MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Breast Cancer Index (BCI) for Managing Breast Cancer Treatment – GA MCD-MM-1512 07/01/2024 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to s uffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the det ermination. 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 appl y to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 3 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Polic ies/R ules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Breast Cancer Index (BCI) for Managing Breast Cancer Treatment-GA MCD-MM-1512 Effective Date: 07/01/2024 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Breast Cancer Index (BCI) for Managing Breast Cancer Treatment B. Background According to the CDC each year in the United States, about 260 ,000 individuals are expected to be diagnosed with invasive breast cancer, of which approximately 90% are diagnosed with early-stage disease. Hormone-receptor positive (HR+) breast cancer is the most common subtype of breast cancer (~80% of cases) and has the most favorable p rognosis overall. Standard-of-care treatment for HR+ disease includes primary adjuvant anti-estrogen therapy with tamoxifen, an aromatase inhibitor (AI), or a sequence of these. A long with anti-estrogen therapy, there are two additional key treatment decisions which are priorities in the management of early stage breast cancer . The first decision is whether the patient is of sufficient risk of recurrence to recommend systemic adjuvant chemotherapy. In addition, while HR+ early-stage breast cancer patients have a favorable prognosis overall, there is an ongoing risk of distant recurrence (DR) beyond year 5 (late recurrence), and 75% of deaths occur more than 5 years post-diagnosis . The second decision is whether to recommend extension of endocr ine therapy beyond the initial primary adjuvant therapy. For each treatment decision, physicians and patients must weigh whether the potential benefit from the additional treatment regimen is likely to outweigh the risks of cardiovascular toxicity, bone fr actures, and other side effects that impair quality of life and compliance. The Breast Cancer Index (BCI) is a gene expression based signature that consists of two functional biomarker panels, the HOXB13/IL17BR (H/I) ratio and the molecular grade index (M GI), that evaluate important estrogen signaling and proliferation pathways in breast cancer. It analyzes the activity of 11 genes that can influence how likely the cancer is to come back 5 to 10 years after diagnosis, as well as how likely a patient is to benefit from 5 additional years of hormonal therapy. The test provides both prognostic and predictive results . The BCI Prognostic result estimates how likely the cancer is to come back 5 to 10 years after diagnosis (late recurrence). The result is given as a percentage. Example: a prognostic result of 2.2% means the patient has a 2.2% risk of the cancer coming back 5 to 10 years after diagnosis. The BCI Predictive result is reported as "yes" or "no." A yes result means the patient is likely to benefit fro m 5 more years of hormonal therapy. A no result means the patient is not likely to benefit from 5 more years of hormonal therapy. BCI is tested once per patient lifetime on formalin-fixed, paraffin-embedded (FFPE) tissue from the primary tumor specimen obtained prior to adjuvant treatment. Breast Cancer Index (BCI) for Managing Breast Cancer Treatment-GA MCD-MM-1512 Effective Date: 07/01/2024 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d.3C. Definitions Adjuvant therapy for early-stage breast cancer Tamoxifen is FDA approved for adjuvant hormone treatment of premenopausal and postmenopausal women (and men) with ER-positive early-stage breast cancer, and the aromatase inhibitors anastrozole, letrozole, and exemestane are approved for this use in postmenopausal women. Gene Expression Testing A laboratory test that analyzes mRNA patterns to determine gene activity . Predictive Molecular Markers Biomarkers which can be used to evaluate the likelihood of benefit from a specific clinical intervention, or the differential outcomes of more than one intervention. Prognostic Molecular Markers Biological characteristics that are objectively measured and evaluated to predict the course of a disease or a response to a therapeutic intervention among patients with the same characteristic. Examples include the presence of a particular gene variant, patterns of gene expression, or levels of a particular protein in body fluids . D. Policy I. CareSource considers Breast Cancer Index for breast cancer as a technique for managing the treatment of breast cancer in females or males with invasive breast cancer medically necessary in the following situations: A. Member is newly diagnosed (within the last 6 months) and ALL of the following criteria are met: 1. Lymph node negative or 1-3 positive ipsilateral axillary lymph nodes; and 2. No distant metastases . 3. Estrogen receptor positive (ER+), or progesterone receptor positive (PR+) or both. 4. HER2 (human epidermal growth factor receptor-2) receptor negative. 5. Adjuvant chemotherapy is not precluded due to any other factor (eg, advanced age and/or significant co-morbidities). B. Member is currently receiving adjuvant hormonal therapy (eg, Tamoxifen or an aromatase inhibitor) for a breast cancer and ALL of the following criteria are met: 1. Hormone receptor-positive (estrogen receptor positive, progesterone receptor positive or both) . 2. HER2 receptor negative. 3. The member and treating physician have had a discussion prior to testing a. regarding the potential results of the test and b. use of the results to guide a decision regarding extended adjuvant hormonal therapy. II. Gene expression profiling in breast cancer are unproven and not medically necessary for all other indications, including ductal carcinoma in situ (DCIS), due to insufficient evidence. Breast Cancer Index (BCI) for Managing Breast Cancer Treatment-GA MCD-MM-1512 Effective Date: 07/01/2024 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d.4E. Conditions of Coverage N/A F. Related Polic ies/Rules Medical Necessity Determinations G. Review/Revision History DATE ACTIONDate Issued 06/21/2023 New Policy. Approved at committee.Date Revised 03/13/2024 Updated reference. Approved at Committee. Date Effective 07/01/2024 Date Archived H. References1. Andre F, Ismaila N, Allison KH, et al. Biomarkers for Adjuvant endocrine and chemotherapy in early-stage breast cancer: ASCO guideline update. JClin Oncol. 2022;40(16):1816-1837. doi:10.1200/JCO.22.00069 2. Local Coverage Determination: MolDX: Breast Cancer Index (BCI) Gen e Expression Test. Medicare Coverage Database; 2023. LCD Id L37913. Accessed February 28, 2024. www.cms.gov 3. Molecular Test Assessment: Breast Cancer Index (BioTheranostics Inc.) for Lymph Node-Negative Patients. Hayes; 2022. Accessed February 28, 2024. www.hayesinc.com 4. Molecular Test Assessment: Breast Cancer Index (BioTheranostics Inc.) for Lymph NodePositive (1-3) Patients. Hayes; 2022. Accessed February 28, 2024. www.hayesinc.com 5. National Ca ncer Institute (NCI) Fact Sheet. Hormone Therapy for Breast Cancer . Accessed February 28, 2024. www.cancer.gov 6. Noodhoek I, Treuner K, Putter H, et al. Breast Cancer Index p redicts extended e ndocrine benefit to individualize selection of p atients with HR+ e arly-stage breast cancer for 10 years of endocrine therapy. Clin Cancer Res . 2021;27(1):311-319. doi:10.1158/1078-0432.CCR-20-2737 7. Optum EncoderPro for Payer Professionals. CPT code 81518. Accessed February 28, 2024 . www.encoderprofp.com 8. Sanft T, Aktas B, Schroeder B, et al. Prospective assessment of the decision-making impact of the Breast Cancer Index in recommending extended adjuvant endocrine therapy for patients with early-stage ER-positive breast cancer. Breast Cancer Res Treat. 2015;154(3):533-541. doi:10.1007/s10549-015-3631-9 . GA-MED-P-2775306 Issue Date 06/21/2023 Approved DCH 04/04/2024
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Special Needs Car Seats-GA MCD-MM-1443 07/01/2024 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 as sessment 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 diag nosis 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These service s 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 o f Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health di sorder 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 ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Special Needs Car Seats-GA MCD-MM-1443Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectSpecial Needs Car Seats B. BackgroundThe American Academy of Pediatrics (AAP) states that all children should have access to proper resources for safe transportation, including children with specific functional needs. Safe transportation includes not only the proper restraints, but also the c orrect positioning to secure the child in the vehicle. A standard car seat provides the best protection for most travel needs. However, additional research is needed for the biomechanics of test dummies representative of children with certain functional ne eds in crash testing so that such test dummies can be utilized by the National Highway Traffic Safety Administration (NHTSF). Currently, the Federal Motor Vehicle Safety Standard (FMVSS) Number 213 regulates the design and performance of child restraint s ystems for children weighing up to 80pounds. However, children greater than 80 pounds may require car seat restraint , and several manufacturers have tested their car seats beyond an 80-pound maximum. Once a child has outgrown a standard 5-point harness ca r seat, options include car seats specially designed for full support of a childs head, neck, and back while supporting up to 115 pounds. Conventional travel vests or specialized medical seating can be used for children who require additional trunk suppor t but have stable neck control. Some older children with certain function al needs, including poor trunk control , can be transported in a special needs belt-positioning booster seat or a conventional belt-positioning booster with trunk support. Data has sh own that rear-facing car seats offer greater protection for the head and neckthan a front-facing car seat, by reducing neck loading in vehicular crashes with a frontal component. Therefore, the AAP encourages use of a rear facing car seat for as long as possible for all children, but especially for children diagnosed with neurological condition (s) , as a forward-facing car seat increases the risk of injury in a crash. Recommendations by the AAP specify that car seats should be placed in the rear seat of the vehicle. However, it is note d that a child with certain functional needs requiringfrequent monitoring may need to be placed in the front seat when no adult is available to sit in the rear seat with the child. If the child is placed in the front seat, the automatic air bag should be disabled. C. Definitions Booster Seat A seat used for a small child during transportation that lifts the child by several inches, designed for use with an adult seat belt. Car Safety Seat (CSS) A portable seat for a person that attaches to an automobile seat and holds the person safely. Federal Motor Vehicle Safety Standard 213 FMVSS No. 213 requires child restraint systems (CRSs) to be equipped with attachments that enable the CRS to Special Needs Car Seats-GA MCD-MM-1443Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 attach to the vehicle’s restrai nt anchorage system. The agency added a height provision to make the new standard’s applicability clear to booster seat manufacturers who choose not to label their restraints with a weight. National Highway Traffic Safety Administration (NHTSA) A divisio n of the U.S. Department of Transportation dedicated to achieving the highest standards of excellence in motor vehicle and highway safety. Neck Loading The dynamic loading of the neck that occurs when the torso is suddenly stopped by the seat belt while the head continues pulling from the neck. Travel Vest Optimizes the existing vehicle seat belt system to protect the child by keeping a low center of gravity and allowing the vehicle seat belt and seat cushion to manage the crash forces. D. PolicyI. CareSource considers a special needs car seat medically necessary when ALL the following clinical criteria are met: A. The car seat is a restraint system that meets National Highway Traffic Safety Administration Federal Motor Vehicle Safety Standard (FMVSS) 213. B. The car restraint system is not modified or used in a manner other than that specified by the manufacturer unless the modified restraint system has been crash tested and has met all applicable FMVSSs approved by the NHTSA. C. The special needs car seat is the most cost-effective option while still addressing the medical/functional needs of the member. D. The safety and effectiveness of the special needs car seat has been substantiated by current evidence-based national, state, and peer-reviewed medical guidelines. E. The length or weight limits of a conventional CRS with an internal 5-point harness has been outgrown and at least one of the following criteria is met. 1. The member has an airway obstruction due to one or more of the following (not an all-inclusive list): a. hypotonia b. craniofacial abnormalities c. primary airway problems 2. The member has a physical condition that prevents the independent maintenance of a seated position or requires support to allow a functional position or prevent further disa bility. 3. The member has gastrointestinal issues, including but not limited to: a. emesis b. gastroesophageal reflux (GERD) c. gastrostomy feeding tube 4. The member uses a spica cast. II. Persons with a tracheostomy tube should not use a CRS with a harness or seat belts that could dislodge the tube. It is strongly recommended that an occupational therapist or passenger safety technician with training and experience in the safeSpecial Needs Car Seats-GA MCD-MM-1443Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 transportatio n of persons with special needs provide guidance for appropriate equipment selection and use . III. A special needs car seat will not be considered medical necessary for any of the following:A. The special needs car seat is a more recent advancement in technology when the members current special needs car seat can meet the members basic medical/functional needs. B. The special needs car seat is considered investigational, experimental, or has unproven medical indications for use. E. Conditions of CoverageN/A F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 03/01/2023 New policy. Approved at committee.Date Revised 02/28/2024 Annual review: editorial changes, adjustment to car seats definition, added Section D.I.C-D., D.I.E.2, and D.II-III., updated the references. Approved at Committee. Date Effective 07/01/2024 Date Archived H. References1. Adams AJ, Johnson MA, Ryan KA, et al. Safe transportation in-spica following surgical treatment of infantile DDH: solutions and threats. JPediatr Orop . 2019;39(7):e488-e493. doi:10.1097/BPO.0000000000001317 2. Angsupaisal M, Maathuis CGB, Hadders-Algra M. Ad aptive seating systems in children with severe palsy across International Classification of Functioning, Disability and Health for Children and Young version domains: a systematic review. Dev Med Child Neurol. 2015;57(10):919-930. doi:10.1111/dmcn.12762 3. Ca r seats and booster seats. National Highway Traffic Safety Administration. Accessed February 16, 2024. www.nhtsa.gov 4. Car seat safety. National Child Passenger Safety Board. Accessed February 16, 2024. www.cpsboard.org 5. Huang PP, Durbin DR. Promoting safety in children with disabilities. UpToDate. Updated January 4, 2024. Accessed February 16, 2024. www.uptodate.com 6. Inthachom R, Prasertsukdee S, Ryan SE, et al. Evaluation of the multidimensional effects of adaptive seating interventions for y oung children with non-ambulatory cerebral palsy. Disabil Rehabil Assist Technol . 2021;16(7):780-788. doi:10.1080/17483107.2020.1731613 Special Needs Car Seats-GA MCD-MM-1443Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 7. Legare JM, Adam MP, Feldman J, et al. Achondroplasia . GeneReviews; 2023. Revised May 11, 2023. Accessed February 16, 202 4. www.ncbi.nlm.nih.gov 8. ONeil J, Hoffman B, American Academy of Pediatrics Council on Injury, Violence, and Poison. Transporting Children with Special Health Needs. Pediatrics . 2019;143(5):e20190724. doi:10.1542/peds.2019-0724 9. Rigby P, Ryan S, Campbell K. Effect of adaptive seating devices on the activity performance of children with cerebral palsy. Arch Phy Med Rehabil . 2009;90(8):1389-1395. doi:10.1016/j.apmr.2009.02.013 10. Ryan SE. Lessons learned from studying the functional impact of adaptive seating interventions for children with cerebral palsy. Dev Med Child Neurol . 2016;58(4):78 – 82. doi:10.1111/dmcn.13046 11. Smith VC, Stewart J. Discharge planning for high-risk newborns. UpToDate. Updated April 10, 2023. Accessed February 16, 2024. www.uptodate.com 12. Vives-Torres CM, Valdamo M, Jimenez-Octavio JR, et al. Comparison of upper neck loading in young adult and elderly volunteers during low speed frontal impacts . Frontiers Bioeng Biotechnol. 2021;9: 682974 . doi :10.3389/fbioe.2021.682974 Independent med ical review 02/15/2023 GA-MED-P-2775306 Issue Date 03/01/ 2023 Approved DCH 04/04/2024
