Speech Therapy and Language Disorder Rehabilitation

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Speech Therapy and Language Disorder Rehabilitation-GA MCD-MM-0714 11/01/2025 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 suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Polices/Rules …………………………………………………………………………………………… 3 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Speech Therapy and Language Disorder Rehabilitation-GA MCD-MM-0714 Effective Date: 11/01/2025 The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectOutpatient Speech Therapy and Language Disorder Rehabilitation B. Background Speech language pathology services include the diagnosis and treatment of speech and language disorders. These services are provided by speech-language-pathologists within the scope of practices. Speech language pathologists diagnose and treat swallowing disorders (dysphagia) and communication disabilities. Speech, language, and swallowing disorders can be a result of a variety causes, such as hearing loss, autism, developmental delay, Parkinsons disease, a cleft palate, stroke or brain injury. C. Definitions Speech-Language Pathology (SLP) A field in which a clinician specializes in the evaluation and treatment of disorders, cognition, swallowing, voice, and communication disorders. Clinicians are referred to as speech language pathologists, speech and language therapists, or speech therapists. Receptive Language The ability to understand what is being said, this can involve the understanding the meaning of words and sentences of what is being spoken. Expressive Language The ability to put thoughts into words and sentences that make sense to others. Language Disorder Disorders that involve the processing of linguistic information, which can involve both receptive and expressive language. D. Policy CareSource requires outpatient speech language pathology services to meet medical necessity criteria. I. Speech language services documentation must include the following: A. An expectation that the patients condition will: 1. improve significantly within 60 days after the evaluation 2. or the services must be for the establishment of a safe and effective maintenance program. B. An order or referral by the referring physician to the SLP, including specific testing in areas of concern. C. SLP documentation of the screening or evaluation, including evidence of a face- to-face assessment supporting medical necessity for speech therapy. II. Per MCG criteria: developmental language disorder rehabilitation may be indicated for 1 or more of the following: A. Initial therapy when ALL of the following are present 1. Diagnosed medical condition as indicated by 1 or more of the following: a. Autism Spectrum Disorder b. central nervous system infection (eg, herpes encephalitis) c. Cerebral palsy d. child abuse or neglect Speech Therapy and Language Disorder Rehabilitation-GA MCD-MM-0714 Effective Date: 11/01/2025 The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 e. developmental language disorder (specific language impairment) f. Dyslexia g. Epilepsy or other seizure disorder h. Fetal Alcohol Syndrome i. genetic syndrome, with associated language disorder j. hearing disorders (eg, auditory processing disorder and hearing loss) k. Inborn error of metabolism (eg, phenylketonuria galactosemia) l. intellectual or developmental disability m. language based learning disabilities n. premature birth or low birth weight o. receptive-expressive language impairment (also referred to as mixed receptive-expressive language impairment) 2. Impairment of function (clinically significant) relative to the developmental normative data, as indicated by 1 or more of the following: a. decreased ability to recall specific content of information read or heard b. decreased oral and written language comprehension, processing and expression c. decreased preliteracy of literacy skills d. decreased sentence or utterance length and complexity e. decreased social communication skills f. difficulty organizing, planning and formulation content or oral and written expressive language g. difficulty with syntax and grammar in oral and written language h. pragmatic deficits i. decreased receptive OR expressive language 3. Recent change in language status as indicated by 1 or more of the following: a. change of symptoms or function in patient with previous chronic or stable pediatric or development language disorder b. recent diagnosis of medical condition or language delay/disorder B. Extended therapy when ALL of the following are present: 1. Functional progress has been made during initial therapy, or patient requires maintenance therapy plan to prevent further deterioration or preserve existing function. 