MEDICAL POLICY STATEMENTNevada Marketplace Policy Name & Number Date Effective Trigger Point Injections-NV MP-MM-1760 04/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, 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 w hich 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 Manua ls, 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 Polic y 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 determinatio n. 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.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 ………………………….. ………………………….. ………………………….. ……………… 5 Trigger Point Injections-NV MP-MM-1760Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectTrigger Point Injections B. BackgroundMyofascial 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. Thes e 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 p ain 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 loc al 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, asneeded.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 ph ysically 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. PolicyI. 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-1760Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL 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 injection g. 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 InjectionsA. 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-1760Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL 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 ma king 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 InformationA. 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 evalu ation 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/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 05/21 /2025 New market, approved at Committee.Date Revised 01/14/2026 Review: updated references. Approved at Committee. Date Effective 04/01/2026 Date Archived Trigger Point Injections-NV MP-MM-1760Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL 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 April 29 , 202 5. Accessed December 12 , 2025. www.uptodate.com 3. Debrosse M, Sukhman S, Shah A, et al. Trigger point injection therapies for chronic myofascial neck and back pain: a systematic review. Interventional Pain Medicine. 2022; 1(3):100076. doi.org/10.1016/j.inpm.2022.100076 4. Hammi C, Schroader JD, Yeung B. Trigger point injection. StatPearls . StatPearls Publishing; 2024. Updated July 24, 2023. Accessed December 12 , 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 September 30 , 202 5. Accessed December 12 , 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 February 14 , 202 5. Accessed December 12 , 2025 . www.uptodate.com 9. Moynihan LK, Elkadry E. Myofascial pelvic pain syndrome in females: treatment. UpToDate. Updated January 11, 2023. Accessed December 12 , 2025. www.uptodate.com 10. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate. Updated September 4 , 202 5. Accessed December 1 2, 2025. www.uptodate.com Independent Medical Review January 2025
30 Day Change Notice Effective Date: January 1, 2026 NEW PREFERRED DRUGS THERAPEUTIC CLASS NO PA REQUIRED PREFERRED Analgesic Agents: Gout febuxostat MITIGARE Blood Formation, Coagulation, and Thrombosis Agents: Oral Anticoagulants dabigatran cap Cardiovascular Agents: Angina, Hypertension and Heart Failure acetazolamide DIURIL SUSP indapamide methazolamide metolazone sacubitril/valsartan (gen of ENTRESTO) Central Nervous System (CNS) Agents: Atypical Antipsychotics * LEGACY CATEGORY ERZOFRI Central Nervous System (CNS) Agents: Multiple Sclerosis * LEGACY CATEGORY PLEGRIDY Endocrine Agents: Diabetes Insulin FIASP HUMULIN NU-100 Endocrine Agents: Diabetes Non-Insulin JENTADUETO XR SYNJARDY XR Gastrointestinal Agents: Bowel Preparations SUFLAVE Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with Diarrhea CNS Agents: Tricyclic Antidepressants Hyperkalemia Agents: Potassium Binders VELTASSA Infectious Disease Agents: Antivirals Coronavirus Agents PAXLOVID Infectious Disease Agents: Antivirals HIV * LEGACY CATEGORY SYMFI Ophthalmic Agents: Ophthalmic Steroids EYSUVIS Respiratory Agents: Inhaled Agents fluticasone/salmeterol diskus PROAIR RESPICLICK Topical Agents: Antiparasitics spinosad [labeler 52246] Topical Agents: Corticosteroids DERMA-SMOOTHE OIL NEW CLINICAL PA REQUIRED PREFERRED DRUGS THERAPEUTIC CLASS CLINICAL CRITERIA REQUIRED PREFERRED Analgesic Agents: Opioids fentanyl patch Immunomodulator Agents: Systemic Inflammatory Disease adalimumab-fkjp [labeler 83257] AVSOLA (Bio of REMICADE) NEMLUVIO SKYRIZI IV SOLN STEQEYMA (Bio of STELARA) Date of Notice: 12/1/2025 30 Day Change NoticeEffective Date: January 1, 2026 NEW CLINICAL PA REQUIRED PREFERRED DRUGS THERAPEUTIC CLASS Respiratory Agents: Hereditary Angioedema CLINICAL CRITERIA REQUIRED PREFERRED HAEGARDA Respiratory Agents: Inhaled Agents AIRSUPRA Respiratory Agents: Monoclonal Antibodies-Anti – IL/Anti-IgE CINQAIR NUCALA Respiratory Agents: Pulmonary Fibrosis pirfenidone NEW STEP THERAPY REQUIRED PREFERRED DRUGS THERAPEUTIC CLASS CLINICAL CRITERIA REQUIRED PREFERRED Respiratory Agents: Inhaled Agents BREZTRI AEROSPHERE TRELEGY ELLIPTA Topical Agents: Immunomodulators OPZELURA VTAMA ZORYVE CREAM, FOAM NEW NON-PREFERRED DRUGS THERAPEUTIC CLASS PA REQUIRED NON-PREFERRED Analgesic Agents: Gout colchicine cap Analgesic Agents: Opioids fentanyl buccal tab, inj, lozenge Blood Formation, Coagulation, and Thrombosis Agents: Colony Stimulating Factors RYZNEUTA Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia A, von Willebrand Disease, and Factor XIII Deficiency * LEGACY CATEGORY ADVATE AFSTYLA RECOMBINATE Blood Formation, Coagulation, and Thrombosis Agents: Oral Antiplatelet clopidogrel 300mg Cardiovascular Agents: Angina, Hypertension and Heart Failure ENTRESTO TAB HEMICLOR LOPRESSOR SOLN spironolactone susp TEZRULY Cardiovascular Agents: Pulmonary Arterial Hypertension * LEGACY CATEGORY bosentan susp TADLIQ Central Nervous System (CNS) Agents: Alzheimers Agents * LEGACY CATEGORY ZUNVEYL Central Nervous System (CNS) Agents: Anti – Migraine Agents, Acute SYMBRAVO Central Nervous System (CNS) Agents: Antidepressants * LEGACY CATEGORY escitalopram cap Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents amphetamine IR, ER tab Dermatologic Agents: Oral Acne Products isotretinoin Date of Notice: 12/1/2025 