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 07/01/2024 Policy Type MEDICAL Medical Policy Statement pr epared 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 clinic al 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 exp ected 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 alter native, 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/o r other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke 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 ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 5 H. References ………………………….. ………………………….. ………………………….. …………………….. 5 Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPeripheral Nerve Blocks for Treatment of Pain B. BackgroundPeripheral nerve blocks are injections of medication into a specific area of the body where nerves cause pain to a specific organ or body region. Nerve block s cause the temporary interruption of impulse conduction in peripheral nerves or nerve trunks and may or may not contain a steroid, which can be used to treat pain. Var ious areas of pain require different types of nerve blocks that can be administered in numerous parts of the body with some of the most common blocks being sympathetic, peripheral, and occipital. Sacroiliac and facet joint interventions, epidural steroid injections, and trigger pointinjections are addressed in other policies.C. Definitions Acute Pain Pain that last s less than 4 weeks. Ambulatory Surgery Surgery performed in a hospital-based or freestanding ambulatory surgery center (ASC) with patient discharge the same day. Chronic Pain Pain lasting more than 3 months , which is considered beyond normal healing time. Conservative Therapy A multimodality plan of care including both active and inactive conservative therapies. o Active Conserva tive Therapies Actions or activities that strengthen muscle groups and target key spinal structures, including physical therapy, occupational therapy, and/or a physician-supervised home exercise program (HEP). 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 due to a stated physical reason (ie , increased pain, inability to physically perform exercise). Patient inco nvenience and/or noncompliance without explanation does not constitute an inability to complete . 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 directed 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 stimulate the release of endorphins . Use, frequency, duration, and start dates must be documented in the medical record . Emergent Medically necessary care, which is immediately needed to preserve life, prevent serious impairment to bodily functions, organs, or parts, or prevent placing the physical or mental health of a patient in serious jeopardy. Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Low-Risk Procedure Pro cedures associated with minimal physiologic effect and excludes any intrathoracic, intra-abdominal, vascular, or orthopedic procedures. Sub-Acute Pain Pain lasting between 4 to 12 weeks. D. PolicyI. CareSource considers peripheral nerve blocks (PNB) , single injection, medically necessary when appropriate documentation for the treatment of acute pain or chronic pain are included, only as part of an active component of a comprehensive pain management program. CareSource uses MCG Health guidelines to address criteria for specific nerve blocks. Documentation must include indications that ALL the following criteria are met: A. Ambulatory or outpatient procedure that is not emergent, low risk, and requires no inpatient care for a preoperative disease or condition (eg, altered mental status, hypotension, hypoxemia, tachycardia) . B. Acute, sub-acute or chronic, neuropathic or radicular pain, as indicated by ONE or more of the following: 1. cancer-related pain 2. complex regional pain syndrome (CRPS) 3. peripheral neur opathy with pain that limits activities of daily living, excluding diabetic neuropathy 4. peripheral vascular disease with rest pain 5. acute herpes zoster of face or neck and prevention of postherpetic neuralgia 6. pancreatic pain, pelvic pain, or abdominal pain related to malignancy 7. chronic, relapsing pancreatitis C. Symptoms poorly controlled by maximum medical therapy or intolerable side effects to such therapy . D. Failure of non-invasive treatment(s) (eg, non-steroidal anti-inflammatory drugs (NSAIDs), exercise, physical therapy, spinal manipulation therapy) . E. No coagulopathy or thrombocytopenia . F. No infection at or underlying the injection site . II. Acute or Sub-Acute PainPNB may provide means of analgesia for acute pain in the following (not an all – inclusive list): A. Patients at risk of respiratory depression related to systemic or neuraxial opioids (eg, obstructive sleep apnea, severe obesity, underlying pulmonary disease, advanced age). B. Patients with another indica tion to minimize opioid use (eg, chronic opioid use, intolerance to opioids). C. Patients with acute, severe pain poorly managed with systemic medication. D. Patients who cannot tolerate chiropractic or other physical and/or manipulative therapies. Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 III. Chro nic PainCareSource considers PNB , single injection, medically necessary when appropriate documentation for the treatment of chronic pain is included, only as part of an active component of a comprehensive pain management program when the following criteri a are met: A. 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 within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance . 2. Documentation in the medical record of at least 6 weeks inactive conservative therapy within the past 6 months . B. Insufficient evidence support s the use of PNB for chronic pain: 1. ge nicular nerve or branches for chronic knee pain 2. cluneal nerve injections or blocks for chronic low back pain 3. pudendal blocks for chronic pelvic pain conditions IV. Radiofrequency Ablation (RFA) or NeurotomyRadiofrequency ablation and/or neurotomy are considered experimental and investigational , or unproven for any indication, including but not limited to the treatment of acute or chronic pain due to insufficient evidence of efficacy in the peer reviewed literature. V. Limitations and ExclusionsA. A member can receive a maximum of 6 injections in a rolling 12 month period.B. Up t o 2 anatomic sites (eg, specific nerve, plexus, or branch as defined by CPT code description) can be injected at any one session. C. Nerve blocks used as part of a surgical procedure or other medical procedure are not separately reimbursable but an inclusive component of that procedure. These injections will not be compensated separately or unbundled for coverage. D. Any procedure submitted for payment with an incorrect CPT code or description will be denied. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. If requesting a block to a specific part of the body, coding to the highest level of specificity should be used. E. Exclusions 1. Treatment of peripheral neuropathy due to diabetes. 2. Use of nerve blocks with or without use of electrostimulation for treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases. Medical management using systemic m edications is clinically indicated for the treatment of these conditions. E. Conditions of CoverageInterventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers within their scope of practice who are qualified to deliver these health services. Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 F. Related Policies/RulesEpidural Steroid Injections Facet Joint Interventions Sacroiliac Joint Procedures Trigger Point Injections G. Review/Revision HistoryDATE ACTIONDate Issued 02/15/2023 Approved at Committee.Date Revised 02/28/2024 Annual review . Updated references. Approved at Committee . Date Effective 07/01/2024 Date Archived H. References1. Ailani J, Burch RC, Robbins MS; American Headache Society. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache . 202 1;61(7):1021-1039. doi:10.1111/head.14153 2. Allen SM, Mookadam F, Cha S S, et al. Greater occipital nerve block for acute treatment of migraine headache: A large retrospective cohort study. JAm Board Fam Med . 2018;31(2):211-218. doi:10.3122/jabfm.2018.02.170188 3. American Headache Society. AHS consensus statement: The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache . 2019;59(1):1-18. doi:10.1111/head.13456 4. Antolak S, Antolak C, Lendway L. Measuring the qua lity of pudendal nerve perineural injections. Pain Physician . 2016;19:299-306. Accessed February 9, 2024 . www.pubmed.ncbi.nlm.nih.gov 5. Caponnetto V, Ornello R, Frattale I, et al. Efficacy and safety of greater occipital nerve block for the treatment of cerv icogenic headache: a systematic review. Expert Rev Neurotherapeutics . 2021; 21(5):59 1-59 7. doi: 10.1080/14737175.2021.1903320 6. Chang A, Dua A, Singh K, White BA. Peripheral nerve blocks. StatPearls . StatPearls Publishing; 2024. Accessed January 30, 2024. www. ncbi.nlm.nih.gov 7. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated June 10, 2021. Accessed February 9, 2024 . www.uptodate.com 8. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain. MMWR Recomm Rep . 2022;71(No. RR – 3):1-95. doi:10.15585.mmwr.rr7103a1 9. Evidence Analysis Research Brief: Cluneal Nerve Block for Treatment of L ow Back Pain. Hayes; 2021. Accessed February 9, 2024 . www.evidence.hayesinc.com 10. Evidence Analysis Research Brief : Pudendal Nerve Decompression Surgery for Treatment of Pudendal Neuralgia. Hayes; 2022. Accessed February 9, 2024 . www.evidence.hayesinc.com 11. Evolving Evidence Review: Middle Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2022. Reviewed April 4, 2023. Accessed February 9, 2024 . www.evidence.hayesinc.com Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 12. Evolving Evidence Review: Superior Cluneal Nerve Block for Treatment of Low BackPain. Hayes; 2021. Accessed February 9, 2024 . www.evidence.hayesinc.com 13. Frank FT, Sawsan A. Chronic pelvic pain in adult females: treatment. UpToDate. Updated March 15, 2023. Accessed February 9, 2024 . www. uptodate.co m 14. Garza I, Schwedt TJ. Chronic migrain e. UpToDate. Updated September 5, 2023. Accessed February 9, 2024 . www. uptodate.com 15. Garza I. Occipital neuralgia. UpToDate. Updated February 7, 2023 . Accessed February 9, 2024 . www.uptodate.com 16. Gautam S, Gupta N, Khuba S, et al . Evaluation of the ef ficacy of superior cluneal nerve block in low back pain: a prospective observational study. JBodyw Mov Ther . 2022;30:221-225. doi:10.1016/j.jbmt.2022.03.001 17. Headaches in Over 12s: Diagnosis and Management . National Institute for Health and Care Excellence ; 2012 . CG150. Updated December 17, 2021. Accessed February 9, 2024 . wwww.ncbi.nlm.nih.gov 18. Health Technology Assessment: Genicular Nerve Block for the Management of Knee Pain . Hayes; 2020. Reviewed May 15, 2023. Accessed February 9, 2024 . www.evidence.haye sinc.com 19. Health Technology Assessment: Greater Occipital Nerve Blocks for Treatment of Migraine. Hayes; 2019. Reviewed October 10, 2022. Accessed February 9, 2024 . www.evidence.hayesinc.com 20. Health Techno logy Assessment: Local Injection Therapy for Cervicogenic Headache and Occipital Neuralgia. Hayes; 2017. Reviewed November 15, 2021. Accessed February 9, 2024 . www.evidence.hayesinc.com 21. Health Technology Assessment: Peripheral Nerve Field Stimulation for T reatment of Chronic Low Back Pain . Hayes; 2021. Reviewed March 16, 2023. Accessed February 9, 2024 . www.evidence.hayesinc.com 22. Hui J, Seko K, Shrikhande G, et al. A novel, nonopiod-based treatment approach to men with urologic chronic pelvic pain syndrome using ultrasound-guided nerve hydrodissection and pelvic floor musculature trigger point injections. Neurourol Urodyn . 2020;39(2):658-664. doi: 10.1002/nau.24242 23. Inan L, Inan N, Una l-Artik H, Atac C, Babaoglu G. Greater occipital nerve block in migraine prophylaxis: narrative review. Cephalagia . 2019;39(7):908-920. doi: 10.1177/0333102418821669 24. Isu T, Kim Ket al. Superior and middle cluneal nerve entrapment as a cause of low back pai n. Neurospine . 2018;15(1):25-32. doi:10.14245/ns.1836024.012 25. Jeng C L, Rosenblatt M A. Overview of peripheral nerve blocks. UpToDate. Updated December 6, 2023. Accessed February 9, 2024 . www.uptodate.com 26. Local Coverage Determinations : Nerve Blocks for Periph eral Neuropathy. Medicare Coverage Database; 2023. LCD ID L35249. Accessed February 9, 2024 . www.cms.gov 27. Local Coverage Determinations : Peripheral Nerve Blocks. Medicare Coverage Database; 2019. LCD ID L33933. Accessed February 9, 2024 . www.cms.gov 28. Local Coverage Determinations : Peripheral Nerve Blocks. Medicare Coverage Database; 2019. LCD ID L36850. Accessed February 9, 2024 . www.cms.gov Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 29. Nerve blocks. Johns Hopkins Medicine. Accessed February 9, 2024 .ww w.hopkinsmedicine.org 30. Matsumoto J, Isu T, Kim K, et al. Middle cluneal nerve entrapment mimics sacroiliac joint pain. Acta Neurochir . 2019;161(4):657-661. doi:10.1007/s00701-019-03861-0 31. Mustafa A, Brooks B, Leishear K, et al. A novel treatment approach for women with chronic pelvic pain syndrome leading to increased pelvic functionality. JWomens Health Gyn . 2020;7: 1-10. doi: 10.17303/jwhg.2020.7.402 32. Nielsen TD, Moriggl B, Barckman, Jet al. Randomized trial of ultrasound-guided superior cluneal nerve block . Reg Anesth Pain Med . 2019; 44(8):772-780. doi: 10.1136/rapm-2018-100174 33. Ornello R, Lambru G, Caponnetto V, et al. Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic r eview and meta – analysis. Expert Rev Neurotherapeutics . 2020;20(11):1157-1167. doi:10.1080/14737175.2020.1809379 34. Piltsis JG, Khazen O. Occipital neuralgia . American Academy of Neurological Surgeons. Accessed February 9, 2024 . www.aans.or g 35. Plavnik K, Tenaglia A, Hill C, et al. A novel, non-opioid treatment for chronic pelvic pain in women with previously treated endometriosis utilizing pelvic-floor musculature trigger-point injections and peripheral nerve hydrodissection. PM R . 2020;12(7):65 5- 662. doi: 10.1002/pmrj.12258 36. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on chronic pain management and the American Society of Regional Anesthesia and Pain Medicine . Anesthesi ology . 2010;112(4):810-833. doi: 10.1097/ALN.0b013e3181c43103 37. Shauly O, Gould DJ, Sahai-Srivastava S, Patel KM. Greater occipital nerve block for the treatment of chronic migraine headaches: a systematic review and meta – analysis. Plast Reconstr Surg . 2019;1 44(4):943-952. doi :10.1097/PRS.0000000000006059 38. Tu F F, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate. Updated March 15, 2023. Accessed February 9, 2024 . www. uptodate.com 39. Watson JC. Cervicogenic headache. UpToDate. Updated August 10, 2023. Accessed February 9, 2024 . www.uptodate.com 40. Wray JK, Dixon B, Przkora R. Radiofrequency ablation. StatPearls. StatPearls Publishing; 2024. Accessed January 30, 2024. www.ncbi.nlm.nih.gov GA-MED-P-2775306 Issue Date 02/15/2023 Approved DCH 04/04/2024