2. Generalization and carryover of targeted skills into natural environment is occurring. 3. Goals of therapy are not yet met. 4. Patient is actively participating in treatment sessions. E. Conditions of Coverage N/A F. Related Polices/Rules N/A Speech Therapy and Language Disorder Rehabilitation-GA MCD-MM-0714 Effective Date: 11/01/2025 The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 G. Review/Revision HistoryDATE ACTIONDate Issued 07/10/2020 New PolicyDate Revised 05/26/2021 07/06/2022 07/19/202307/17/202407/02/2025 Removed language with PA limits on 2-and under. Bolded 2.8 Decreased receptive OR expressive language. Removed Covid red box; updated references; title Highlighted slight change in MCG from 25 th to 26 th ed. Updated references. Approved at Committee. Updated references. Approved at Committee Updated references. Approved at Committee Date Effective 11/01/2025 Date Archived H. References1. Introduction to Medicaid . Accessed June 5, 2025. www.asha.org 2. Understanding Language Disorders . Accessed June 5, 2025. www.understood.org 3. Developmental Language Disorders Rehabilitation ACG: A-0561 (AC). MCG, 28 th ed. Updated 2024. Accessed June 5, 2025. www.careweb.careguidelines.com 4. Georgia Department of Community Health. CIS/CISS Provider Manual (2024). Accessed June 5, 2025. www.georgia.gov Independent medical review 06/2019 GA-MED-P-4186818 Issue Date 07/10/2020 Approved DCH 08/06/2025

Skin Substitutes

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Skin Substitutes-GA MCD-MM-1399 10/01/2025 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 suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. 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 …………………………………………………………………………………………………………. 6 Skin Substitutes-GA MCD-MM-1399Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectSkin Substitutes B. Background Wounds are disruptions of the skins structural and functional integrity and normally transition through distinct phases until the skins structure and function are restored, including hemostasis, inflammation, cellular migration and proliferation, and remodeling. Chronic wounds can result in loss of function, wound recurrence, and significant morbidity. Pressure ulcers, diabetic foot ulcers, and venous leg ulcers are the three categories that comprise the majority of chronic wounds. Skin substitutes are a heterogeneous group of biologics, synthetics, or biosynthetic materials. When determining if the use of a skin substitute is appropriate, the clinician evaluates the material being used and its properties. Individual wounds have a specific microenvironment. Various manufacturers may utilize differing processes in the development of skin substitutes but generally seed selected cells onto a matrix. The matrices subsequently receive proteins and growth factors necessary to divide and develop into the desired tissue. Skin substitutes provide coverage for open wounds, both deep thermal and full-thickness wounds. Skin substitutes have the function and composition of skin or have the potential for autologous regenerative healing when applied to a wound. Uses span acute or chronic wounds, burns, or reconstruction, such as release of contractures secondary to severe burns. The most common classification system utilized to determine the type of skin substitute that would be appropriate for a particular wound is the Kumar Classification system, in which Class I includes temporary impervious dressing material, Class II includes single-layer durable skin substitutes, and Class III includes composite skin substitutes that replace both dermal and epidermal layers. C. Definitions Ankle-Brachial Index A comparison of the blood pressure measured at the ankle with blood pressure measured at the arm with lower numbers indicating narrowing or blockage of the arteries in the legs. Autologous Derived from the same individual, such as an individual serving as both donor and recipient. Cellular and Tissue-Based Products (CTPs) Wound dressings or coverings that contain or consist of cells and/or tissue to promote wound healing. They are often used as alternatives to skin grafts for chronic wounds, burns, and ulcers. Chronic Wounds Wounds that have not progressed along the normal healing