30 Day Change Notice Effective Date: January 1, 2026 NEW NON-PREFERRED DRUGS THERAPEUTIC CLASS Endocrine Agents: Diabetes Insulin PA REQUIRED NON-PREFERRED insulin glargine-yfgn MERILOG (Bio of NOVOLOG) TRESIBA 200U Endocrine Agents: Diabetes Non-Insulin sitagliptin Endocrine Agents: Estrogenic Agents estrogens, conjugated tab Endocrine Agents: Osteoporosis Bone Ossification Enhancers CONEXXENCE (Bio of PROLIA) JUBBONTI (Bio of PROLIA) STOBOCLO (Bio of PROLIA) Gastrointestinal Agents: Ulcerative Colitis budesonide rectal foam Genitourinary Agents: Benign Prostatic Hyperplasia TEZRULY Immunomodulator Agents: Systemic Inflammatory Disease adalimumab-fkjp [labeler 49502] IMULDOSA (Bio of STELARA) LEQSELVI Infectious Disease Agents: Antivirals HIV * LEGACY CATEGORY EDURANT SUSP YEZTUGO Ophthalmic Agents: Dry Eye Treatments TRYPTYR Ophthalmic Agents: Ophthalmic Steroids difluprednate prednisolone acetate Respiratory Agents: Hereditary Angioedema ANDEMBRY Respiratory Agents: Inhaled Agents ADVAIR DISKUS fluticasone/salmeterol HFA Topical Agents: Antiparasitics spinosad [labeler 28595] THERAPEUTIC CATEGORIES WITH CHANGES IN CRITERIA Analgesic Agents: Gout Analgesic Agents: Opioids Blood Formation, Coagulation, and Thrombosis Agents: Hematopoietic Agents Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia A, von Willebrand Disease, andFactor XIII Deficiency * LEGACY CATEGORY Blood Formation, Coagulation, and Thrombosis Agents: Hemophilia B * LEGACY CATEGORY Car diovascular Agents: Angina, Hypertension and Heart Failure Cardiovascular Agents: Pulmonary Arterial Hypertension * LEGACY CATEGORY Cent ral Nervous System (CNS) Agents: Anti-Migraine Agents, Acute Central Nervous System (CNS) Agents: Anticonvulsants * LEGACY CATEGORY Cent ral Nervous System (CNS) Agents: Anticonvulsants Rescue Central Nervous System (CNS) Agents: Antidepressants * LEGACY CATEGORY Central Nervous System (CNS) Agents: Narcolepsy Central Nervous System (CNS) Agents: Parkinson's Agents Dermatologic Agents: Topical Acne Products Endocrine Agents: Diabetes Insulin Endocrine Agents: Diabetes Non-Insulin Gastrointestinal Agents: Hepatic Encephalopathy Gastrointestinal Agents: Irritable Bowel Syndrome (IBS) with Diarrhea Date of Notice: 12/1/2025 Date 12/1/2025 Notice: of Department of Medicaid 30 Day Change Notice Effective Date: January 1, 2026 THERAPEUTIC CATEGORIES WITH CHANGES IN CRITERIA Gastrointestinal Agents: Ulcerative Colitis Gastrointestinal Agents: Unspecified GI Immunomodulator Agents: Systemic Inflammatory Disease Infectious Disease Agents: Antivirals HIV * LEGACY CATEGORY Ophthalmic Agents: Dry Eye Treatments Ophthalmic Agents: Ophthalmic Steroids Respiratory Agents: Cystic Fibrosis Respiratory Agents: Hereditary Angioedema Respiratory Agents: Inhaled Agents Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE Respiratory Agents: Pulmonary Fibrosis Topical Agents: Antifungals Topical Agents: Immunomodulators REVISED THERAPEUTIC CATEGORY CRITERIA THERAPEUTIC CLASS SUMMARY OF CHANGE Analg esic Agents: Gout Must !=lave l=lad aR iRade~uate cliRical resJ30Ase of 30 days witt=i C9kh i{iR@ t~b l@~ An algesic Age nt s: Op ioids AND MORPHI NE SU LFA TE ER MS CONTIN CRIT ER ,A: Unl ess receivi ng for cancer pain, pa lliative ca re, or end-of l ife/hosp ice care, must prov ide documentat,i on of an inadequate clini ca l response w ith at least one op ioid formu lation taken for at least 30 of the last 60 days Must also meet LONG-ACTING OP IOID CRllERIA !Bloo d F orma tion , Coag ulati o.n, and Thr ombo sis Ag ent s: He mat opo ieti c Agen ts ON-PREF :ERR ED CRliJ ER IA: Must have had an ina dequate clini ca l response of at least Oda .s with at least two prefe rred dru ~ in this UPDL category and indicated for diagnosis 14 DDITIONAL DARBOPOETIN ALFA ARANESP CRITERIA Mus t have been receiving a pre fer red product fo r~ 30 days with no positive response to hemogl obin levels, OR Must have a documented allergy, cont raindication, or side effect to pre ferred agents and has a hemog lobin level at ini tiat ion of therapy of 7% AND Must have had an inadequate clinical response of at least 120 days with OZEMPIC OR must provide documentation of medical necessity for patients inability to use OZEMPIC For medical necessi ty requests due to OZEMPIC intolerance, must submit chart documentation that the following approaches were tried for at least 30 days: o Dietary changes (e.g., eating ap ples, crackers, or mint-orginger-based drinks 30 minutes after administering the GLP-1 Receptor Agonist) o Prescription antiemetics AND o Dose adjustment to remediate side effects experienced with higher doses of the GLP-1 Receptor Agonist ADDITIONA LINFORMATION An inadequate clinical response is defined as the inability to reachA1C goal aft er at least 120 days of current regimen, with use of two or more drugs concomitantly concurrently per ADA guidelines, documented adherence, and appropriate dose escalation (must achieve maximum recommended dose or document that maximum recommended dose is not tolerated or is clinically inappropriate). SUBSEQUENT AUTHORIZATION CRITERIA: Must provide documentation of patients clinical response to treatment and ongoing safety monitoring o Must include a patient specific A1C goal if less than 7% o Must submit recent hemoglobin A1C level (within 6 months) o Must i nclude documentation showing improvement in current A1C (within last 6 months) if not already at goal A1C Gastrointestinal Agents: Hepatic Encephalopathy All products are covered without a PA LENGTH OF AUTHORIZATIONS: 365 Days STE PTHERAPY CRITERIA: Mus t have had an inadequate clinical response of at least 14 days with at least one preferred drug in this UPDL category Gast rointestinal Agents: I rritable Bowel Syndrome (IBS) with Diarrhea STE PTHERAPY CRI TERIA: Must have had an inadequate clinical response of at l east 14 days with at least one preferred drug in this UPDL category Gast rointestinal Agents: Ulcerative Colitis LENGTH OF AUTHORIZ ATIONS: 365 Days ; Date of Notice: 12/1/2025 except UCERIS FOAM 90 days Department of Medicaid 6a stro 1 liltestina I Agents : Unspe cified Gii ADDl lllONAL .. a.–r.1v ~ “‘” ~ TD~v':'o. ~ !"''.:~ l~T':'D ""'~ NALDEM EDINE ISYM PR OIC) CRlllil ERJA : IADD llll ONAL RIFAMYON OELAfED-RElEASE (AEMCOLO) O RITEIR IA: Mu st have the ina bm ty to take, or fa ii u re of AUL of the fo I low ing: azit hromyd n, dpr ofloxad n, levo floxaci rn, or oflox acin, eF rifa 111iJ;1iR lmm unom od ‘ulato :r Agents : S ys temic Infl amm ato ry Disease !iI!AD DITIONAL NEMOLIZUMAB {NEMLUVI O) CR ITER IA: Mu st have had an inade qu ate clini ca l res ponse of at least 90 days with DUPIXENT and indi cated for pr urigo nodularis ADD:rT IONAL ATOPilC DBRMAT1TI S1CRITE RIA: Mu st hlave at l ea st 10% bo d:y s urf ace area [ BSA ) in vo lveme,nt with an inadequate clinical re spo nse of at least W ~S days with two of the follow in,g: top ical co rticost eroids or top ical caloineu nin inhibitors [e.g.,~ tacrolimus, pimecrolimu :sl] unless atopic 1de rm ati tis is severe a nd imiol’v, es >25% BSA Infecti ou s Disea