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Inhaled Nitric Oxide-GA MCD-MM-1187 07/01/2024 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, n ationally 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 s upplies 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, dysfunctio n 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 als o include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the 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 ………………………….. ………………………….. ………………………….. ……………………… 7 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 7 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 8 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 Inhaled Nitric Oxide-GA MCD-MM-1187Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectInhaled Nitric Oxide (iNO) B. BackgroundInhaled nitric oxide (iNO) is a lipophilic gas that is naturally produced in numerous cells in the body and readily absorbed across pulmonary membranes in the ventilated lung after inhalation. In the body, nitric oxide is involved in oxygen transport to the tissues, the transmission of nerve impulses , and other physiological activities. When adminis tered via inhalation, it is a potent endogenous vasodilator that induces relaxation of vascular and bronchial smooth muscle, vasodilation of blood vessels, and can increase the partial pressure of arterial oxygen. iNO was initially approved by the U.S. Foo d and Drug Administration (FDA) in 1999. A complete nitric oxide delivery system is comprised of a nitric oxide administration apparatus, a nitric oxide gas analyzer, and a nitrogen dioxide gas analyzer. Additional warnings and precautions were added in 20 13 , including rebound hypertension following abrupt discontinuation, hypoxia from methemoglobinemia, and airway injury from nitrous dioxide. Dilation of pulmonary vessels in well-ventilated lung areas redistributes blood flow awayfrom lung areas where ve ntilation/perfusion ratios are poor. iNO has been used in conjunction with ventilator support as a treatment of hypoxic respiratory failure associated with persistent pulmonary hypertension of the newborn (PPHN), in infants who are at term or near-term (gr eater than 34 weeks gestation) to improve oxygenation, and to decrease the need for extracorporeal membrane oxygenation (ECMO). Respiratory failure is a clinical state that is defined either by the inability to rid the bodyof carbon dioxide or establis h an adequate blood oxygen level. Acute respiratory failure is the most common clinical problem seen in term, near-term (born at 34 or more weeks of gestation), and pre-term (less than 34 weeks of gestation) infants admitted to neonatal intensive care uni ts. Acute respiratory failure is frequently associated with meconium aspiration syndrome, sepsis, pulmonary hypoplasia, and/or primary pulmonary hypertension of the newborn. Management of infants with respiratory failure includes administration of high concentrations of oxygen, hyperventilation, high-frequency ventilation, neuromuscularblockade, antenatal steroids for the prevention of respiratory distress syndrome, use of post-natal steroids to decrease inflammation, as well as iNO therapy.Clinical studies have shown that iNO is a selective pulmonary vasodilator without significant effects on the systemic circulation. There is scientific evidence that iNO therapy improves oxygenation and ventilation, reduces the need for extracorporeal membr ane oxygenation (ECMO), and lowers the incidences of chronic lung disease anddeath among infants with respiratory failure. Moreover, the literature indicates that iNO does not appear to increase the incidence of adverse neurodevelopmental, behavioral, or medical sequelae in these high-risk neonates. Infants with congenital diaphragmatic hernia (CDH) have not been shown to benefit from iNO therapy. Clark , et al (2000) Inhaled Nitric Oxide-GA MCD-MM-1187Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 concluded iNO does not lead to reduced ECMO use and Putnam , et al (2016) concluded iNO use in CDH may be associated with increased mortality. In preterm infants, the most common cause of acute respiratory failure is respiratory distress syndrome as a result of surfactant deficiency. According to the available literature, treatment of preterm i nfants usually entails exogenous surfactantadministration. A systematic review of the evidence (Barrington and Finer, 2003)concluded: “The currently published evidence from randomized trials does not support the use of inhaled nitric oxide in preterm inf ants with hypoxic respiratory failure.” Carey , et al (2018) also concluded, Off-label prescription of iNO is not associated with reduced in-hospital mortality among premature infants with respiratory distress syndrome (RDS). In an Agency for Healthcare Research and Qualitys assessment on Inhaled Nitric Oxidein Preterm Infants , Allen , et al (2010) systematically reviewed the evidence on the use of iNO in preterm infants born at or before 34 weeks gestation age who receive res piratory support. They searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Studies (CENTRAL) and PsycInfo in June 2010. They also searched the proceedings of the 2009 and 2010 Pediatric Academic Societies Meeting and ClinicalTrials.gov. T hey identified additional studies from reference lists of eligible articles and relevant reviews, as well as from technical experts. Questions were developed in collaboration with technical experts, including the chair of the upcoming National Institutes o f Health Office of Medical Applications of Research Consensus Development Conference. These researchers limited their review to randomized controlled trials (RCTs) for the question of survival or occurrence of bronchopulmonary dysplasia (BPD) , and for the question on short-term risks. All study designs were considered for long-term pulmonary or neurodevelopmental outcomes, and for questions about whether outcomes varied by subpopulation or by intervention characteristics. Two investigators independently scr eened search results and abstracted data from eligible articles. These investigators identified a total of 14 RCTs, reported in 23 articles, and 8 observational studies. Chronic Lung Disease (CLD) or BPD studies have shown that there is insufficient eviden ce to support iNO for the treatment of CLD or BPD. Mortality rates in the neonatal intensive care unit (NICU) did not differ for infants treated with iNO versus those not treated with iNO (RR 0.97 (95 % CI: 0.82 to 1.15)). Broncho-pulmonary dysplasia at 3 6 weeks for iNO and control groups also did not differ (RR 0.93 (0.86, 1.003) for survivors). A small difference was found between iNO and control infants in the composite outcome of death or BPD (RR 0.93 (0.87, 0.99)). There was inconsistent evidence abou t the risk of brain injury from individual RCTs, but meta – analyses showed no difference between iNO and control groups. These researchers found no evidence of differences in other short-term risks. There was no evidence to suggest a difference in the incid ence of cerebral palsy (RR 1.36 (0.88, 2.10)), neurodevelopmental impairment (RR 0.91 (0.77, 1.12)), or cognitive impairment (RR 0.72 (0.35, 1.45)). Evidence was limited on whether the effect of iNO varies by subpopulation or by characteristics of the ther apy (timing, dose and duration, mode of delivery, or concurrent therapies). The authors concluded that there was a 7% reduction Inhaled Nitric Oxide-GA MCD-MM-1187Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 in the risk of the composite outcome of death or BPD at 36 weeks PMA for infants treated with iNO compared to controls, but no r eduction in death or BPD alone. They stated that further studies are needed to explore subgroups of infants and to assess long-term outcomes including function in childhood. There is currently no evidence to support the use of iNO in preterm infants with r espiratory failure outside the context of rigorously conducted RCTs. To provide health care professionals, families, and the general public with a responsible assessment of currently available data regarding the benefits and risks of iNO in premature inf ants, the Eunice Kennedy Shriver National Institute of Child Health andHuman Development, the National Heart, Lung, and Blood Institute, and the Office of Medical Applications of Research of the National Institutes of Health (Cole , et al, 2011)convened a consensus-development conference. Findings from a substantial body of experimental work in developing animals and other model systems suggest that iNO may enhance lung growth and reduce lung inflammation independently of its effects on blood vessel resist ance. Although this work demonstrates biological plausibility and the results of RCTs in term and near-term infants were positive, combined evidence from the 14 RCTs of iNO treatment in premature infants of gestation of 34 weeks or less shows equivocal eff ects on pulmonary outcomes, survival, and neurodevelopmental outcomes. A National Institutes of Health Consensus Development Conference for inhaled nitric oxygen in premature infants (Cole, et al, 2010) recommended the following:1. Taken as a whole, t he available evidence does not support use of iNO in early routine, early rescue, or later rescue regimens in the care of premature infants
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Breast Reduction Surgery-GA MCD-MM-0253 07/01/2024 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 o f Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the cont rolling 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 fav orable 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 ………………………….. ………………………….. ………………………….. …… 6 F. Related Polic ies /R ules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 Breast Reduction Surgery-GA MCD-MM-0253Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectBreast Reduction Surgery B. BackgroundGynecomastia is the benign proliferation, either unilateral or bilateral, of glandular tissue of the breast in males. This develops most often in the setting of altered estrogen/androgen balance or increased sensitivity of breast tissue to estrogen. Causes may include androgen deficiency (eg , treatments for prostate carcinoma), con genital disorders (eg, Klinefelter Syndrome (47,XXY)), medication s (eg, estrogen replacement therapy, calcium channel blockers, cimetidine, phenothiazines, spironolactone, theophylline, highly active antiretroviral therapy), chronic medical conditions (eg, cirrhosis, chronic kidney disease), tumors (eg, adrenal or testicular) , or endocrine disorders (eg, hyperthyroidism). As a result of this hormonal imbalance , medica tion therapy may be offered in the treatment of gynecomastia (ie, anti-estrogens, androgens , or aromatase inhibitors). Women diagnosed with macromastia (or excessively large breasts) seeking breastreduction typically present with complaints of a feeling of heaviness, chronic pain , and tension in the neck, shoulders , and upper back. Macromastia commonly causes permanent grooving and ulceration of the shoulder following years of wearing support bras to try to minimize symptoms. The physical and psychological symptoms of macromastia c an significantly and negatively impact an individuals life and should be taken into consideration when evaluating surgical intervention. Reduction mammoplasty is a surgical procedure that reduc es the weight and volume ofthe breast. As much as two to five pounds of excess breast tissue is routinely removed during a reduction mammoplasty. Indications for surgery include chronic pain and skin symptoms , neuropathy, breast discomfort, physical impairm ent , and psychological symptoms that can be associated with poor self-esteem and loss of desire to engage in activities. C. Definitions Body Surface Area (BSA) A metric used for physiologic measurements, pharmacologic dosing, as well as for therapeutic c alculations, including the Schnur Sliding Scale for breast reduction surgery. Cosmetic Procedures Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic procedures. Functional/Physical or Physiological Impairment Impairment caus es deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired , or delayed capacity to move and coordinate actions , or perform physical activiti es exhibited by difficulties in one or more of the following areas: physical and motor tasks, independent movement, and performing basic life functions. Breast Reduction Surgery-GA MCD-MM-0253Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Intertriginous Rash Dermatitis occurring between juxtaposed folds of skin,caused by retention of moi sture and warmth and providing an environment favoring overgrowth of normal skin micro-organisms. Kyphosis Over-curvature of the thoracic vertebrae (upper back) associated with degenerative diseases , such as arthritis, developmental problems, or with ost eoporotic compression fractures of vertebral bodies. Macromastia (Breast Hypertrophy) An increase in the volume and weight of breast tissue relative to the general body habitus. Persistent Pubertal Gynecomastia The persistence of breast enlargement following the end of puberty and occasionally lasting into adulthood. Postpubertal Male Tanner sta ge Vmilestones have been completed . Precocious Puberty in Males Onset of secondary sexual characteristics before the age of nine. Pseudo-Gyne comastia Enlargement of the breast due to fat deposition (without glandular involvement), typically occurring in the setting of obesity. Pubertal Gynecomastia A benign process occurring most commonly between the ages of 10 to 14 , typically followed by regression in most cases. Pubertal Male Onset of secondary sexual characteristics that is measured using the Tanner stages; puberty includes stages II, III, and IV. Symptomatic Breast Hypertrophy A syndrome of persistent neck and shoulder pain, shoulder grooving from brassiere straps, chronic intertriginous rash of the infra – mammary fold , and/or frequent episodes of headache, backache, and upper extremity neuropathies caused by breast tissue volume and weight exceeding normal proportions. Schnur Sliding Scale An evaluation method promoted for use in calculating the amount of breast tissue to be removed in reduction mammoplasty (Appendix A). Tanner Stages Sexual maturity rating of secondary sexual characteristics. D. PolicyI. CareSource considers breast reduction surgery for gynecomastia medically necessary when ALL of the following clinical criteria are met: A. Member is at least 18 years old or older (or 18 months after the end of puberty, whichever occurs last ). B. The tissue being removed is glandular breast tissues and not the result of obesity, adolescence, or reversable effects of drug treatment that can be discontinued. Documentation should be maintained in the medical record. C. Documentation indicat es any condition associated with gynecomastia (eg, androgen deficiency, chronic liver disease that causes decreased androgen availaibilty, Klinefelter syndrome, adrenal tumors that cause androgen deficiency or increased secretion of estrogen, brain tumors that cause androg en deficiency, testicular tumors causing adrogen deficiency or tumor secretion of estrogen, or endocrine disorders such as hyperthyroidism ). D. Documentation supports that breast malignancy was ruled out. E. The use of liposuction to perform breast reduction is considered investigational Breast Reduction Surgery-GA MCD-MM-0253Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 and is noncovered.II. CareSource considers b reast reduction surgery for macromastia medically necessary when ALL of the following clinical criteria are met: A. Member is 18 years or older , or under 18 years with documented evidence that breasts have finished growing for a minimum of one year (parental/guardian consent is required for members under age 18 ). B. Breast size interferes with activities of daily living , as indicated by 1 or more of the following: 1. arm numbness consis tent with brachial plexus compression syndrome 2. cervical pain 3. chronic breast pain 4. headaches 5. nipple position greater than 21 cm below suprasternal notch 6. persistent redness and erythema (intertrigo) below breasts 7. restriction of physical activity 8. severe bra strap grooving or ulceration of shoulder 9. shoulder pain 10. thoracic kyphosis 11. upper or lower back pain C. Preoperative evaluation by surgeon concludes that the amount of breast tissue to be removed (by mass or volume) will provide a reasonable expectation of symptomatic relief. D. No evidence of breast cancer 1. As evidenced by results of a physical exam completed by a physician within the last year if under 40 . 