLICYLEQEMBI (LECANEMAB ) 04/01/2026OHIO MEDICAID REVISED POLICYLEQVIO(INCLISIRAN) 04/01/2026OHIO MEDICAID REVISED POLICYPALSONIFY (PALTUSOTINE ) 04/01/2026OHIO MEDICAID NEW POLICYSAPHNELO (ANIFROLUMAB-FNIA ) 04/01/2026OHIO MEDICAID REVISED POLICY3 Policy Updates Network Notification | March 2026 | OH-MED-P -5210200 PHARMACY POLICY UPDATES POLICY NAMEEFFECTIVE DATE PLAN IMPACT TYSABRI (NATALIZUMAB) 04/01/2026OHIO MEDICAID REVISED POLICYVYJUVEK ( BEREMAGENEGEPERPAVEC-SVDT ) 04/01/2026OHIO MEDICAID REVISED POLICY4 Policy Updates Network Notification | March 2026 | OH-MED-P -5210200
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