process, generally after a 4-week duration. Chronic Venous Ulcers A wound that takes longer than usual to heal and often occurs on the legs or ankles when oxygen-poor blood flow is impaired and pools, creating pressure in the veins. Skin Substitutes-GA MCD-MM-1399Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Diabetic Foot Ulcers An open sore or wound located on the foot occurring in approximately 15% of patients with diabetes. Pressure Ulcers Injuries to skin and underlying tissue resulting from prolonged pressure on the skin, including bedsores that most often develop on skin covering bony areas of the body, such as heels, ankles, hips, and tailbone. Tissue Engineering The practice of combining scaffolds, cells, and biologically active molecules into functional tissues to assemble functional constructs that restore, maintain, or improve damaged tissues or whole organs. D. PolicyI. CareSource considers the use of skin substitute products medically necessary under ANY of the following circumstances: A. The presence of a chronic, non-infected diabetic foot ulcer (DFU) having failed to achieve at least 50% ulcer area reduction with documented standard of care (SOC) treatment) for a minimum of 4 weeks with documented compliance. Treatment of diabetic foot ulcer as indicated by all of the following: 1. when adequate circulation to the affected extremity is present as indicated by ONE of the following: a. palpable pedal b. ankle-brachial index (ABI) between 0.7 and 1.2 c. dorsum transcutaneous oxygen test (TcPO2) 30 mm Hg within the last 60 days d. triphasic or biphasic Doppler arterial waveforms at the ankle of affected leg 2. appropriate glycemic control 3. no wound infection. 4. no response to conventional therapy, including all of the following: a. offloading (pressure relief) b. appropriate dressings to facilitate healing c. debridement as needed B. The presence of a chronic, non-infected venous insufficiency ulcers having failed to respond to documented SOC treatment for a minimum of 4 weeks with documented compliance. Treatment of venous insufficiency ulcers when ALL of the following criteria are met: 1. noninvasive duplex ultrasound documenting chronic venous disease 2. adequate perfusion of involved limb 3. appropriate surgical venous interventions 4. concurrent conventional wound care 5. concurrent glycemic management if patient is also diabetic 6. duration greater than 6 weeks 7. partial-thickness or full-thickness ulcer due to venous insufficiency 8. no allergy to bovine products 9. no response to conventional therapy, including all of the following: a. compression therapy b. surgical intervention for UVD (if applicable) Skin Substitutes-GA MCD-MM-1399Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 c. dressings to maintain moist wound environment (eg, saline-moistened dressings, negative pressure wound therapy) d. sharp debridement 10. no wound infection C. Treatment of burn wounds when ONE of the following criteria are met: 1. a temporary wound covering for excised full-thickness and deep partial- thickness burn wounds in individuals who require such a covering prior to autograft placement 2. treatment of mid-dermal to indeterminate depth burn wounds that typically require debridement and that may be expected to heal without autografting D. Repair of scar contractures when more conservative therapeutic options have failed when used in conjunction with a breast reconstruction procedure. E. Pressure redistribution supports surfaces for pressure ulcers II. Documentation RequirementsA. Standard of Care treatment documentation includes: 1. Comprehensive patient assessment (history, exam, vascular assessment) and diagnostic tests as indicated as part of the implemented treatment plan 2. Assessment of Type 1 or 2 diabetes for DFU patients including management history and any comorbidities (eg. vascular disease, neuropathy, osteomyelitis), current blood glucose levels (A1c) and assessment of off-loading devices and footwear. 