2. Wom en 40 to 54 years of age or older must have documentation of a mammogram negative for cancer performed within the year prior to the date of the planned breast reduction surgery. 3. Women 55 years of age and older may switch to mammograms every 2 years . III. Breast reduction surgery following mastectomy to achieve symmetry is covered as part of the Womens Health and Cancer Rights Act (WHCRA). Please refer to theCareSource Medical policy titled Breast Reconstruction Post Mastectomy for additional information. IV. Schnur Sliding ScaleThe S chnur Sliding Scale is an evalu ation tool u sed to de termine the appr opriate volume of tissue to be r emoved relati ve to a members total body surface area ( BSA ). A. This esti mation can be instr umental in determining whet her br east reducti on sur gery is being planned for cos metic reas ons or as a medical ly neces sary procedure. In a s urvey of plastic s urgeons util izing this scale, Sc hnur , et al (1991) de termin ed t hat a member whose r emoved breast weight was abo ve the 22nd percentile were likely to recei ve the pro cedure for medi cal reasons. Breast Reduction Surgery-GA MCD-MM-0253Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 B. The weight of tiss ue to be r emoved from each brea st must be above t he 22nd percentile on the Sc hn ur Sliding Scale ( App endix A belo w) based on t he indi viduals BSA. C. The BSA in met ers s quar ed ( m2) is c alcula ted using the Mos teller f ormu la as follows: 1. Square root of the result of height (inches) multiplied by weight (lbs.) and divided by 3131. App endix A: Schnur Sliding Sca leBody Su rface Ar ea an d M inim um Re quirement for Breast Tissue R emoval Body Surface Area (m2)Gr ams per Br east of Minimum Breast T issue to be Remo ved 1.350-1.374 199 1.375-1.399 208 1.400-1.424 218 1.425-1.449 227 1.450-1.474 238 1.475-1.499 249 1.500-1.524 260 1.525-1.549 272 1.550-1.574 284 1.575-1.599 297 1.600-1.624 310 1.625-1.649 324 1.650-1.674 338 1.675-1.699 354 1.700-1.724 370 1.725-1.749 386 1.750-1.774 404 1.775-1.799 422 1.800-1.824 441 1.825-1.849 461 1.850-1.874 482 1.875-1.899 504 1.900-1.924 527 1.925-1.949 550 Breast Reduction Surgery-GA MCD-MM-0253Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 1.950-1.974 5751.975-1.999 601 2.000-2.024 628 2.025-2.049 657 2.050-2.074 687 2.075-2.099 717 2.100-2.124 750 2.125-2.149 784 2.150-2.174 819 2.175-2.199 856 2.200-2.224 895 2.225-2.249 935 2.250-2.274 978 2.275-2.299 10 22 2.300-2.324 10 68 2.325-2.349 11 17 2.350-2.374 11 67 2.375-2.399 12 19 2.400-2.424 12 75 2.425-2.449 13 33 2.450-2.474 13 93 2.475-2.499 14 55 2.500-2.524 15 22 2.525-2.549 15 90 2.550 or grea ter 16 62 E. Conditions of CoverageN/A F. Related Polic ies /R ulesBreas t Reconstruction Surgery Breast Reduction Surgery-GA MCD-MM-0253Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 G. Review/Revision HistoryDATE ACTIONDate Issued 04/02/2019Date Revised 04/15/2020 03/17/202103/16/202203/15/202306/21/2023 02/28/2024Annual Update: Update to MCG Health Clinical Indications; addition of Related Policies . Added male breast reduction surgery criteria. Updated references. Approved at PGC.Revised D.I, D.I.A., D.II. and D.II.A. Updated references. Approved at CommitteeRe moved II.C. Updated references. Approved at Committee. Revision: expanded policy to cover members under 18 years of age, removed definitions, and updated references. Approved at Committee. Date Effective 07/01/2024 Date Archived H. References1. Biro F M, Chan Y M. Normal puberty. UpToDate. Updated October 25, 2023. Accessed February 16, 2024. www.uptodate.com 2. Braunstein G D, Anawalt BD. Clinical features, diagnosis, and evaluation of gynecomastia in adults. UpToDate. Updated April 26, 2023. Accessed February 16, 2024. www.uptodate.com 3. Braunstein G D, Anawalt BD . Management of gynecomastia. UpToDate. Updated May 10, 2021. Accessed February 16, 2024. www.uptodate.com 4. Briefing paper: plastic surgery for teenagers. American Society of Plastic Surgeons. Accessed February 16, 2024. www.plasticsurgery.org 5. Fagerlund A, Lewin R, Rufolo G, et al. Gynecomastia: a systematic review. JPlast Surg Hand Surg . 2015;49(6):311-318. doi:10.3109/2000656X.2015.1053398 6. Guliyeva G, Cheung JY, Avila FR, et al. Effect of reduction mammoplasty on pulmonary function tests: a s ystematic review. Ann Plast Surg . 2021;87(6):694-698. doi:10.1097/SAP.0000000000002834 7. Hansen J, Chang S. Overview of breast reduction. UpToDate. Updated April 19, 2023. Accessed February 16, 2024. www.uptodate.com 8. Kanakis GA, Nordkap L, Bang AK, et al. EA A clinical practice guidelines – gynecomastia evaluation and management. Andrology . 2019;7(6):778-793. doi:10.1111/andr.12636 9. Kimia R, Magee L, Caplan HS, et al. Trends in insurance coverage for adolescent reduction mammoplasty. Am JSurg . 2022;224(4):1068-1073. doi:10.1016/j.amjsurg.2022.07.030 10. Knox JA, Nelson DA, Latham KP, et al. Objective effects of breast reduction surgery on physical fitness. Ann Plast Surg . 2018;80(1):14-17. doi:10.1097/SAP.0000000000001167 Breast Reduction Surgery-GA MCD-MM-0253Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 11. Lewin R, Liden M, Lundberg J, et al. Prospect ive evaluation of health after breast reduction surgery using the Breast-Q, Short-Form 36, Breast-Related Symptoms Questionnaire, and Modifed Breast Evaluation Form. Ann Plast Surg . 2019;83(2):143-151. doi:10.1097/SAP.0000000000001849 12. Morrison KA, Vernon R , Choi M, et al. Quantifying surgical complications for reduction mammaplasty in adolescents. Plast Reconstr Surg . 2023;151(3):376e – 383e. doi:10.1097/PRS.0000000000009905 13. Nuzzi LC, Firriolo JM, Pike CM, et al. The effect of reduction mammoplasty on quality of life in adolescents with macromastia. Pediatrics . 2017;140(5):e20171103. doi:10.1542/peds.2017-1103 14. Nuzzi LC, Pramanick T, Walsh LR, et al. Optimal timing for reduction mammoplasty in adolescents. Plast Reconstr Surg . 2020;146(6):1213-1220. doi:10.1097 /PRS.0000000000007325 15. Patel K, Corcoran J. Breast reduction surgery in adolescents. Pediatr Ann . 2023;52(1):e31-e35. doi:10.3928/19382359-20221114-06 16. Perdikis G, Dillingham C, Boukovalas S, et al. American Society of Plastic Surgeons evidence-based clinical practice guideline revision : reduction mammaplasty. Plast Reconstr Surg . 2022;149(3):392e-409e. doi:10.1097/PRS.0000000000008860 17. Perez-Panzano E, Gascon-Catalan A , Sousa-Dominguez R, et al. Reduc tion mammoplasty improves levels of anxiety, depression and body image satisfaction in patients with symptomatic macromastia in the short and long term. JPsychosom Obstet Gynaecol . 2017;38(4):268-275. doi:10.1080/0167482X.2016.1270936 18. Reduction mammoplast y. MCG. 28 th ed draft. Updated December 12, 2023. Accessed February 16, 2024. www.careweb.careguidelines.com 19. Taylor SA. Gynecomastia in children and adolescents. UpToDate. Updated June 10, 2022. Accessed February 16, 2024. www.uptodate.com 20. Womens Health a nd Cancer Rights Act (WHCRA). Centers for Medicare and Medicaid Services . Accessed February 16, 2024. www.cms.gov 21. Xia TY, Scomacao I, Duraes E, Cakmakoglu C, Schwarz G. Aesthetic, quality-of-life, and clinical outcomes after inferior pedicle oncoplastic re duction mammoplasty. Aesthetic Plast Surg . 2023;47(3):905-911. doi:10.1007/s00266-023-03257-7 22. Zeiderman MR, Kelishadi SS, Tutela JP, et al. Reduction mammoplasty: intraoperative weight versus pathology weight and its implications . Eplasty . 2017;17:e32. Accessed February 16, 2024. www.pubmed.ncbi.nlm.nih.gov GA-MED-P-2775306 Issue Date 04/02/2019 Approved DCH 04/04/2024
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Trigger Point Injections-GA MCD-MM-0221 07/01/2024 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 o f Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the cont rolling 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 fav orable 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-GA MCD-MM-0221Effective Dat e: 07/01/2024The 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, standi ng , 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 i s responsive to appropriate treatment. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor. The purpose of a trigger point injection (TPI) is to treat not only the symptom but also the cause through the injection of a single substance (e g, a local anesthetic) or a mixture of substances (e g, 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 within their scope of practice who are qualified to deliver these health services.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Subacute Pain Pain that has lasted between 4 weeks and 12 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 (i e, increased pain, inability to physic ally perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. 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 Injection A. Trigger point injections of anesthetic and/or corticosteroid for back pain, neck pain, or myofascial pain syndrome will be considered medically necessary when pain has persisted despite appropriate medical management and ALL the following criteria are met: Trigger Point Injections-GA MCD-MM-0221Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 1. Patient presents with new (acute or subacute) localized pain, occurring in the last 3 months . 2. Patient has been refractory or intolerant of conservative therapies for at least 1 month, including at least ONE 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 manage ment (usually short term) plan, including at least ONE 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 ONE of the following : a. non-steroidal anti-infammatory drugs (NSAIDS ) b. muscle relaxants c. non-narcotic analgesics d. anti-depressants 5. The patient must have a diagnosis for which the trigger point injection is an appropriate treatment; ALL the following information must be documented in the patient’s medical record: 1. proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point 2. reason (s) for select ing this therapeutic option 3. affected muscle or muscles 4. muscle or muscles injecte d and the number of injections 5. frequency of injections required 6. name of the m edication used in the injection 7. results of any p rior treatment 8. 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. For trigger point injections of a local anesthetic or a steroid, payment will be made for no more than 8 dates of service per calendar year per patient . Trigger Point Injections-GA MCD-MM-0221Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 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. III. There is no laboratory or imag ing 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 clai m 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 indica tion on the claim (e g, in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. D. Dry needling is not an acceptable alternative to trigger point injections by an appropriately licensed clinician. E. Conditions of CoverageN/A F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 02/08/2018Date Revised 03/06/2019 Annual Update: No changesTrigger Point Injections-GA MCD-MM-0221Effective Dat e: 07/01/2024The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 05/13/202009/01/202005/26/202104/15/2022 03/29/202302/28 /2024Annual Update and Revision: PA is required for each trigger point injection. Revisions include: such as was changed to ONE of the following : I. B. 2. and 3. Annual Update: Removed PA language. Annual Review. Updated references, formatting, split policy into initial and subsequent injections, added conservative care modalities Annual review: updated references, added definition and payment information . Approv ed at Committee. Annual review: editorial changes and updated references. Approved at Committee. Date Effective 07/01/2024 Date Archived 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 June 10, 2021. Accessed February 6, 2024. www.uptodate.com 3. Gerwin R. Myofascial trigger point pain syndromes. Semin Neurol . 2016;36(5):469 – 473. doi:10.1055/s-0036-1586262 4. Hammi C, Schroader JD, Yeung B. Trigger point injection. StatPearls . StatPearls Publishing; 20 24. Updated July 24, 2023. Accessed February 6, 2024. 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 January 12, 2024. Accessed February 6, 2024. 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 s yndrome. UpToDate . Updated September 27, 2022. Accessed February 6, 2024. www.uptodate.com 9. Moynihan LK, Elkadry E. Myofascial pelvic pain syndrome in females: treatment. UpToDate . Updated January 11, 2023 . Accessed February 6, 2024 . www.uptodate.com 10. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate . Updated March 15, 2023. Accessed February 6, 2024 www.uptodate .com GA-MED-P-2775306 Issu e Date 02/08/2018 Approved DCH 04/04/2024