RedeterminationIs When You Renew Your MedicaidCoverage.Knowing what you need to have to complete your renewal can make the process easier. GreAt! Let me cHecK yOu in to oUr sysTem.YoU are alL cHecKed in to seE Dr. JacobS todaY. | can alSo seE tHat yOu are goInG to lose MedicaId coverage nexT monTh. Have yOu sTarTed tHe pRocesS to renew yOur coverage witH tHe sTate? IsNt tHat sometHinG tHat CareSource doEs for me?No, yOu have to take acTiOn anD renew witH yOur CoUnTy Job anD Family SerVices. Did yOu get a pacKet in tHe maIl asKinG yOu to renew? Hello! My son has an appointment with Dr. Jacobs. Louisa is taking her son to the doctors office for his 18-month check up. Welcome!What insurance do you have?We haveCareSourceMedicaid. You are all checked in to see Dr. Jacobs today. I can also see that you are going to lose Medicaid coverage next month. Have you started the process to renew your coverage with the state? Great! Let me check you in to our system.No, you have to take action and renew with your County Job and Family Ser vices. Did you get a packet in the mail asking you to renew?Isnt that something that CareSource does for me? | did get sometHinG in tHe maIl, but did not tHinK it was imPorTanT. | have never heArD of tHis. Louisa remembers getting something in the mail from her County Job and Family Services ofce. It seemed long and complex so she put it in a pile of bills to deal with later. It is imPorTanT! The sTate has everyOne go tHroUgH tHe redeterMinatiOn pRocesS eAcH yEar. Make sure yOu lL oUt tHe pacKet anD returN it to yOur CoUnTy Job anD Family SerVices of ce as soOn as yOu can. Louisa Jefferson1235 Highland Ave.Anytown, OH Louisa Jefferson1235 Highland Ave.Anytown, OH IMPORTANT INFORMATIONLouisa Jefferson1235 Highland Ave.Anytown, OH Louisa Jefferson1235 Highland Ave.Anytown, OH The goverNmenT isSuEd a PubLic HeAlTh EmerGenCy (PhE) durinG tHe COVID-19 panDemic. YoU did not have to renew yOur MedicaId coverage unDer tHe PhE. The PhE enDed, so yOu wilL neEd to renew yOur coverage every yEar agaIn. Louisa remembers getting something in the mail from her County Job and Family Services office. It seemed long and complex so she put it in a pile of bills to deal with later. I did get something in the mail, but did not think it was important.I have never heard of this.It is important! The state has everyone go through the redetermination process each year. Make sure you fill out the packet and return it to your County Job and Family Ser vices office as soon as you can. Redetermination is when you renew your Medicaid coverage with the state. You need to renew each year. CareSource cannot renew for you.I have so much going on. It was hard enough getting my son here on time! Isnt there an easier way to do this? There are many ways to renew. If you got a renewal packet in the mail, fill it out and return it as quickly as you can. Or, you can renew: – Online-By Phone-In Person We know that the packet to renew your Medicaid coverage may seem complicated. It asks for a lot of information! Knowing what you need to have to complete your renewal can make the process easier. THERE ARE MANY WAYS TO RENEW There are many ways to renew. Knowing what you need to have to complete your renewal can make the process easier.Hi Dr. JacobS! | was in yOur sHoEs not tHat lonG ago. | woUlD be hapPy to sHare a few tipS | leArNed to make tHe renewal pRocesS go more sMoOtHly. Hi Dr. Jacobs! There are many ways to renew. Knowing what you need to have to complete your renewal can make the process easier. I was in your shoes not that long ago. I would be happy to share a few tips I learned to make the renewal process go more smoothly.I will put together a list of tips I have and can give them to you after your visit! Online1. Go to benefits.ohio.gov. 2. Log in to your account with your username and password. If you do not have an account, click sign up to make one. Write your username and password down and keep it where you will remember it. Follow the steps below the log in if you forgot your username or password.3. Once you are in the portal, click Link My Case(s). 4. Choose the Renew My Benefits option. 5. Follow the steps to submit your renewal. By Phone1. Call the Medicaid Hotline at (800) 324-8680. For TTY, call (800) 292-3572. You can call Monday through Friday, 7 a.m. to 8 p.m. or Saturday 8 a.m. to 5 p.m. Eastern Time (ET). 2. Choose 1 for English or 2 for Spanish. 3. Choose option 8 to renew your benefits. 4. Try not to get discouraged if you are on hold for a few minutes. Have the information you need in front of you. This will make your call go much smoother once you are talking with someone. In Person1. Your local County Job and Family Services office can help you fill out your renewal. Find yours at jfs.ohio.gov 2. Bring the information you need to fill out the renewal. 3. You can get a free ride to the office if you need it. Learn how to get a ride at CareSource.comYou can also call us at 1-800-488-0134 (TTY: 711).Have as much information ready as you can when you renew, even if you do not have it all.Here are examples of what you may need:The birth dates for you and everyone in your household.Social security numbers for everyone in your household (if you know them).The address(es) and phone number(s) of employers for those in your household who have a job. Information about other health insurance if you or others in your household have it.Information about other income. This could be Social Security, Pensions or Unemployment Compensation.Tax forms and wage statements. This could be pay stubs, W-2 forms or other information. OH-MED-M-4737601 ODM Approved: 12/23/2025 2026 CareSource. All Rights Reserved.