3. Assessment of clinical history for venous insufficiency ulcer patients including a. prior ulcers b. body mass index c. history of pulmonary embolism or superficial/deep venous thrombosis d. number of pregnancies and physical inactivity e. physical exam f. evaluation of venous reflux, perforator incompetence, and venous thrombosis g. the use of any compression garments B. Treatment Plan documentation Includes ALL of the following: 1. debridement as appropriate to a clean granular base 2. documented evidence of offloading for DFUs 3. documented evidence of sustained compression dressings for venous insufficiency ulcers 4. infection control with removal of foreign body or focus of infection 5. management of exudate with maintenance of a moist environment 6. documentation of smoking history, counseling on the effects of smoking on wound healing 7. treatment for smoking cessation and current status III. Non-Covered or Medically Necessary Skin Substitutes-GA MCD-MM-1399Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 A. New Quarterly skin substitutes or Q-codes that have not been used outside clinical trials B. Greater than 3 applications of a skin substitute graft/CTP over 12 weeks if volume has not decreased by at least 50% C. Repeat applications of skin substitute graft/CTP when a previous application was unsuccessful. Unsuccessful treatment is defined as an increase in size or depth of an ulcer, no measurable change from baseline, and no sign of significant improvement or indication that significant improvement is likely (such as granulation, epithelialization, or progress towards closure). D. Application of skin substitute graft/CTP in patients with inadequate control of underlying conditions or exacerbating factors, or other contraindications (eg, active infection, progressive necrosis, active Charcot arthropathy of the ulcer extremity, active vasculitis, ischemia E. Use of surgical preparation services (eg, debridement), in conjunction with routine, simple or repeat skin replacement therapy with a skin substitute graft/CTP F. All liquid or gel skin substitute products or CTPs for ulcer care G. Placement of skin substitute graft/CTP on infected, ischemic, or necrotic wound bed H. Skin substitute products that are not on the applicable fee schedule may not be reimbursable and may be considered experimental and investigational. I. Life expectancy would not allow long-term healing or clinical benefit or decrease of substantive morbidity. E. Conditions of CoverageNA F. Related Policies/Rules Breast Reconstruction Surgery Experimental or Investigational Item or Service G. Review/Revision History DATE ACTIONDate Issued 02/15/2023 New Policy.Date Revised 02/14/2024 02/12/2025 07/02/2025Updated references. Approved at Committee. Added I. A. 1-4. Added II. B. Life expectancy would not allow long-term healing or clinical benefit or decrease of substantive morbidity. Review: added new requirements for D.I.A, B, and E, added D.II, Non-Covered items to D.III, and Experimental or Investigational Item or Service to Related Policies/Rules. Updated references. Approved at Committee. Date Effective 10/01/2025 Skin Substitutes-GA MCD-MM-1399Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 Date ArchivedH. References1. Ankle-brachial index. Mayo Clinic. Accessed January 3, 2025. www.mayoclinic.org 2. Bedsores (pressure ulcers). Mayo Clinic. Accessed January 3, 2025. www.mayoclinic.org 3. Hart CE, Loewen-Rodriguez A, Lessem J. Dermagraft: use in the treatment of chronic wounds. Adv Wound Care . 2012;1(3):138-141. doi:10.1089/wound.2011.0282 4. James CV, Murray Q, Park SY, et al. Venous leg ulcers: potential algorithms of care. Wounds. 2022;34(12):288-296. doi:10.25270/wnds/21160 5. Porcine skin and gradient pressure dressings. Centers for Medicare & Medicaid Services. Accessed January 3, 2025. www.cms.gov 6. Research Protocol: Skin Substitutes for Treating Chronic Wounds . Effective Health Care Program, Agency for Healthcare Research and Quality; 2018. Reviewed January 2020. Accessed January 3, 2025. www.effectivehealthcare.ahrq.gov 7. Shahrokhi S. Skin substitutes. UpToDate. Updated August 2, 2023. Accessed January 03,2025. www.uptodate.com 8. Skin substitute, tissue-engineered (human cellular), for diabetic foot ulcer and venous ulcer: A-0326. MCG Health. 28th ed. Accessed August 3, 2025. www.careweb.careguidelines.com 9. Tissue engineering and regenerative medicine. National Institute of Biomedical Imaging and Bioengineering. Accessed August 3, 2025. www.nibib.nih.gov 10. Venous ulcers. Cleveland Clinic. Reviewed May 26, 2022. Accessed August 3, 2025. www.myclevelandclinic.org 11. What is a diabetic foot ulcer? American Podiatric Medical Association. Accessed January 3, 2025. www.apma.org GA-MED- MED-P-4186818 02/14/2024 Issue date Approved DCH 8/06/2025Independent medical review 01/19/2023

Radiofrequency and Microwave Ablation of Tumors