MEDICAL POLICY STATEMENTGeor gia Medicaid Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 07/01/2024 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 wit hout which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a bo dy 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 o f Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the cont rolling 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 fav orable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………. 3 D. Policy ………………………….. ………………………….. ………………………….. ……………….. 4 E. Conditions of Coverage ………………………….. ………………………….. …………………. 13 F. Related Policies/Rules ………………………….. ………………………….. …………………… 14 G. Review/Revision History ………………………….. ………………………….. ………………… 14 H. References ………………………….. ………………………….. ………………………….. ……… 14 Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectApplied Behavior Analysis for Autism Spectrum Disorder B. BackgroundThe Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition, Text Revised (DSM-5-TR) classifies Autism Spectrum Disorder (ASD) as a neurodevelopmental disorder vary ing widely in severity and symptoms, depending on the developmental level and chronological age of the individual . ASD is characterized by specific developmental deficits that affect socialization, communication, academic , and personal functionin g. Individuals are typically diagnosed before entering grade school, and symptoms are noticed across multiple contexts, including social reciprocity, nonverbal communicative behaviors, and skills in developing, maintaining , and understanding relationships. Restricted, repetitive patterns of behavior, interests , or activities are also often present. Currently, no cure exists for ASD, nor is there any single treatment for the disorder. Thediagnosis may be managed through a combination of therapies, including behavioral,cognitive, pharmacological, and educational interventions with a goal of minimiz ing the severity of ASD symptoms, maximiz ing learning , facilitat ing social integration, and improv ing quality of life for members and families/caregivers. Applied behavior analysis (ABA) , one such therapy, is an evidence-based practice that may be provided in centers or at home . ABA is based on the science of behavior, which was founded on the premise thatunderstanding behavior functioning, how it is affected by the environment, and how learning to change behavior can improve the human condition. It is a flexible treatment in that it should always b e adapted to the needs of the individual, teaches skills that are useful and generalizable, and involves individual, group and family training. Qualified and trained practitioners provide and/or oversee ABA programs and are accountable to state boards for registration, certification, or licensure requirements. Clinical decisions on telehealth service delivery models should be selected based on the individual needs, strengths, preference of service modality, caregiver availability and environmental support a vailable. CareSource follows the Georgia Department of Community Health (DCH) Division of Medicaid and applicable state and federal laws in the provision of ABA services, which are based on a diagnosis from the Diagnostic and Statistical Manual of MentalDisorders, 5 th ed., Text Revised (DSM-5-TR). Severity levels are divided into two domains, social communication and restricted, repetitive behaviors, and are defined by the DSM-5-TR as follows: Severity Levels for Autism Spectrum DisorderSeverity Leve l Social Communication Restricted, Repetitive Behaviors Level 3 Requiring very Severe deficits in verbal & nonverbal social communication Inflexibility of behavior, extreme difficulty c oping with change, or Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 substantial support skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. other restricted/ repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action. Level 2 Requiring substantial support Marked deficits in verbal and nonverbal social c ommunication skills, social impairments apparent even with supports in place, limited initiation of social interactions, and reduced or abnormal responses to social overtures from others. Inflexibility of behavior, difficulty coping with change, or other restricted/ repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action. Level 1 Requiring support Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in soc ial interactions. Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence. C. Definitions Applied Behavior Analysi s The design, implementation, and evaluation or systematic instructional and environmental modifications by a behavior analyst to produce socially significant improvements in behavior. Autism Spectrum Disorder (ASD ) DSM-5-TR disorder with identified diagnostic criteria and associated severity levels characterized by persistent deficits in social communication /interaction across multiple contexts and the presence of restricted, repetitive patterns of behavior, interests, or activities causin g significant impairment. Behavioral Assessmen t Separate from the initial diagnostic evaluation , the administration of an industry-standard assessment tool for skill acquisition and/or behavior reduction required to substantiate future tre atment services. Caregiver/Family Training Training taught by a therapist to parents/caregivers on how to implement methods utilized in a clinical setting into other environments, such as the home or community, to maximize outcomes furthering generalization of skills, and maximizing and reinforcing methods being taught. Plan of C are (POC ) A document submitted for authorizatio n of treatment services that includes member goals, background, parent/caregiver training and other criteria associated with treatment. Qualified Health Care Professional (QHCP) An individual licensed, certified, or permitted to provide ASD services and enrolled with Georgia Medicaid , including physicians, psychologists, BCBA-D, or a BCBA . Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 Supervisio n The direct clinical review, for the purpose of training or teaching, by a physician, psychiatrist, BCBA-D, or BCBA to promote the development of the practitioners skills. D. PolicyI. General Guidelines A. Medical review must be submitted with appropriate do cumentation as indicated in this policy and align with the States definition of medical necessity that includes that treatment is not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or d iagnostic results. Along with this policy, CareSource utilizes the following resources for the provision of ABA therapy: 1. Autism Spectrum Disorder Services Manual provided by Georgia Department of Community Health Division of Medicaid 2. MCG Health B. The following providers are authorized to deliver ABA services: 1. Licensed physician may supervise BCaBAs and RBTs 2. Licensed psychologist may supervise BCaBAs and RBTs 3. Board Certified Behavioral Analyst Doctoral Level (BCBA-D) may supervise BCaBAs, RBTs and other implementing ABA interventions 4. Board Certified Behavior Analyst (BCBA) may supervise BCaBAs and RBTs 5. Board Certified Assistant Behavior Analyst (BCaBA ) must be supervised by a physician, psychologist, or BCBA /BCBA-D but may super vise RBTs and may not be the enrolled QHCP 6. Registered Behavior Technician must be supervised by a BCBA/BCBA-D or BCaBA and may not be the enrolled QHCP C. Eligibility 1. Member is under the age of 21 and must be able to participate in sessions. 2. Behaviors must be exhibited and present as clinically significant health or safety risks to self or others or significantly interfe re with basic selfcare, communication, or social skills . 3. Parent/c aregivers must be able to participate in ABA therapy and have the ability to implement ABA techniques in the home environment. If unwilling or unable, consideration will be given to other modalities of treatment . D. Diagnos tic Evaluation s Evaluations should be comprehensive with multiple informants, covering multi ple domains , and m ust be completed prior to requesting prior authorizations (PAs) for behavioral assessment or treatment services . Primary hearing deficits, speech disorder, and heavy metal poisoning must be ruled out as causal reasons for behavior. The following guidelines apply to the diagnostic evaluation: 1. Documentation must be established by the following practitioner: a. licensed physician or psychologist b. other licensed professional as designated by Medical Composite Board Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 2. Completion of one acceptable evidence-based tool and one caregiver tool (a list can be located in the Georgia Autism Spectrum Disorder Services Policies and Procedures Manual ). 3. Initial evaluation results should be sub mitted in report format with a summary of each individual evaluation instrument, developmental history, and present concerns , include the following information: a. date completed b. minimum of 2 assessment tools , including 1 clinician tool and 1 caregiver tool with a summary of each individual assessment c. any t ests administered with scores d. evaluators name , signature, and credentials E. Diagnostic Reevaluations A diagnostic reevaluation , which must include, at a minimum, 1 clinician observational assessment (school psychoeducation assessments are not acceptable), that re confirm s the diagnosis may be required in certain conditions as outlined in the Georgia Autism Spectrum Disorder Services Policies and Procedures M anual , including the following: 1. The diagnosis of ASD is provisional. 2. No formal neuropsychological evaluation was completed. 3. The initial diagnosis is at least 5 years old with no evidence of ongoing assessment and treatment. II. Authorization of ServicesCareSource considers ABA services , both the behavioral assessment and treatment services, medically necessary when the following criteria are met , and these service authorizations are to be completed separately : A. Behavioral Assessment (BA) Prior Authorization (PA) 1. Authorization may be requested in 3-month increments and completed one time during the 6-month treatment author ization period no more than 2 months prior to the effective date of the next treatment authorization . 2. PA must be requested by the enrolled QHCP . 3. The BA is c onducted by a n independent practitioner who also develop s a treatment plan before services are provided . Comprehensive behavioral assessments are not to exceed 8 hours every 6 months unless additional justification is provided. 4. BA will assess the following: a. sk ill acquisition, which may include: 01. Verbal Behavior Milestones and Assessments Placement Program (VB-MAPP) 02. Assessment of Basic Language and Learning Skills-Revised (ABLLS-R) 03. Assessment of Functional Living Skills (AFLS) 04. Promoting the Emergence of Advanced Knowledge Generalization (PEAK) 05. Skills assessment Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 b. maladaptive behavior, which may include:01. functional behavioral assessment s 02. traditional functional analyses 03. Interview-Informed Synthesized Contingency Analysis (IISCAs) 5. Summarized re sults will be used to develop interventions in the form of a plan of care (POC) , a required document for treatment service authorization . 6. Behavior analysts, with appropriate consent, shou ld conduct record reviews of all available data at the outset of receiving members from other facilities; however, BAs and treatment plans must be developed by the current provider. a. A behavior analyst should not submit B As and treatment plans that are the work product of another b ehavior analyst to obtain a PA. b. If a member transfers to another provider within the same company during a period covered under an active PA, the behavior analyst receiving the transferred member must review and attest that the treatment plan has been appr oved. 7. Authorization request d ocumentation should include the following: a. diagnostic evaluation b. Letter of Medical Necessity (LMN) c. individualized Family Service Plan , if applicable d. Individual Education Plan (IEP), if applicable e. previous hospitalization or out-of-home placement documents , if applicable f. Medicaid Cover Page (see Georgia Autism Spectrum Disorder Services Policies and Procedures M anual ) g. any other clinical documentation needed to support the plan of care as supported by best practices (eg, behavioral, psychological or medical history, evidence of previous therapies with results, history of symptom intensity that demonstrates how the member s ability to function in various setting is impacted) B. Treatment Services Prior Authorization (PA) 1. Authorization may be requested in 6-month increments . 2. Documentation should include the following: a. diagnostic evaluation b. Letter of Medical Necessity (LMN ) c. descriptive results of the BA, conducted/dated no more than 2 months prior to the treatment services PA effective date d. proposed Plan of Care (POC) e. updated data collected during previous treatment authorizations , if not initial request f. individualized Family Service Plan , if applicable g. Individual Education Plan (IEP), if applicable h. previous hospitalization or out-of-home placement documents , if applicable i. progress notes , if applicable Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 j. Medicaid Cov er Page (see Georgia Autism Spectrum Disorder ServicesPolicies and Procedures Manual ) k. any other clinical documentation needed to support the POC as supported by best practices 3. Medical necessary will determine approved hours per week (eg, typically 10 – 30 hours) but should be commensurate with skill deficit or behavioral excesses as identified in the BA. 4. Active parent/caregiver participation and involvement is required to increase behavior improvement in behaviors identified as causing lim itations or deficits in functional skills . C. Follow-up service PA requests , following the initial treatment PA , must include the following: 1. a summary of previous goals and progress 2. results of a recent BA within the previous 2 month s 3. individualized goals for the member and parent/ caregivers as described in the practice guidelines for treatment of ASD developed by the Behavior Analyst Certification Board (BACB) III. Plan of Care (P OC)The POC must be submitted for review and authorization of treatment services and must comply the following provisions: A. It should include a clear connection between the results of the BA to specific goals developed for the member. B. Goals should highlight ar eas in need of remediation, focusing on functional skills related to core deficits of ASD. C. Baseline data, measurement and mastery criteria should be included and address core deficits as described in the practice guidelines for treatment set forth by the B ACB . D. Treatment must 1. demonstrate that interventions are not custodial or maintenance-oriented in nature 2. include coordination across all providers, supports, and resources, particularly that applicable community resources have been identified and engaged 3. include c riteria and specific behavioral goals and interventions for lesser intensity of care and discharge 4. identify parent, guardian, and/or caregiver involvement in prioritizing target behaviors and training in behavioral techniques to provide a dditional supportive interventions 5. provide evidence/support for reasonable expectation that the member can benefit from services provided IV. Parent/ Caregiver TrainingTraining will evolve as goals are met. Parent/caregiver(s) must actively work on at least one unmet goal with the provider documenting and tracking 2-4 goals. The Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 plan of care must include documentation of the following:A. parent/caregiver (s) understanding and agreement to comply with the require ments of treatment B. how the parent/caregiver (s) will be trained in skills g eneraliza ble to the home and other environments , how the treatment goas are addressed when providers are not present, and overall skill abilities C. methods by which the parent/caregive r(s) will demonstrate trained skills (presence during sessions is not sufficient for a goal or method of training ) D. barriers to parent involvement and how those are being addressed ( eg, parents having the skills to assist with generalization of skills developed by the member) E. training and time involvement, including any materials or meetings occurring on a routine basis V. Discontinuation of ABA TherapyTitration and/or discontinuation of ABA therapy should occur when the following conditions are met (not an all-inclusive list): A. Treatment ceases to produce significant meaningful progress or maximum benefit has been reach ed . B. Member behavior does not demonstrate meaningful progress for two successive 6-month authorization periods as demonstrated via standardized assessments. C. ABA therapy is making symptoms, behaviors or impairments worse. D. Symptoms have stabilized, allowing m ember transition to a less intensive type of treatment or level of care to manage symptoms. E. Parent/caregiver(s) have refused