MEDICAL POLICY STATEMENT Ohio MyCare Policy Name & Number Date Effective Intraosseous Basivertebral Nerve Ablation-MyCare OH FIDE-MM-1827 04/01/2026 Policy Type MEDICAL 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 guid elines. 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 expec ted 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 Handb ooks, 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 State ment. Exc ept 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. 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-M M-1827 Effective Date: 04/01/2026 The MEDICAL Pol i cy St a tem e nt d e t ai l e d a bove h a s r ecei v e d due c on si de ra t i on a s d e f i n e d i n the MEDICAL Po li cy St a t e m e nt Po li cy and i s a pp r o v e d. 2 A. SubjectIntraosseous Basivertebral Nerve AblationB. BackgroundInterventional 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-m anagement 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 qual ified 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 ofCLBP. While discs are avascular with limited nerve distribution, vertebral endplates ha ve 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 c hronic 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 MCtype 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 scler osis.Analysis of Modic lesions shows that MC I is characterized by high bone turnover, MC IIis 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 dysfunct ion,or other complications. Intracept is an RFA system designed to ablate the basivertebral nerve of the vertebral endplate.C. DefinitionsChronic Low Back Pain Persistent pain in the lumbar region lasting more than 12weeks.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, occupational Intraosseous Basivertebral Nerve Ablation-MyCare OH FIDE-M M-1827 Effective Date: 04/01/2026 The MEDICAL Pol i cy St a tem e nt d e t ai l e d a bove h a s r ecei v e d due c on si de ra t i on a s d e f i n e d i n the MEDICAL Po li cy St a t e m e nt Po li cy and i s a pp r o v e d. 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 physi cally 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 endorphin s. 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 reques t.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. PolicyI. I ntraosseous basivertebral nerve ablation is considered medically necessary whenALL the following clinical criteria are met:A. Member has a diagnosis and documentation of chronic low back pain of at least6 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 ORinability to complete active conservative therapy due to contraindication,increased pain, or intolerance2. 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-M M-1827 Effective Date: 04/01/2026 The MEDICAL Pol i cy St a tem e nt d e t ai l e d a bove h a s r ecei v e d due c on si de ra t i on a s d e f i n e d i n the MEDICAL Po li cy St a t e m e nt Po li cy and i s a pp r o v e d. 4 C. MRI demonstrates Type I or Type II modic changes at one or more vertebral endplates from level L3 to S1, as demonstrated by1. hypointense T1-weighted signal and hyperintense T2-weighted signal (ie,bone marrow edema and inflammation), or2. 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 compromise2. 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 treated4. current pregnancy5. skeletal immaturity6. implantable pulse generator (eg, pacemaker, defibrillator) or other electronic implant7. scoliosis8. spinal instabilityII. 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 bas ivertebral nerve (BVN) for the treatment of chronic low back pain. The trial involved225 patients diagnosed with chronic low back pain at 18 sites across the United States and Europe. Patients were skeletally mature, experienced chronic, isolated lumbar p ain,had failed at least 6 months of conservative management, and demonstrated Type 1 orType 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 (OD I) of30 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 3months. At 3 months, the average ODI in the treatment arm decreased 20.5 points,compar ed 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-M M-1827 Effective Date: 04/01/2026 The MEDICAL Pol i cy St a tem e nt d e t ai l e d a bove h a s r ecei v e d due c on si de ra t i on a s d e f i n e d i n the MEDICAL Po li cy St a t e m e nt Po li cy and i s a pp r o v e d. 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-rep orted 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 imp rovement 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 clinic ally 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, starti ng 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 ODIs core 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 patie nts 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 skele tally 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 STATEMENTMarketplace Policy Name & Number Date Effective Trigger Point Injections-MP-MM-1317 04/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, 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 w hich 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 Manua ls, 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 Polic y 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 determinatio n. 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.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………… 2 B. Background ………………………….. ………………………….. ………………………….. ……………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ……………………….. 2 E. State-Specific Information ………………………….. ………………………….. …………………………. 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. .. 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. . 4 I. References ………………………….. ………………………….. ………………………….. ………………… 5 Trigger Point Injections-MP-MM-1317Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectTrigger Point Injections B. BackgroundMyofascial trigger points are self-sustaining hyper-irritative foci in any skeletal muscle, often occurring in response to strain produce d 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 treatme nt. 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 , asneeded.Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers acting within their scope ofpractice 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 ph ysically 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 P oint 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. PolicyI. 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-MP-MM-1317Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL 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 motio n e. heating or cooling treatments f. massage 3. TPIs are being given as a part of an overall conservative manage ment (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-inf lammatory 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 select ing this therapeutic option c. affected muscle or muscles d. muscle or muscles injecte d and the number of injections e. frequency of injections required f. name of the m edication used in the injection g. 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 InjectionsA. 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 si te. Documentation should include at least 50% improvement in pain, functioning , and activity tolerance. Trigger Point Injections-MP-MM-1317Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL 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 respo nse to snapping palpitation H. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point IV. Payment InformationA. 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 pa rticular 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. State-Specific InformationN/A F. Conditions of CoverageN/A G. Related Policies/RulesN/A H. Review/Revision HistoryDATE ACTIONDate Issued 04/27/2022 New policy , replacing individual state policiesDate Revised 03/29/2023 02/28 /2024Annual review: updated references, added definition and payment information. Approved at Committee Annual review: moved state-specific information to section E, updated references, approved at Committee. Trigger Point Injections-MP-MM-1317Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 02/12/202501/14 /2026 Review: updated references, approved at Committee. Review: updated references. Approved at Committee. Date Effective 04/01/2026 Date Archived I. 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 April 29, 2025 . Accessed December 12 , 2025. www.uptodate.com 3. Debrosse M, Sukhman S, Shah A, et al. Trigger point injection therapies for chronic myofascial neck and back pain: a systematic review. Interventional Pain Medicine . 2022; 1(3):100076. doi.org/10.1016/j.inpm.2022.100076 4. Hammi C, Schroader JD, Yeung B. Trigger point injection. StatPearls . StatPearls Publishing; 2024. Updated July 24, 2023. Accessed December 12 , 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 September 30, 2025 . Accessed December 12 , 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 February 14, 2025 . Accessed Dec ember 12 , 2025 . www.uptodate.com 9. Moynihan LK, Elkadry E. Myofascial pelvic pain syndrome in females: treatment. UpToDate . Updated January 11, 2023 . Accessed December 12 , 2025. www.uptodate.com 10. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate . Updated September 4, 2025 . Accessed December 12 , 2025. www.uptodate .com Independent Medical Review January 2025