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Radiofrequency and Microwave Ablation of Tumors-GA MCD-MM-1350 10/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Radiofrequency and Microwave Ablation of Tumors-GA MCD-MM-1350Effective Dat e: 10/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectRadiofrequency and Microwave Ablation of Tumors B. BackgroundRadiofrequency ablation of a tumor involves the delivery of high frequency alternating current to induce thermal injury of target ed tissue. Evidence for the use of radiofrequency ablation is constantly evolving based on the type of tumor and its location. Hepatocellular carcinoma is the most common type of primary liver cancer. For most patients, treatment with curative intent is not possible. Treatment options include surgical excision, hepatic artery infusion chemotherapy, trans-arterial bland orchemo embolization, selective interstitial radiotherapy (Yttrium 90 microspheres),percutaneous ethanol injection, cryoablation, and thermo-ablation . Liver transplantation for curative intent may be appropriate for some patients. Radiofrequency ablation and microwave ablation, which are types of thermos-ablation, have proven to be effective local therapy techniques with similar results to other treatment options for smaller tumors. Liver metastases are a common manifestation of many primary cancers. The number, location, size, and patients general health influence the choice of treatment for liver metastases. Surgical resection with curative intent is ideal, however this applies to aminority of patients. Non-surgical ablative techniques may be used for both curative and palliative intent, includ ing systemic chemotherapy , targeted therapy, immunotherapy , external beam radiotherapy, cryoablation, thermo-ablation, arterial embolization techniques, and selective internal radiation therapy. Lung cancer is one of the most common types of cancer, with symptoms often not appearing until advanced disease, causing poor prognosis. Common treatments for primary or metastatic cancer in the lung includes surgery, chemotherapy, radiotherapy, photodynam ic therapy, thermal ablation, immunotherapy, and biological therapy.Treatment selection is based on type, size, position and stage of cancer, and the patients overall health.Microwave ablation (MWA) uses microwave energy to cause thermal coagulation and tissue necrosis at a specific location. When a tumor is not amenable to resection or a patient is ineligible for surgery, MWA may be an appropriate alternativ e definitivetreatment. This procedure can be done percutaneously, using minimally invasive surgical techniques, or during open surgery, and involves placement of one more probe s directly into the t umors location, where microwave energy can be directly applied, causing des truction of the tumor and limited s urrounding tissues. Microwave ablation does not spare vessels. Radiofrequency and Microwave Ablation of Tumors-GA MCD-MM-1350Effective Dat e: 10/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 C. Definitions Tumor Ablation Direct application of energy to eradicate or destroy focal tumors. The method of ablation is dependent on the characteristics of the lesion and risk mitigation. o Microwave Ablation (MWA) Delivery of high-frequency microwave energy to rapidly agitate water molecules in the target tissue; the energy is converted to heat, which causes tissue necrosis. o Radiofrequency Ablation (RFA) Delivery of radio waves to generate heat and induce tissue destruction in the targeted area. D. PolicyI. Microwave ablation for tumor treatment using an FDA-approved device is considered medically necessary when ANY (either A or B) of the following indications are met: A. Member has primary or metastatic hepatic (liver) tumor and ALL the following: 1. The tumor is unresectable due to location of lesion(s) , OR the member has comorbid condition (s) that are contraindicative to surgery . 2. The t umor is at most 5cm in size , OR there are no more than 3 nodules, all of which are no more than 3cm in size . 3. Microwave ablation may be used alone or in conjunction with open or minimally invasive resection of other liver tumors. Curative resection of all disease must be the stated goal of therapy . or B. Member has primary or metastatic lung tumor and ALL the following: 1. The tumor is unresectable due to location of lesion(s), OR the member has comorbid condition(s) that are contraindicative to surgery . 