treatment recommendations, are unable to participate in the treatment program, and/or do not follow through on treatment recommenda tions to an extent that compromises the effectiveness of the services for member progress. VI. Other Documentation RequirementsThe State of Georgia and DCH enacts code and establishes guidelines related to requirements for documentation expectations for client records maintained for third party billing. Each dated entry in the professional record is maintained for a period of not less than 5 years after the last date of service or not less than the length of time required by other regulat ions if longer , including those outlined by Centers for Medicare and Medicaid Services (CMS) and Health Insurance Portability and Accountability Act (HIPAA) . All written, electronic and other records will be stored and disposed of in such a manner as to en sure confidentiality . General documentation requirements are included in Caresources policies Behavioral Health Service Record Documentation Requirement and Medical Record Documentation Standards for Practitioners. DCH outlines the following minimum st andards for records, including: A. complete medical file with sufficient information to validate the diagnosis and establish the basis for treatment , including, at a minimum, the following: 1. member name or other information related to identification ( eg, soci al security number, medicaid identification number, date of birth) Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.9 2. date and time of admission3. admitting, and then, verified diagnosis 4. name, address, telephone number of emergency contact 5. appropriate authorizations and consents for procedures and treatment 6. medical necessity of the service(s) being provided 7. results of any testing and/or assessments, including previous testing 8. records or reports from previous or current providers 9. documented correlation between assessed need and care plan 10. documentation of treat ment that supports billing and clear evidence that the services billed are the services provided 11. financial and insurance information 12. pertinent medical information with physician, nursing, other practitioner , and case management progress notes 13. any treatment and medication orders 14. date and time o f discharge or death and/or condition on discharge B. plan of care that includes clear and specific coordination with all providers involved in treatment with individualized expectations and the following: 1. individualized expectations 2. prescribed services 3. service frequency 4. scope and duration of treatment 5. measurable goals to be achieved C. progress notes that are legible, detailed, complete, signed and dated, including 1. signatures must be legible, original , and belonging to the person creating the signature 2. if illegible, the name should be printed as well as signed 3. signatures must be dated the actual date signed 4. rubber stamps are not acceptable but electronic signatures are acceptable in certain circumstances (see Part I Policies and Procedures for Medicaid/Peachcare for Kids , Section 106, General Conditions of Participation) D. corrections should be made by striking one line through the error, writing the correction, and including the initials of the person making the correction along with the date the correction is made (whiteout or any such product is unacceptable) E. back-dated records are not allowed, as records sho uld be documented in real – time VII. Codes of ConductCodes of conduct exist to meet credentialing needs of professionals but also function to protect members by establishing, disseminating, and managing professional standards. Additionally, the State o f Georgia mandates requirements for providers within the profession to comply with and train in standards and ethics . CareSource supports professional standards established by licensing and credentialing bodies, and therefore, encourages professional compl iance to any and all standards across Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.10 disciplines for the protection of members and families. The ethics code written by the Behavior Analyst Certification Board includes the following standards (not all-inclusive): A. Family oversight must occur by/with the BCBA or BCaBA. An RBT may be present during a family training session to provide assistance with interventions, but the training or supervision of interventions cannot be completed by the RBT. B. Providers will create a contract for consent to services ( eg, Declaration of Professional Practices and Procedures) at the onset of services that defines and documents, in writing, the professional role with relevant parties. C. Appropriate effort will be made to involve members and stakeholders in treatment, including selecting goals, designing assessments and interventions, and conducting continual progress monitoring. D. Providers will identify and address environmental conditions ( eg, behavior of others, hazards to client or staff) that may interfere with service delivery, including the identification of effective modifications to interventions and appropriate documentation of conditions, actions taken, and eventual outcomes. E. Continuit y of services will be facilitated to avoid interruption or disruption of services for members, including documentation of actions taken and eventual outcomes. F. Providers will address any possible circumstances when relevant stakeholders are not complying wi th the behavior-change intervention(s) despite documented and appropriate efforts to address barriers to treatment. VIII. Supervision ExpectationsThe State of Georgia and DCH enacts codes and guidelines with requirements for supervision and documentat ion. Supervision does not require the supervisor to be present at the work site with the supervisee. If there are any discrepancies with supervision documentation, the associated claims are subject to recoupment. At a minimum, supervision must include the following and records maintained by the supervisor and supervisee to be submitted for auditing upon request: A. GA DCH requirements (at a minimum): 1. duration and type of supervision session 2. brief summary of pertinent activity for each session B. The BACB outlines the following minimum provisions for supervision documentation: 1. RBTs must document the following during supervision (not all-inclusive): a. days and times behavior-analytic services were provided b. dates and duration of supervision c. supervision format (individual, group) d. dates of direct observation e. names of supervisors providing supervision f. noncertified RBT supervisor form, if applicable g. proof of supervisors relationship to the client h. additional documenta tion in the event of discrepant records (session notes) Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.11 2. Supervisors must document the following for any supervision hours conducted (not an all-inclusive list):a. date with start and stop times b. fieldwork type c. supervision type (group, indi vidual) d. activity category (restricted or unrestricted) e. summary of supervision activity, including 01. discussion of activities completed during independent hours and any feedback provided 02. progress toward individual member goals 03. outcome of supervision, including any modification to treatment interventions or plans of care 04. collaboration of care among providers f. dated signatures of supervisor and supervisee, including credentials 3. Observations must include the following (at a min imum): a. date with start and stop times b. fieldwork type c. setting name d. supervisor name e. activity category (restricted or unrestricted) C. QHCPs are required to follow DCH guidance regarding delegation of work, including the following: 1. QHCP s are responsible for all delegated work performed by any supervisee. 2. QHCPs will not delegate professional responsibilities to a person not qualified to provide those services. Responsibilities, even with appropriate levels of supervision, must be within the su pervisees scopes of practice. 3. QHCP must have education completion and training on supervision rules, professional ethics, standards of practice, and certification guidelines. 4. QHCPs are responsible for determining competency of supervisee and will provide specific instructions regarding limits of the supervisees role. 5. Any QHCP contracts for independent contractors must maintain compliance with DCH policies, including Medicaid enrollment requirements. IX . Special Provisions Related to RBTsA. Current Standards for RBTs1. RBT services must be supervised by a qualified RBT supervisor (BCBA,BCBA-D, or BCaBA) . RBTs may not be the enrolled QHCP and must obtain ongoing supervision for a minimum of 5% of the hours spent providing ABA services per month. 2. An RBT certified by the National Behavior Analyst Certification Board may provide ABA under the supervision of an independent practitioner if enrolled in the Medicaid program and affiliated with the organization under which he/she is employed o r contracted. If the independent practitioner leaves the affiliated organization and no longer provides supervision, the RBT may not continue to provide services under that independent practitioner. Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.12 Additionally, if the RBT leaves the affiliated organizati on and no longer receives mandated supervision, the RBT may not continue to provide services to the member. 3. RBTs must use appropriate modifiers that indicate qualifications of staff delivering services. B. Upcoming RBT Changes from the Behavior Analyst Certification Board 1. Effective January 1, 2026 : In the interest of consumer protection, the BACB Board of Directors approved a recommendation that RBT supervisors must hold BCBA or BCaBA certification. Non certified supervisors will not be allowed to provide BACB-required supervision to RBTs. During this transition, RBT Requirements Coordinators who currently attest to the qualifications of noncertified supervisors should make preparations to ensure continui ty of care for clients. 2. Effective January 1, 2026 : New rules regarding eligibility for and maintenance of certification for RBTs were adopted by the BACB Board of Directors and can be located in the BACB Newsletter: December 2023 at www.bacb.com. X. ExclusionsAB A is not covered in the following circumstances: A. rehabilitative services (eg, community psychiatric supportive treatment, therapeutic behavioral service, and psychosocial rehabilitation service ) for the provision of AB A B. reimbursement is not permitted under any of the following situations: 1. any services not documented in the treatme nt plan 2. behavioral methods or mode s considered experimental 3. educatio nal-related services or activities described under Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. 1400 (IDEA) 4. vocational services in nature or those available through program s funded under Section 110 of the Rehabilitation Act of 1973 5. component s of adult day care programs C. treatment solely for the benefit of the family, caregiver or therapist D. treatment solely focused on recreational or educational outcomes E. goals focused on academic targets ( eg, treatment should address autistic symptoms impeding deficits in the home environment, such as reduction of frequency of self-stimulatory behavior to follow through with toilet training or completing a mathematic sorting task) F. treatment un expected to cause measurable , functional improvement or im provement is not documented G. duplicative therapy services addressing the same behavioral goals using the same techniques as the treatment plan, including services under an IEP H. services provided by family or household members I. care primarily custodial in nature and not requiring trained/professional ABA staff J. shadow ing , para-professional, or companion services in any setting K. personal training or life coaching Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.13 L. services more costly than an alternative service (s) , which are as likely to produce equivalent diagnostic or therapeutic results for the member M. program s or service s performed in nonconventional settings , even if performed by a licensed provider, including spas/resorts , vocational or recreational settings , Outward Bound , and wilderness cam p or ranch programs E. Conditions of CoverageI. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. II. When a member has other insurance, Medicaid is always the payer of last resort.CareSource will not pay more than the Medicaid rate totals for service. The p rimary payer must provide evidence of determinations for consideration of Medicaid coverage for services. III. CareSource reserves the right to request supervision documentati on .IV. Providers a gree to bill Medicaid for only those services rendered by the provider or by a Qualified Health Professional under the provider s direct supervision . Under no circumstances may a provider bill for services rendered by another practitioner w ho is enrolled or eligible to enroll as a provider. All services are to be billed with modifiers specific for practitioner level and service delivery setting/modality , as follows: Practioner Level Legend Physician, Psychiatrist U1 Level 1 Psychologist, BCBA-D U2 Level 2 BCBA U3 Level 3 BCaBA U4 Level 4 RBT U5 Level 5 V. Providers a gree to bill Medicaid the procedure code(s) which best describes theservice rendered and not to bill under separate procedure codes for services included under a single procedure code. Coding of both diagnoses and procedures is required for all claims and must be to the highest level. VI. Both codes and modifiers can be found in the Georgia Autism Spectrum DisorderServices Policies and Procedures Manual. The maximum daily units per procedure code as mandated by CMS and published by the State of GA is as follows: Procedure Code Max Units Per Day97151 32 97152 16 97153 32 Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.14 97154 1897155 24 97156 16 97157 16 97158 16 0362T 16 0373T 32 F. Related Policies/RulesI. CareSource Documents A. Medical Necessity Determination Standards B. Behavioral Health Service Record Documentation Standards II. Other SourcesA. Health Insurance Po rtability and Accountability Act (HIPAA) of 1996 B. Diagnostic, screening, preventive, and rehabilitative services , 42 C .F.R. 440.130(c) (2023) C. Definitions, 42 U.S.C. 1396d (2019) G. Review/Revision HistoryDATE ACTIONDate Issued 11/29/2017Date Revised 04/19/2018 04/01/202004/28/202112/01/202104/27/202204/12/2023 03/13/2024 04/24/2024Addition of qualified healthcare profession re: final diagnosis criteria . Section III. DiagnosisUpdated policy. Annual review. Updated medical necessity criteria, exclusions, discontinuation criteria, and added in language from GAMMIS. Clarified documents referenced. Title change Removed telehealth exclusion Changed assessment from 3 to 5 years; removed Appendix G; added note D.2.k. Updated definitions. Reorganized. Approved at Committee. Annual review. Expanded background. Added sections VII-X. Added sections VII X & MUE information to Cond of Coverage sect ion . Updated H. A pproved at Committee . Added II.A.5. GAMMIS update 4/1/24. Approved at Committee. Date Effective 07/01/2024 Date Archived H. References1. 2024 Q 2 NCCI MUE Edits-Practitioner Services . Centers for Medicare and Medicaid Services. Updated March 1 , 202 4. Accessed March 12 , 2024. www.cms.gov Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.15 2. Anglim M, Conway EV, Barry M, et al. An initial examination of the psychometric properties of the Diagnostic Instrument for Social and Communication D isorders(DISCO-11) in a clinical sample of children with a diagnosis of autism spectrum disorder. Ir JPsychol Med . 