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Interest Payments-MP-PY-1391 04/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management 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 federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy 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. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. State-Specific Information ………………………………………………………………………………………. 3 F. Conditions of Coverage …………………………………………………………………………………………. 3 G. Related Policies/Rules …………………………………………………………………………………………… 3 H. Review/Revision History ………………………………………………………………………………………… 3 I. References ………………………………………………………………………………………………………….. 3 Interest Payments-MP-PY-1391Effective Date: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectInterest Payments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements, of which the provider has knowledge. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by State and/or Federal regulation defining timeliness and interest requirements. D. PolicyI. CareSource strictly adhere to all regulatory guidelines relating to interest. CareSource follows the guidelines outlined in Prompt Payment regulations. (42 C.F.R. 422.520). II. Payment of interest is made when CareSource fails to pay the claim within the applicable state and federal prompt pay timeframes on clean claims. III. CareSource considers interest payment on claims that were not paid accurately onprior processing attempts. If CareSource had the information to pay the claim correctly on a previous payment but failed to do so, CareSource will pay the claim within the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe.IV. CareSource only pays interest on claim payments that are occurring under promptpay regulations. A contractual adjustment of a claim is not subject to state andInterest Payments-MP-PY-1391Effective Date: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 federal regulations for interest payment. CareSource performs regular audits to correct claim payment. A. Audits on retroactive eligibility updates, authorization updates, coordination of benefits updates, and fee schedule updates. B. Audits include proactive measures to correct claim payment when it has been determined that a systemic issue has paid claims incorrectly. C. Claims are not subject to interest payment when CareSource takes proactive measures to pay claims correctly. E. State-Specific Information A. Georgia 1. Definitions; Prompt Pay Requirements; Penalties, G A. C ODE ANN . 33-24-59.14 (2024). B. Indiana 1. Payment or Denial of Claims; Interest, I ND . C ODE 27-13-36.2-4 (2024). 2. Required Rules, I ND . C ODE 12-15-21-3 (2024). C. West Virginia 1. Minimum Fair Business Standards Contract Provisions Required; Processing and Payment of Health Care Services; Provider Claims; Commissioner's Jurisdiction, W. VA. C ODE 33-45-2 (2024). F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. G. Related Policies/Rules NA H. Review/Revision History DATE ACTIONDate Issued 04/12/2023 New Policy.Date Revised 01/31/2024 01/15/2025 01/14/2026 Updated references. Approved at Committee. Updated references. Approved at Committee. Updated references. Approved at Committee. Date Effective 04/01/2026 Date Archived I. References1. Interest, 41 U.S.C. 7109 (2022). 2. Interest Penalties, 31 U.S.C. 3902 (2023). 3. Interest rates. Bureau of the Fiscal Service. Updated July 1, 2025. Accessed November 21, 2025. www.fiscal.treasury.gov 4. Prompt Payment Interest Rate; Contract Disputes Act, 88 Fed. Reg. 55,501 (2023). Accessed November 21, 2025. www.govinfo.gov Interest Payments-MP-PY-1391Effective Date: 04/01/2026The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 5. Prompt Payment of Claims, 42 U.S.C. 1395h(c)(2)(B) (2021). 6. Prompt Payment of Claims, 42 U.S.C. 1395u(c)(2)(B) (2021). 7. Prompt Payment by MA Organization, 42 C.F.R. 422.520 (2022).
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Experimental or Investigational Item or Service-MP-AD-1354 04/01/2026 Policy Type ADMINISTRATIVE Administrative 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. Administrative 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 Administrative Policy Statement. If there is a conflict between the Administrative 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.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. State-Specific Information ……………………………………………………………………………………… 4 F. Conditions of Coverage ………………………………………………………………………………………… 4 G. Related Policies/Rules ………………………………………………………………………………………….. 4 H. Review/Revision History ……………………………………………………………………………………….. 4 I. References …………………………………………………………………………………………………………. 4 Experimental or Investigational Item or Service-MP-AD-1354Effective Date: 04/01/2026The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectExperimental or Investigational Item or Service B. Background Experimental and/or investigational items or services are not covered. This includes, among other things, services or procedures considered to be investigational, cosmetic, or not medically necessary. This policy defines the medical review decision process around such treatment requests. CareSource members have the right to refuse or participate in experimental or investigational items or services. Providers are encouraged to inform members in advance when they may be financially responsible for the cost of non-covered or excluded services. C. Definitions CPT Category III Codes A set of temporary (T) codes assigned to emerging technologies, services, and procedures. These codes are intended to be used for data collection to substantiate more widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. Experimental or Investigational Items or Services Medical, surgical, diagnostic, psychiatric, substance use disorders treatment or other health care services, technologies, equipment, supplies, treatments, procedures, therapies, biologics, drugs, or devices (each a Health Care Item or Service) that, at the time CareSource has made a determination regarding coverage in a particular case, are: o not approved by the United States Food and Drug Administration (FDA) to be lawfully marketed for the proposed use o not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use, or o determined by the FDA to be contraindicated for the specific use o subject to review and approval by any institutional review board or other body serving a similar function for the proposed use, and such final approval has not been granted o the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2, or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight o provided as part of a clinical research protocol or clinical trial or is provided in any other manner that is intended to evaluate the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply o provided pursuant to informed consent documents that describe the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply as experimental or investigational, or otherwise indicate that the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is under evaluation o The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is Experimental or Investigational Item or Service-MP-AD-1354Effective Date: 04/01/2026The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 actually subject to FDA oversight. This includes diagnostic testing for purposes of possible inclusion in a clinical trial.Devices that are FDA approved under the Humanitarian Use Device exemption are not considered to be experimental or investigational. Drugs used in Phase 4 trials may be covered if they are part of the formulary. D. PolicyI. Any health care item or service that CareSource determines to be experimental or investigational is not covered. II. According to Centers for Medicare & Medicaid Services: Early and PeriodicScreening, Diagnostic and Treatment services (EPSDT) does not require coverage of treatments, services, or items that are experimental or investigational. However, requested treatments for members