2. Single tumor is no more than 3cm in size. II. Microwave ablation is not covered for any other indication, including (but not limited to), the following:A. Microwave ablation for any other tumor type is considered experimental and investigational due to a lack of clinical evidence on its efficacy . B. Microwave ablation for tumors larger than 5cm or more than 3 nodules larger than 3cm is considered experimental and investigational due to a lack of clinical evidence on its efficacy compared to other treatment modalities. III. Radiofrequency ablation for tumor treatment is considered medically necessary forANY of the following indications : A. Barrett esophagus with dysplasia B. bone metastases C. hepatocellular carcinoma with ALL the following: 1. Child-Pugh class A or Bliver function (score of 9 or less) 2. surgical evaluation indicates at least one of the following: a. patient is a candidate for surgical resection following radiofrequency ablation Radiofrequency and Microwave Ablation of Tumors-GA MCD-MM-1350Effective Dat e: 10/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 b. patient is a candidate for transplant following bridge therapy by radiofrequency ablation c. patient is not a surgical candidate (or elects against surgery) d. patient is not a transplant candidate 3. tumor has all the following: a. location amenable to percutaneous, minimally invasive or open surgical ablation b. margins accessible to ablation c. not in close proximity to critical structures (eg, major vessels, major bile ducts, diaphragm, other intra-abdominal organs) d. single tumor 5cm or smaller in diameter OR no more than 3 tumors, each of which is 3cm or smaller in diameter 4. no portal hypertension D. kidney tumor with ALL the following: 1. clinical stage T1 renal lesion 2. patient is not candidate for or elects against active surveillance 3. patient is not a surgical candidate (or elects against surgery) 4. tumor is not a renal angiomyolipoma E. liver metastases from colorectal carcinoma with ALL the following: 1. patient is not an ideal surgical candidate (or elects against surgery) 2. tumor has all the following: a. location amenable to percutaneous or surgical ablation b. margins accessible to ablation c. no t in close proximity to critical structures (eg, major vessels, major bile ducts, diaphragm, other int ra-abdominal organs) d. single tumor 5cm or smaller in diameter OR no more than 3 tumors, each of which is 3cm or smaller in diameter 3. no extrahepatic disease F. lung cancer (non-small cell [NSCLC ]) with ALL the following: 1. patient is not a surgical candidate (or elects against surgery) 2. tumor with ALL the following: a. less than 3cm in diameter b. node negative (stage I) c. not in close proximity to major pulmonary vessels or esophagus G. osteoid osteoma H. soft tissue sarcoma with at least ONE of the following: 1. gastrointestinal stromal tumor with limited progressive disease (ie, appearance of new lesion, increase in tumor size) 2. soft tissue sarcoma of extremity, superficial trunk, or head/neck, as indicated by both : a. synchronous stage IV disease b. need for treatment of tumor bulk limited to single organ that is amenable to local therapy, or palliation of disseminated metastases I. thyroid cancer with at least ONE of the following: Radiofrequency and Microwave Ablation of Tumors-GA MCD-MM-1350Effective Dat e: 10/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 1. differentiated thyroid carcinoma (eg, follicular, papillary) with at least ONE of the following: a. distant metastasis or persistent disease not amenable to treatment with radioactive iodine b. recurrent disease following treatment of locoregional disease 2. medullary carcinoma with at least ONE of the following: a. palliative treatment of symptomatic metastases or progressive disease needed b. patient asymptomatic, with at least ONE of the following: 01. disease metastasis 02. persistent disease following treatment of locoregional disease 03. recurrent disease following treatment of locoregional disease J. thyroid nodules, with ALL the following: 1. compressive symptoms from nodules (eg, cough, dysphagia, foreign body sensation, pain, voice changes) 2. patient not a surgical candidate (or elects against surgery) K. uterine leiomyomas with ALL the following: 1. laparoscopic ultrasound-guided procedure planned 2. leiomyomas documented by imaging study (eg, ultrasound) or hysteroscopy 3. patient desires uterine conservation or is not a surgical candidate 4. patient is premenopausal 5. persistent symptoms (3 months or greater in duration) directly attributed to presence of leiomyomas, as indicated by at