2022;39(3):251-260. doi:10.1017/ipm.2020.100 3. Applied Behavior Analysis: B-806-T. MCG. 28th ed. Updated March 14 , 2024 . Accessed April 11, 2024 . www.careweb.careguidelines.com 4. Augustyn M. Autism spectrum disorder in children and adolescents: evaluation and diagnosis. UptoDate. Updated May 16, 2022. Accessed February 19, 2024. www.uptodate.com 5. Augustyn M. Autism spectrum disorder (ASD) in children and adolescents: terminology, epidemiology, and pathogenesis. UptoDate. Updated January 24, 2024. Accessed February 19, 2024. www.uptodate.com 6. Augustyn M, Von Hahn E. Autism spectrum disorder in children and and adolescents: clinical features. UptoDate. Updated May 17, 2023. Accessed February 19, 2024. www.uptodate.com 7. Autism spectrum disorder. American Academy of Pediatrics. Updated April 5, 2023. Accessed February 19, 2024. www.aap.org 8. Autism spectrum disorder i n young children: screening. U.S. Preventive Services Task Force; 2016. Accessed February 19, 2024. www.uspreventiveservicestaskforce.org 9. Autism Spectrum Disorders: M-7075. MCG. 28th ed. Updated March 14, 2024 . Accessed Ap ril 11, 2024 . www.careweb.careguidelines.com 10. Autism Spectrum Disorders: B-012-HC. MCG. 28th ed. Updated March 14, 2024 . Accessed April 11, 2024 . www.careweb.careguidelines.com 11. Autism Spectrum Disorders, Adult, Inpatient Care: B-012-IP. MCG. 28th ed. Updated March 14 , 2024 . Accessed April 11, 2024 . www.careweb.careguidelines.com 12. Autism Spectrum Disorders, Child or Adolescent: B-019-IP. MCG. 28th ed. Updated March 14, 2024 . Accessed April 11, 2024 . www.careweb.careguidelines.com 13. Autism Spectrum Disorders, Intensive Outpatient Program: B-012-IOP. MCG. 28th ed. Updated March 14, 2024 . Accessed April 11, 2024 . www.care web.careguidelines.com 14. Autism Spectrum Disorders, Outpatient Care: B-012-AOP. MCG. 28th ed. Updated March 14, 2024 . Accessed April 11, 2024 . www.careweb.careguidelines.com 15. Autism Spectrum Disorders, Partial Hospitalizatio n Program: B-012-PHP. MCG. 28th ed. Updated March 14, 2024 . Accessed April 11, 2024 . www.careweb.careguidelines.com 16. Autism Spectrum Disorders, Residential Care: B-012-RES. MCG. 28th ed. Updated March 14, 2024 . Accessed April 11, 2024 . www.careweb.careguidelines.com 17. BACB Newsletter . Behavior Analyst Certfication Board; September 2023. Accessed February 23, 2024. www.bacb.com 18. BACB Newsletter: Introducing the 2026 RBT Examination and Cert ification Requirements . Behavior Analyst Certification Board; December 2023. Accessed February 23, 2024. www.bacb.com Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.16 19. Bak M, Plavnick J, Dueas A, et al. The use of automated data collection in applied behavior analytic research: a systematic review. Behav ior Analysis: Res Practice.2021;21(4), 376 405. https://doi.org/10.1037/bar0000228 20. Board Certified Behavior Analyst Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed February 19, 2024. www.bacb.com 21. Board Certified Assistant Behavior Analyst Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed February 19, 2024. www.bacb.com 22. Buckley A, Hirtz D, Oskoui M, et al.; Guideline Development, Dissemination, and Implementation Subcommittee of the Am erican Academy of Neurology. Practice guideline: treatment for insomnia and disrupted sleep behavior in cihldre n and adolescents with autism spectrum disorder. Neurology . 2020;94(9):392-404. doi:org/10.1212/WNL0000000000009033 23. Chun T, Mace S, Katz E; Americ an Academy of Pediatrics; Committee on Pediatric Emergency Medicine and American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Evaluation and management of children and adolescents with acute mental health or behavioral health pr oblems: part I, common clinical challenges of patients with mental health or behavioral emergencies. Pediatr. 2016;138(3):e20161570. doi:org/10.1542/peds.2016-1570 24. Chun T, Mace S, Katz E; American Academy of Pediatrics; Committee on Pediatric Emergency Med icine and American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Evaluation and management of children and adolescents with acute mental health or behavioral health problems: part II, recognition of clinically challenging mental health related conditions presenting with medical or uncertain symptoms. Pediatr. 2016;138(3):e20161573. doi:org/10.1542/peds.2016-1573 25. Coverage for Autism, O.C.G.A 33-24-59.10 (2023). 26. Crockett, JL, Fleming RK, Doepke K, et al. Parent training: acquisit ion and generalization of discrete trials teaching skills with parents of children with autism. Res Dev Disabilities . 2007; 28 (1):23-36. doi.org/10.1016/j.ridd.2005.10.003 27. Declaration of Purpose, O.C.G.A 37-2-1 (2023). 28. Ethics Code for Behavior Analysts. B ehavior Analyst Certification Board; 2020. Updated January 1, 2023. Accessed February 19, 2024. www.bacb.com 29. Evidence analysis research brief: applied behavior analysis training via telehealth for caregivers of children with autism spectrum disorder. Hayes ; 2022. Accessed February 19, 2024. www.evidence.hayesinc.com 30. Evidence analysis research brief: direct-to-patient applied behavior analysis telehealth for children with autism spectrum disorder. Hayes; 2022. Accessed February 19, 2024. www.evidence.hayesinc.com 31. Gonzlez MC, Vsquez M, Hernndez-Chvez M. Autism spectrum disorder: clinical diagnosis and ADOS Test. Rev Chil Pediatr . 2019;90(5):485-491. doi:10.32641/rchped.v90i5.872 32. Health technology assessment: comparative effectiveness review of intensive behavioral intervention for treatment of autism spectrum disorder. Hayes; 2019. Updated February 10, 2022. Accessed February 19, 2024. www.evidence.hayesinc.com Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.17 33. Hyman S, Levy S, My ers S; Council on Children with Disabilities. Developmental and behavioral pediatrics: identification, evaluation, and management of children with autism spectrum disorder. Pediatr. 2020;145(1):e20193447. doi:org/10.1542/peds.2019-3447 34. Information on autis m spectrum disorder for healthcare providers. Centers for Disease Control and Prevention (CDC). Updated December 6, 2022. Accessed February 19, 2024. www.cdc.gov 35. Lebersfeld JB, Swanson M, Clesi CD, et al. Systematic review and meta-analysis of the clinical utility of the ADOS-2 and the ADI-R in diagnosing autism spectrum disorders in children. JAutism Dev Disord . 2021;51(11):4101-4114. doi:10.1007/s10803-020-04839-z 36. Lefort-Besnard J, Vogeley K, Schilbach L, et al. Patterns of autism symptoms: hidden struct ure in the ADOS and ADI-R instruments. Transl Psychiatry . 2020;10(1):257. doi:10.1038/s41398-020-00946-8 37. Lim N, Russell-George A. Home-based early behavioral interventions for young children with autism spectrum disorder. Clin Psychol . 2022;29(4):415-416. doi:org/10.1037/cps0000117 38. Registered Behavior Technician Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed February 19, 2024. www.bacb.com 39. Medicare Claims Processing Manual. Centers for Medicare and Medicaid Services; Publication # 100-04. Accessed February 19, 2024. www.cms.gov 40. Policies and Procedures for Autism Spectrum Disorder Services, Part II . Georgia Dept. of Community Health, Division of Medicaid. Revised April 1, 2024 . Accessed April 11, 2024 . www.mmis.georgia.gov 41. Practice of Applied Behavior Analysis, O.C.G.A 43-7A-1 to 11 (2023) . 42. Sneed L, Little S, Akin-Little A. Evaluating the effectiveness of two models of applied behavior analysis in a community-based setting for children with autism spectrum disorder. Behav Anal: Res Pract . 2023;23(4):238-253. doi:org/10.1037/bar0000277 43. Society guideline links: autism spectrum disorder. UptoDate. Accessed February 19, 2024. www.uptodate.com 44. Volkmar F, Siegel M, Woodbury-Smith M, et al.; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. JA m Acad Child Adolesc Psychiatry . 2014;53(2):237-57. doi: 10.1016/j.jaac.2013.10.013 45. Weissman L. Autism spectrum disorders in children and adolescents: behavioral and educational interventions . UptoDate. Updated December 4, 2023. Accessed February 19, 2024. www.uptodate.com 46. Weissman L. Autism spectrum disorder in children and adolescents: overview of management. UptoDate. Updated September 8, 2023. Accessed February 19, 2024. www.uptodate.com 47. Weissman L. Autism spectrum disorder in children and adolescents: pharmacologic interventions. UptoDate. Updated October 27, 2021. Accessed February 19, 2024. www.uptodate.com Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.18 48. Weissman L. Autism spectrum disorder in children and adolescents: screening tools.UptoDate. Updated January 24, 2024. Accessed February 19, 2024. www.uptodate.com 49. Weissman L. Autism spectrum disorder in children and adolescents: surveillance and screening in primary care. UptoDate. Updated May 5, 2022. Acc essed February 19, 2024. www.uptodate.com 50. Weissman L, Harris H. Autism spectrum disorder in children and adolescents: complementary and alternative therapies. UptoDate. Updated June 20, 2022. Accessed February 19, 2024. www.uptodate.com 51. Wergeland J, Posserud M, Fjermestad K, et al. Early behaviora l interventions for children and adolescents with autism spectrum disorder in routine clinical care: a systematic review and metaanalysis. Clin Psychol . 2022;29(4):400-414. doi:org/10.1037/cps0000106 52. Witwer A, Walton K, Held M. Taking an evidence-based chi ld-and family-centered perspective on early autism intervention. Clin Psychol . 2022;29(4):420-422. doi:org/10.1037/cps0000122 GA-MED-P-2725701 Issue Date 11/29/2017 Approved DCH 4/18/2024
REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Overpayment Recovery-IN MCD-PY-1111 07/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts 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, m edical 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 no t limited to, those health care services or suppli es 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 functi on, dysfunction of a body organ or part, or si gnificant 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 inc lude 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 Rei mbursement 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 c ontract (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 mo dify 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 li mitations 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 Policies/R ules ………………………….. ………………………….. ………………………….. ….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. .. 5 H. References ………………………….. ………………………….. ………………………….. …………………. 5 Overpayment Recovery-IN MCD-PY-1111Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectOverpayment Recovery B. BackgroundReimbursement policies are designed to assist you 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 their 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 code(s) for the product or service that is being provided. Theinclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Retrospective review of claims paid to providers assist CareSource with e nsuringaccuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified.Fraud, waste , and abuse investigations are an exception to this policy. In theseinvestigations, the look back period may go beyond 2 years.C. Definitions Claims Adjustment Adjustment is defined as a claim that was previously paid and is being updated for one of the following reasons: o denied as a zero payment o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Overpaymen t Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 C .F.R. o A claim adjustment is only considered to result in an overpayment when a claim that previously p aid is updated to a denied status as a zero payment or results in a reduced payment. Explanation of Payment (EOP ) A statement contain ing the payment and adjustment information for claims the provider has submitted for payment to CareSource. Overpayment Recovery-IN MCD-PY-1111Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. Improper Payment A payment that should not have been made or an overpayment was made. Exam ples include, but are not limited to: o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. Provider Level Balancing (PLB ) Adjustments to the total check / remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. T he sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment. (Beginning Segment for Payment Order/Remittance Advice (BPR ), which means total payment within the EOP ). Forwarding Balance (F B) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past claim has been adjusted to a di fferent dollar amount and that funds are owed to CareSource. D. PolicyI. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider : A. the name and patient account number of the member to whom the service (s) were provided ; B. the date(s) of services provided C. the amount of overpayment D. the reason for the recoupment E. that the provider has a ppeal rights II. Overpayment RecoveriesA. Lookback period is 24 months from the claim paid date. B. Advanced notification will occur 60 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. Overpayment Recovery-IN MCD-PY-1111Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 III. Coordination of Benefit RecoveriesA. Lookback period is 12 months from claim paid date. B. Advanced notification will occur 60 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active E ligibility RecoveriesA. Lookback period is 24 months from da te CareSource is notified by Medicaid of the updated eligibility status. B. Advanced notification will occur 60 days in advance of recovery. V. Management of Claim Credit Balances.A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated rec onciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previousl y but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D.IV. 2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D.IV. b. The reduced payment will trigger a 30-day adv anced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through EOPs and 835s. Providers are expected to use this information to reconcile and maintain their accounts receivable (AR) to account for the reconciliation of negative balances. E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain AR for the reconciliation of negative balances when that occurs. Overpayment Recovery-IN MCD-PY-1111Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 VI. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropr iate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesCareSource Provider Agreement , ARTICLE V. CLAIMS AND PAYMENTS G. Review/Revision HistoryDATE ACTIONDate Issued 04/29/2020 New policyDate Revised 10/13/2021 10/26/202201/31/2024Updated definitions. Added D. V. and D. VI. Updated references. Approved at PGC. Updated references. Updated III. C. to 30 days and IV. C. to 30 days. Annual review. Removed IV. C. Updated references. Approved at Committee . Date Effective 07/01/ 2024 Date Archived H. References1. Claim Payment Errors, IND . CODE 27-13-36.2-8 (2023). 2. Claim Overpayment Adjustment, IND . CODE 27-13-36.2-9 (2023). IN-MED-P-2691376 Issue date 04/29/2020 Approved OMPP 03/25/2024