under the age of 21 will be reviewed individually to determine if the request is medically necessary. III. Any health care item or service not deemed experimental or investigational based on the criteria in Section C. may still be deemed experimental or investigational if it is not supported by credible research that soundly demonstrates that such item or service will have a measurable and beneficial health outcome. In determining whether such health care item or service is experimental or investigational, CareSource, will consider the information and evidence from one or more of the sources in Section III below and assess whether: A. The scientific evidence is conclusory concerning the effect of the health care item or service on health outcomes. B. The evidence demonstrates that the health care item or service improves net health outcomes of the total population for whom the item or service might be proposed by producing beneficial effects that outweigh any harmful effects. C. The evidence demonstrates that the health care item or service has been shown to be as beneficial for the total population for whom the service might be proposed as any established alternatives. D. The evidence demonstrates that the health care item or service has been shown to improve the net health outcomes of the total population for whom the service might be proposed under the usual conditions of medical practice outside clinical investigatory settings. IV. When reviewing requests, CareSource will consider information and evidence from the following non-exhaustive list: A. published authoritative, peer-reviewed medical or scientific literature, or the absence thereof B. evaluations of national medical associations, consensus panels, and other technology evaluation bodies Experimental or Investigational Item or Service-MP-AD-1354Effective Date: 04/01/2026The ADMINISTRATIVE Policy Statement detailed above has received due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 C. documents issued by and/or filed with the FDA or other federal, state or local agency with the authority to approve, regulate, or investigate the use of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply D. documents of an institutional review board or other similar body performing substantially the same function E. consent document(s) and/or the written protocol(s) used by providers studying substantially the same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply F. medical records G. opinions of consulting providers and other experts in the field E. State-Specific Information NA F. Conditions of Coverage NA G. Related Policies/RulesClinical Trial Coverage Medical Necessity Determinations policy H. Review/Revision HistoryDATES ACTIONDate Issued 01/31/2024 New Policy. Approved at Committee.Date Revised 01/15/2025 01/14/2026 Updated references. Approved at Committee Added EPSDT requirements to Section II. Updated references. Approved at Committee Date Effective 04/01/2026 Date Archived I. References1. Biological Products, 21 C.F.R. 600.2-.90 (2024). 2. Coverage and Authorization of Services, 42 C.F.R. 438.210 (2024). 3. Investigational Device Exemptions, 21 C.F.R. 812.1-.46 (2025). 4. Medical Services Coverage Decisions That Relate to Health Care Technology, 42 C.F.R. 405.201-.215 (2025). 5. Medicare Coverage of Items and Services in Category A and BInvestigational Device Exemption (IDE) Studies . Centers for Medicare & Medicaid Services; 2015. MLN Matters MM8921. Accessed December 2, 2025. www.cms.gov 6. Phases of an Investigation, 21 C.F.R. 312.21 (2025). 7. Premarket Approval of Medical Devices, 21 C.F.R. 814.1-.19 (2025). 8. Utilization Control, 42 C.F.R. 456.1-.725 (2025).
ADMINISTRATIVE POLICY STATEMENTMarketplace Policy Name & Number Date Effective Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation-MP-AD-1237 04/01/2026 Policy Type ADMINISTRATIVE Administrative 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 industr y 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 M anuals, Member Handbooks, and/or other policies and procedures. Administrative 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 Adminis trative Policy Statement. If there is a conflict between the Administrative 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 determina tion. 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.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Electrocardiogram (EKG/ECG) Interpretation and ImagingInterpretation-MP-AD-1237Effective Dat e: 04/01/2026 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectElectrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation B. BackgroundAn electrocardiogram (EKG/ECG) is a non-invasive test that records the electrical activity of the heart and is used when a possible cardiac issue occurs. The recording is reviewed by a qualified provider who provides an interpretation and written report. An EKG/ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspects together as one service. For the purpose of this policy, EKG will be used to represent both EKG and ECG. C. Definitions Electrocardiogram (EKG/ECG) A test that records the electrical activity of the heart. Imaging Several different technologies that are used to view the human body in order to diagnose, monitor, or treat medical conditions. D. PolicyI. Electrocardiogram (EKG/ECG) Interpretation A. CareSource will reimburse the first EKG interpretation claim that is received for the member on the date of service. 1. If another claim for the same EKG interpretation is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service. 2. CareSource will not reimburse for duplicate claims for the same service on the same date of service for the same member without the appropriate modifier. B. If a second EKG interpretation is medically necessary on the same date of service before the member is discharged, modifier 76 or modifier 77 must be appended to the second EKG interpretation for reimbursement. II. Imaging InterpretationA. CareSource will reimburse the first imaging interpretation claim that is received for the member on the date of service. 1. If another claim for the same imaging interpretation is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service. 2. CareSource will not reimburse for duplicate claims for the same service on the same date of service for the same member without the appropriate modifier. B. If a second imaging interpretation is medically necessary on the same date of service before the member is discharged, modifier 76 or modifier 77 must be appended to the second imaging interpretation for reimbursement. Electrocardiogram (EKG/ECG) Interpretation and ImagingInterpretation-MP-AD-1237Effective Dat e: 04/01/2026 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 III. CareSource expects providers to work with other departments within the provider organization to determine which department will submit the claim to prevent duplicate claim submissions. E. State-Specific InformationNA F. Conditions of CoverageCareSource expects provider s to use appropriate , standard billing guidelines. Modifiers and place of service codes are listed below only as a reference. Modifier Description 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional Imaging ModifiersModifier Description26 Professional Component TC Technical component G. Related Policies/RulesModifier 26 and TC: Professional and Technical Component H. Review/Revision HistoryDATE ACTIONDate Issued 09/14/2022 New policyDate Revised 09/13/2023 01/29/202501/14/2026Removed place of service language. Updated references. Approved at Committee. Annual review. Updated background, definitions, and references. Added Imaging modifiers. Approved at Committee. Annual review. Updated references. Approved at Committee Date Effective 04/01/2026 Date Archived I. References1. Hussain S, Mubeen I, Ullah N, et al. Modern diagnostic imaging technique applications and risk factors in the medical field: a review. Biomed Res Int . 2022;5164970. doi:10.1155/2022/5164970 2. Sattar Y, Chhabra L. Electrocardiogram . StatPearls Publishing; 2025. Updated January 2025. Accessed December 11, 2025 . www.ncbi.nlm.nih.gov 3. Medical Imaging. US Food and Drug Administration. Published August 28, 2018. Accessed December 11, 2025 . www.fda.gov Electrocardiogram (EKG/ECG) Interpretation and ImagingInterpretation-MP-AD-1237Effective Dat e: 04/01/2026 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 4. What are medical coding modifiers? American Academy of Professional Coders.Updated August 19, 2022. December 11, 2025 . www.aapc.com