MEDICAL POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Non-Emergency Facility to Facility Transfers-IN MCD-MM-1446 07/01/2024 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 o f Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the cont rolling 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 fav orable 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/R ules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Non-Emergency Facility to Facility Transfers-IN MCD-MM-1446 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNon-Emergency Facility to Facility Transfers B. BackgroundThis policy addresses the necessity of transferring a patient to a second acute care facility (receiving facility) when the individual requires care not available at the original facility. The goal of any transfer is to maintain the optimal health of the p atient. This is accomplished by transferring the patient to the nearest facility that provides the highest specialized care needed. Inter-hospital patient transfer is an important aspect of patient care, most often toimprove patient management. During su ch transfers, there must be continuity of medical care. Key elements include the decision to transfer and communication, pre-transfer stabilization and preparation, choosing the appropriate mode of transfer, personnel accompanying the patient, equipment an d monitoring required during the transfer, and documentation and handover of the patient at the receiving facility. Transfer, admission , and subsequent care to the receiving facility is not medicallynecessary when the needed care is available at the orig inating facility.C. Definitions Non-Emergency A situation for which immediate response is not needed for the provision of medical treatment. Inter-Facility Transfer The transfer of patients between two healthcare facilities. Intra-Facility Transfer The transfer of patients within the same facility. Originating Facility The current facility to which an individual has been admitted for care and from which a trans fer is planned. Participating (In-Network) Facility Facility that is contracted with CareSource. Non-Participating (Out-of-Network) Facility Facility that is not contracted with CareSource. Receiving Facility The facility to which a transfer is plann ed. D. PolicyI. The following non-emergency transfers require prior authorization: A. A non-emergency transfer from a participating inpatient facility to a participating inpatient facility that is not within the same healthcare system. B. A n on-emergency transfer from a non-participating facility to a participating facility . C. A n on-emergency transfer from a non-participating facility to a non-participating facility. II. For n on-emergency transfers that require a prior authorization , the receiving facility submits the prior authorization request to CareSource. Non-Emergency Facility to Facility Transfers-IN MCD-MM-1446 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 III. Requests for transfers that require a prior authorization must meet the following criteria: A. Member must be medically s table for transfer AND 1. Member requires transfer to a level of care which is not available at the originating facility . 2. Member requires transfer for a medically necessary diagnostic or therapeutic service which is not available at the originating facility . 3. Member requires transfer for services of a specialist to evaluate, diagnose , or treat their condition when that specialist is not available at the originating facility . 4. Member requires transfer because member has received care at a specific prior institution for a condition not normally managed at the originating facility and ret urn to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue . 5. Member requires transfer to improve the health and welfare of the member (ie, parental bonding) . 6. Transfer to allow a parent who gave birth to remai n with the neonate is considered medically necessary when the neonate transfer meets the medically necessary criteria listed above and the parent who gave birth requires continued hospitalization due to birth complications or other medically necessary cond itions . IV. The following non-emergency transfers do not require a prior authorization :A. Inter-facility transfers within the same healthcare system . B. Intra-facility transfers within the same facility . V. Non-emergency (elective) transfers are not a covered service for the following:A. The criteria above have not been met . B. The transfer is for the convenience of the member , the members family, the physician, or the originating facility . E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/15/2023 New policy. Approved at Committee.Date Revised 02/14/2024 Annual review. Updated references. Approved at Committee. Date Effective 07/01/202 4 Date Archived Non-Emergency Facility to Facility Transfers-IN MCD-MM-1446 Effective Dat e: 07/01/2024 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 H. References1. Appropriate interhospital patient transfer. American College of Emergency Physicians. January 2022. Accessed January, 22, 2024. www.acep.org 2. Heaton J K. EMS Inter-Facility transport. In: StatPearls . StatPearls Publishing; 2022. 3. Discharges and Transfers, 42 C.F.R. 412.4 (2022). 4. Obstetric Care Consensus Number 9. Levels of Maternal Care. American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine ; 2019. Accessed January, 22, 2024. www.acep.org Independent med ical review 02/21/2023IN-MED-P-2691375 Issue Date 03/15/2023 Approved OMPP 04/04/2024
ADMINISTRATIV E POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Continuity of Care-IN MCD-AD-0743 07/01/2024 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 techno logy 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 th e 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These se rvices 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 Eviden ce 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 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Continuity of Care-IN MCD-AD-0743Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectContinuity of Care B. BackgroundContinuity of care (COC) comprises a series of separate health care services so that treatment remains coherent, unified over time, and consistent with a members health care needs and preferences. To ensure that care is not disrupted, COC becomes a bridge of coverage, allowing members to transition to CareSources provider network. Newly enrolled members can continue to receive services by an out-of-network provider when an established relationship exists with that provider, and/or the member will be recei ving services for which a prior authorization was received from another payer. Existing members may also utilize COC when a participating provider or acute care hospital terminates an agreement with CareSource. COC promotes safety and effective healthcare to transitioning members. C. Definitions Acute Conditio n A medical or behavioral health (BH) condition that involves a sudden onset of symptoms due to an illness, injury or other medical problem requir ing prompt medical attention and with a limited durati on. Chronic Conditio n A medical or BH condition due to a disease, illness, or other medical problem that is complex in nature , persists wit hout cure and/ or worsens over an ex tended period or requires ongoing tr eatment to maintain remission o r prevent deterioration . In-Network (Network) Provide r Any provider, group of providers, or entity that has a network provider agreement with CareSource or a subcontractor and receives Medicaid funding directly or indirectly to order, refer , or render covered services . Level-of-Care (LOC ) The outcome of the measure of an individuals care needs , includ ing nursing home or institutional placement ne ed s of an individual. Out-of-Network Provider Any provider , group of providers, or entity not directly or indirectly employed by or does not have a provider agreement with CareSource or any of its subcontractors. Primary Car e All health care and laboratory services furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/ gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes the service. [42 CFR 438.2]. Primary Medical Provider (PMP) Also called a Primary Care Physician (PC P) , a PCP or other licensed health practitioner practicing in accordance with state law who is responsible for providing preventive and primary health care to patients , initiating referrals for specialist care , and maintaining the continuity of patient car e. At a minimum, providers allowed to serve as PMPs must include physicians, physician assistants, and advanced practice registered nurses. Specialis t A Board-eligible or certified physician who declares him /her self as a specialist and practices a specific medical specialty. For the purposes of this Continuity of Care-IN MCD-AD-0743Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 definition, Board-eligible means a physician who meets all the requirements for certification but has not tested for or has not been issued certification. Terminal Illnes s 6-month or less life expectancy if the illness runs a normal course. Transition of Car e A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. D. PolicyI. CareSource supports COC to ensure that consistent healthcare services are delivered through proper coordination combined with information sharing among providers to enhance a patient focused approach. Requests will be accepted from a member, a members representative, or a provider on behalf of a member. CareSource follows Indiana Health Coverage Programs ( IHCP ) requirements to facilitate the exchange of member-specific data and ensure facilitiation of care among all stages to enrollment or termination completion. All transitions of care between healthcare settings will be handled according to IHCP requirements, including care coordination guidance, discharge planning, and followup with providers/member s, particularly regarding outpatient followup after inpatient discharge. Critical continuity of care areas include, but are not limited to: A. members receiving HIV, Hepatitis Cand/or behavioral health services, especially when a PA was received from a previous payer B. pregnant members C. members transitioning into the Hoosier Healthwise or HIP program from traditional fee-for-service or into HIP from Hoosier Healthwise D. members transitioning between managed care entities, particularly during an inpatient stay E. members transitioning between IHCP programs, particularly when a HIP member becomes preg nant or disabled F. members exiting the Hoosier Healthwise or HIP program to receive excluded services G. members transitioning to a new PMP H. members transitioning to private insurance, Marketplace coverage, or no coverage I. members transitioning between HIP plans II. COC services will be provided when ONE of the following occurs:A. Newly enrolled, CareSource members may qualify for COC coverage in the following circumstances: 1. The member chooses to receive care from an out of network provider. Coverage will be extended as follows: a. eligibility for 180 days if the provider was providing treatment prior to enrollment . b. eligibility during the 30-day transition period . Continuity of Care-IN MCD-AD-0743Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 c. pregnant women in the 3rd trimester throughout prenatal, delivery , and postpartum periods or women with a history of high risk pregnancy who want to see a treating provider from a previous high risk pregnancy . 2. The member is or will be receiving services for which a prior authorization (PA) was received from another payer. Services will be pro vided for 180 days. The date of member enrollment for purposes of the PA time frames begins on the date CareSource receives the members fully eligible file from the State. Authorization extends to any service o r procedure previously authorized, including, but not limited to, the following: a. surgeries and therapies b. home health c. physician services B. Terminations of contractual relationships between CareSource an d providers, provider groups, or entities will result in changes to provider network status. Termination requests will be reviewed when a health partner is terminated from the CareSource network , and that termination was not related to a fraud or quality of care issue . S ervices will be provided for 60 days . C. Inpatient stays will be handled in the following manner: 1. For r eimbursement s based on diagnos is-related group (DRG) methodology, the admitting managed care entity ( MCE ) is responsible for the entire inpatient stay through member discharge or ineligibility for medicaid , including the hospital DRG payment and any outlier payments (without a capitation payment). If the member is transitioning from the admitting MCE to anoth er MCE or traditional Medicaid, the admitting MCE will provide care coordination, including coordination of discharge plans, with the receiving MCE or inpatient provider, as applicable. 2. For reimbursement based on a level-of-care (LOC) methodology, the adm itting MCE is responsible for the days during which the member is enrolled with the MCE and the transition of care coordination for the remainder of the stay. The admitting MCE is financially responsible for the per diem payments and any outlier payments ( without capitation payment) associated with the days the member remains enrolled with the admitting MCE. If the member is transitioning from the admitting MCE to another MCE or to traditional Medicaid, the receiving MCE or traditional Medicaid program is r esponsible for the per diem payments associated with the days the member is enrolled with the receiving MCE or in traditional Medicaid until the member is discharged from the hospital or eligibility for Medicaid terminates. The admitting MCE is responsible for the transition of care coordination with the receiving MCE or the inpatient provider, as applicable . III. To coordinate care and facilitate transition , COC services will be provided for 180calendar days , including out of network provider s, but the following may be subject to a medical necessity review : A. tra nsportation on a scheduled basis B. physical therapy, speech therapy, occupational therapy and rehabilitation therapy Continuity of Care-IN MCD-AD-0743Effective Dat e: 07/01/2024The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 C. inpatient and outpatient behavioral health careD. inpatient substance abuse treatment E. long term care, including nursing homes, skilled nursing facilities, psychiatric residential treatment facilities , and other facilities that provide long term non – acute care . F. post-emergency care (covered 30 days without a medical necessity review after member sees an out of network provider in an emergency department) G. home health services H. specialized medical care requir ing ongoing care from specialist s I. specialized durable medical equipment , including ventilators and other respiratory assistance equipment E. Conditions of CoverageIf a n out of networ k provider s services meet medical necessity and the COC policy, CareSource will work to obtain a single case agreement (SCA) document. F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATES ACTIONDate Issued 04/01/2020Date Revised 08/17/2022 02/14/2024 Updated in line with UM P&P. Editorial revisions. Annual review. Definitions updated to contract. Added contract language to D.I., added D.II.C. Updated F. and G. Approved at Committee. Date Effective 07/01/2024 Date Archived H. References1. CareSource Indiana Medicaid Provider Manual . CareSource; 2023. Accessed January 31, 2024. www.caresource.com 2. Continuation of Care Provisions, IND . CODE 27-13-36-6 (1998). 3. Continuity of Care and Referrals when Specialty Care Warranted, IND . CODE 27 – 13-37-3 (1998). 4. Healt hy Indiana Plan Policies and Procedures Manual . Indiana Health Coverage Programs. Revised January 24, 2024. Accessed January 31, 2024. www.in.gov 5. Managed Care, 42 C.F.R. 438 (2024). 6. Problems with Continuity of Care, Reporting, IND . CODE 12-24-12-4 (1994). 7. Speci al Rules for Ambulance Services, Emergency and Urgently Needed Services, and Maintenance and Post-Stabilization Care Services, 42 C.F.R. 422.113 (2024). 8. Standards for Continuity of Care, IND . CODE 27-13-36-11 (1998). 9. State Plans for Medical Assistance , 42. U.S.C. 1396a(e)(5) (2024). IN-MED-P-2691373 Issue date 04/01/2020 OMPP Approved 03/25/2024
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