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Sacroiliac Joint Procedures-OH MCD-MM-0010 04/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, 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 w hich 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 Manua ls, 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 Polic y 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 determinatio n. 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.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Polices/Rules ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectSacroiliac Joint Procedures B. BackgroundNearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent. Persistent pain is categorized as subacute when lasting between four and twelve weeks , and chronic when persisting for at least three months. Up to 10% to 30 % of patients with persistent low back pain may have a component ofpain related to sacroiliac joints (SIJ) . Comprehensive pain management care plans are most effective in managing a patients chronic pain. These plans focus on a person – centered approach and incorporate conservative treatment with other modalities. These multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a pat ients daily life, even if the pain cannot be relieved completely. In addition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic tre atments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be effective for diagnostic purposes but provide limited short-term relief from pain resulting from SI Jdysfunction. Long-term use has not be en adequately studied to establish standards of care. Radiofrequency ablation (RFA) is another treatment method, which uses heat to destroy nerves. RFA for the treatment of low back pain has inconsistent results in the peer-reviewed medical literature with limited fol low – up. However, clinical experience suggests that some patients obtain more significant relief from these procedures, making it reasonable to offer SIJ injections and/or RFA when conservative management has failed. C. Definitions Conservative Therapy A multimodality plan of care includ ing both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational 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 physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Inactive Conservative Therapies Passive activities that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS unit, and/or pharmacotherapy (prescription or over the counter [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 endorphin s. 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. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. Sacroiliac Joint (SIJ) Injections Corticosteroid and local anesthetic therapeutic injections into the SIJ to treat pain that hasnt responded to conservative therapies. Functional Disability Acquired difficulty in performing basic everyday tasks or more complex tasks needed for independent living. D. PolicyI. Sacroiliac Joint Injections A. Diagnostic i njections: CareSource considers up to 2 diagnostic SIJ injection s for the treatment of chronic low back pain medically necessary when ALL the following criteria are met: 1. somatic or nonradicular low back and lower extremity pain experienced for at least 3 months 2. severe pain (ie. at least a 6 out of 10 on pain scale) and tenderness are located in SIJ region and cause functional disability 3. positive response to at least 3 SIJ pain provocation test (eg, distraction, compression, thigh thrust, Gaenslens, Patricks test/FABER test, sacral thrust) 4. failure of conservative therapy, as evidenced by ALL the following: a. documentation in the medical record of a t least 6 weeks of active conservative therapy (as defined above ) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance b. documentation in the medical record of a t least 6 weeks of inactive conservative therapy ( as defined above ) within the past 6 months 5. If a second diagnostic injection is requested, at least 1 week has passed since the initial injection. B. Therapeutic i njections : CareSource considers therapeutic SIJ injections medically necessary when ALL the following criteria are met: 1. previous SIJ injection led to significant functional pain relief as measured by a decrease in pain level (demonstrated on a qualitative pain scale), decrease in pain medications, and/or increase in physical function Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 2. member experiences return of severe pain or deterioration in function3. injection is used in conjunction with conservative therapy (as defined above) 4. injections should not be repeated more frequently than every 2 months 5. no more than 4 injections total ( diagnostic and therapeutic ) have been administered at the same site the last 12 months C. Exclusions/Limitations: 1. Codes 64451 and 27096 may not be billed together (on the same date for the same side of the body). Only one code will be reimbursed . 2. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately. 3. If neural blockade is applied for different regions or different sides, injections are performed at least one week apart. 4. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated injections of the SI Jto be effective as a long-term management modality. Long-term continuation may be subject to medical necessity review. 5. Monitored anesthesia and conscious sedation are not medically necessary. 6. The use of SI Jinjections for the treatment of pain as a result of Herpes Zoster is not indicated due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. II. Radiofrequency Ablation of the SIJA. Initial radiofrequency ablation of the SI J 1. Radiofrequency ablation is considered medically necessary when ALL the foll owing have been met in the last 6 month s: a. The clinical criter ia above for failed conservative therapy (I.A. 4.a. and I.A.4. b.) has been met . b. One diagnostic injection per joint to evaluate pain and attain therapeutic effect has been performed , with significant functional pain relief as measured by a decrease in pain level (demonstrated on a qualitative pain scale), decrease in pain medications, and/or increase in physical function . B. Repeat radiofrequency ablation of the SI J 1. Conservative therapy and diagnostic injections are not required if there has been a reduction in pain for at least 12 months or more from the initial RFA within the last 36 months. 2. When there has not been a repeat RFA in the last 36 months, a diagnostic injection is required. 3. A maximum of 1 RFA for SI Jpain per side per rolling 12 months is considered medically necessary. C. Exclusions/Limitations 1. Codes 64451 and 27096 are considered the same procedure and may not be billed together. Only one code will be reimbursed. Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 2. The use of cooled RFA for SI J-mediated low back pain is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. 3. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated the effectiveness of RFA as a long-term management modality. Long-term continuation may be subject to medical necessity review. III. Implantable Spinal Cord StimulatorsPatients with indwelling implanted spinal cord stimulators or pain pumps should have a device interrogation report submitted with medical records for a prior authorization request for proposed interventional pain injections. If a device is not functioning properly, an escalation in pain may warrant evaluation and management of the implanted device. E. Conditions of CoverageNA F. Related Polices/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/10/2015 New PolicyDate Revised 07/28/2015 07/26/2016 02/08/2018 03/06/2019 10/8/201905/13/202004/28/202103/29/202203/01 /202301/31 /202401/29/2025Removed Herpes CriteriaAnnual Update: Removed start and end dates. Addition of PA clarification and documentation requirements. Revision of injection frequency. Removed joint fusion denial language. This service will be addressed in the Sacroiliac Joint Fusion policy. Annual Update: Added clinical criteria for coverage of radiofrequency ablation of the SI Joint. Added coding information. Annual Update: Removed PA language. Annual Review: Updated background and references, re – organized criteria into initial and subsequent procedures, type of procedure. Annual Review: restructured conservative management and clinical criteria, added provocation tests Annual review: updated formatting and references, approved at Committee. Review: updated references, approved at Committee Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 12/17 /2025 Review: added pain level criteria, increased number of positive provocation test positives and updated references . Approved at Committee. Date Effective 04/01/2026 Date Archived H. References1. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med . 2017;166(7):493-505. doi:10.7326/M16-2459 2. Chou R, Cohen SP. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated April 29 , 202 5. Accessed November 24 , 2025 . www.uptodate.com 3. Cine HS, Uysal E, Demirkol M, Cetin E. Under what conditions is the intra-articular steroid injection superior to nonsteroidal anti-inflammatory drugs for treating sacroiliac joint pain? Eur Rev Med Pharmacol Sci . 2023;27(21):10539-10546. doi:10.26355/eurrev_202311_34331 4. Immunizations, injections and infusions ( including trigger-point injections), skin substitutes, and provider-administered pharmaceuticals , OHIO ADMIN . CODE 5160-4- 12 (2022 ). 5. Jamjoom AM, Saeedi RJ, Jamjoom AB. Placebo effect of sham spine procedures in chronic low back pain: a systematic review. JPain Res . 2021;14:3057-3065. doi:10.2147/JPR.S317697 6. Janapala RN, Knezevic E, Knezevic NN, et al. Systematic review and meta-analysis of effectiveness of therapeutic sacroilic joint injections. Pain Phys ician . 2023;26:E413-E435. Accessed November 24 , 2025 . www.painphysicianjournal.com 7. Lee DW, Pritzlaff S, Jung MJ, et al. Latest evidence-based application for radiofreq uen cy neurotomy (LEARN): best practice guidelines from the American Society of Pain and Neuroscience (ASPN). JPain Res . 2021;14:2807-2831. doi:10.2147/JPR.S235665 8. Liu Y, Suvithayasiri S, Kim JS. Comparative efficacy of clinical interventions for sacroiliac joint pain: systematic review and network meta-analysis with preliminary design of treatment algorithm. Neurospine . 2023 Sep;20(3):997-1010. doi: 10.14245/ns.2346586.293. 9. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint inerventions 2020 guidelines. Pain Phys ician . 2020;23(3S):S1-S127. Accessed November 24 , 2025 . www.painphysicianjournal.com 10. Sacroiliac Joint Injection: A-1048 (AC). MCG. 29 th ed. Updated June 23, 2025. Accessed December 1, 2025. www.careweb.careguidelines.com 11. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 12. Stevens AC, Carroll DD, Courtney-Long EA, et al. Adults with one or more functional disabilisties United States, 2011-2014. MMWR Morb Mortal Wkly Rep Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 2016;65:1021-1025. doi:10.15585/mmwr.mm6538a113. Szadek K, Cohen SP, de Andres Ares J, et al. Sacroiliac joint pain. Pain Pract. 2023 ;00:1-20. doi:10.1111/papr.13338 14. Wu L, Tafti D, Varacallo M. Sacroiliac joint injection. StatPearls . StatPearls Publishing; 2023. Updated August 4, 2023. Accessed November 24, 2025 . Independent Medical Review January 2025Approved by ODM 01/08/2026
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Retrospective Authorization Review-OH MCD-AD-1334 04/01/2026 Policy Type ADMINISTRATIVE Administrative 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 industr y 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 M anuals, Member Handbooks, and/or other policies and procedures. Administrative 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 Adminis trative Policy Statement. If there is a conflict between the Administrative 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 determina tion. 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.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………….. ……… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. ………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ………………… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………………. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………………. 3 H. References ………………………….. ………………………….. ………………………….. ………………………….. ………. 4 Retrospective Authorization Review-OH MCD-AD-1334 Effective Dat e: 04/01/2026 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectRetrospective Authorization Review B. BackgroundA retrospective review is a request for an initial review for an authorization of care, service, or benefit for which a prior authorization (PA) is required but was not obtained prior to the delivery of the care, service, or benefit. Occasionally, situations arise in which a PA cannot be reasonably obtained prior to care, service, or benefit . In these cases, CareSource will conduct a retrospective review of medical services received by members when the request is received within 30 days of the date of servi ce or discharge. Retrospective reviews are performed by licensed clinicians who are supported by licensed physicians. A decision is rendered within 30 days of receipt of all necessarydocumentation. In the event of an adverse determination, the provider and/or member are notified of the decision and supporting rationale.C. Definitions Claim Dispute Process A dispute is the first formal review of the processing of a claim by CareSource, excluding denials based on medical necessity, submitted when the provider disagrees with payment of any other post-service claim denial. Providers should submit corrected c laims if it is considered that a claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim. A dispute or appeal does not have to be filed. Clinical Review Criteria The written screening procedures, decision abstracts, clinical protocols and practice guidelines used by CareSource to determine the medical necessity and appropriateness of health care services. Coordination of Benefits (COB) The process used for determining which health plan or insurance policy pays first and/or determining the payment obligations of each health plan, medical insurance policy, or third-party resource when 2 or more resources cover the same benefits for the s ame member. Explanation of Benefits (EOB)/Explanation of Payment (EOP) A written explanation of benefits summarizing the benefits a member receives. Prior Authorization Utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with CareSources requirement that the health care service or course of treatment, in whole or in part, be approved prior to provision. Retrospective Authorization Review The process of reviewing and making a coverage decision for a service or procedure that has already been performed (eg, post service decision). D. PolicyI. CareSource considers retrospective authorization review appropriate when ANY of the following circumstances have occurred: Retrospective Authorization Review-OH MCD-AD-1334 Effective Dat e: 04/01/2026 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 A. A CareSource member is unable to advise the provider what plan they are enrolled in due to a condition that renders them unresponsive or incapacitated;B. The member is retrospectively enrolled and covers the date of service. C. Urgent service(s) requiring authorization was/were performed and it would have been to the members detriment to take the time to request authorization. D. A prior authorization had been issued, however a new service/procedure was needed and/or performed that was not known to be needed at the time of the original prior authorization request. II. All retrospective authorization requests must be submitted within 30 calendar days ofA. the date of service B. date of discharge C. as specified in a provider contract III. Providers have 90 days from the granting of eligibility to submit retrospective authorizations requests . IV. In the event of the discovery that CareSource is primary, providers are required to submit the EOB/EOP with an authorization request.V. Claim Dispute Process for Providers A. Claim disputes must be submitted in writing or via the CareSource Provider Portal. B. The dispute must be submitted within 90 calendar days after the providers receipt of the written determination of the claim. C. If CareSource fails to render a determination for the dispute within 30 days after receipt, the provider may request an external medical review (EMR) . VI. Unless the CareSource member is transitioning and qualifies under the retroactive coverage requirements, retrospective reviews requested greater than 30 days past date of service or date of discharge will be administratively denied. Administrative denials do not require a review by a CareSource Medical Director. VII. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.E. Conditions of Coverage NA F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision History DATE ACTION Retrospective Authorization Review-OH MCD-AD-1334 Effective Dat e: 04/01/2026 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 Date Issued 06/21/2023 New policy. Approved at Committee.Date Revised 11/06 /2024 11/19/2025Periodic review. References updated. Approved at Committee. Periodic review. Updated definitions, section D. and references. Approved at Committee. Date Effective 04/01/2026 Date Archived H. References1. CareSource Ohio Medicaid Provider Manual . CareSource; 2025. Accessed November 5, 2025. www.caresource.com ODM Approved 01/20/2026
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