least ONE of the following: a. abnormal uterine bleeding unresponsive to conservative management (eg, hormonal therapy) b. bowel dysfunction c. dyspareunia d. infertility e. iron deficiency anemia f. pelvic pain or pressure g. urinary dysfunction 6. testing has ruled out other potential ca uses of symptoms E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/12/2022Date Revised 09/27/2023 08/28/2024 Annual review: updated references, approved at Committee Review: updated references, approved at Committee Radiofrequency and Microwave Ablation of Tumors-GA MCD-MM-1350Effective Dat e: 10/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 06/18/2025 Review: added indications for Barrett and thyroid nodules, updated references, approved at Committee.Date Effective 10/01/2025 Date Archived H. References1. Abdalla M, Collings AT, Dirks R, et al. Surgical approach to microwave and radiofrequency liver ablation for hepatocellular carcinoma and colorectal liver metastases less than 5cm: a systematic review and meta-analysis. Surg Endosc. 2023;37(5):3340-3353. doi:10.1007/s00464-022-09815-5. 2. Chung SR, Suh CH, Baek JH, et al. Safety of radiofrequency ablation of benign thyroid nodules and recurrent thyroid cancers: a systematic review and meta – analysis. Int JHyperthermia . 2017;33:920-930. doi:10.1080/02656736.2017.1337936. 3. Cui R, Yu J, Kuang M, et al. Microwave ablation versus other interventions for hepatocellular carcinoma: a systematic review and meta-analysis. JCancer Res Ther . 2020;16(2):379-386. doi:10.4103/jcrt.JCRT_403_19 4. Curley SA, Stuart KE, Schwartz JM, et al. Localized hepatocellular carcinoma: liver – directed therapies for nonsurgical candidates who are eligible for local ablation. UpToDate. Updated April 23, 2025. Accessed May 19, 2025. www.uptodate.com 5. Dupuy DE. Image-guided ablation of lung tumors. UpToDate. Updated November 6, 2023. Accessed May 19, 2025. www.uptodate.com 6. Genshaft SJ, Suh RD, Abtin F, et al. Society of Interventional Radiology quality improvement standards on percutaneous ablation of non-small cell lung cancer and metastatic disease to the lungs. JVasc Interv Radiol . 2021;32:1242.e1-1242.e10. doi:10.1016/j.jvir.2021.04.027 7. Glassberg MB, Ghosh S, Clymer JW, et al. Microwave ablation compared with hepatic resection for the treatment of hepatocellular carcinoma and liver metastases: a systematic review and meta-analysis. World JSurg Oncol . 2019;17(1):98. doi:10.1186/s12957-019-1632-6 8. Han Y, Yan X, Zhi W, et al. Long-term outcome following microwave ablation of lung metastases from colorectal cancer. Front Oncol . 2022;12:943715. doi:10 .3389/fonc.2022.943715 9. Matsui Y, Tomita K, Uka M, et al. Up-to-date evidence on image-guided thermal ablation for metastatic lung tumors: a review. Jpn JRadiol . 2022 ;40(10):1024-1034. doi:10 .1007/s11603-022-01302-0. 10. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Hepato cellular Carcinoma . Version 1.2025 . Issued March 20, 2025. Accessed May 9, 2025. www.nccn.org 11. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology . Non-Small Cell Lung Cancer. Version 3.2025 . Issued January 14, 2025. Accessed May 9, 2025. www.nccn.org 12. National Institute for Health and Care Excellence. Microwave ablation for treating liver metastases [IPG553]. Published April 27, 2016 . Accessed May 9, 2025. www.nice.org Radiofrequency and Microwave Ablation of Tumors-GA MCD-MM-1350Effective Dat e: 10/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 13. National Institute for Health and Care Excellence. Microwave ablation of hepatocellular carcinoma [IPG214]. Published March 28, 2007 . Accessed May 9, 2025. www.nice.org 14. National Institute for Health and Care Excellence. Microwave ablation for primary or metastatic cancer in the lung [IPG 716 ]. Published February 2, 2022 . Accessed May 9, 2025. www.nice.org 15. Nelson DB, Tam AL, Mitchell KG, et al. Local recurrence after microwave ablation of lung malignancies: a systematic review. Ann Thorac Surg . 2019;107(6):1876-1883. doi:10.1016-j.athoracsur.2018.10.049 16. Palussiere J, Chomy F, Savina M, et al. Radiofrequency ablation of stage IA non – small cell lung cancer in patients ineligible for surgery: results of a prospective multicenter phase II trial. JCardiothorac Surg . 2018;13(1):91. doi:10 .1186/s13019 – 018-0773-y 17. Radiofrequency Ablation of Tumor. ACG: A-0718 (AC). 28th ed. MCG Health; 2024. Updated March 14, 2024. Accessed August 7, 2024. www.careweb.guidelines.com 18. Wang N, Xu J, Wang G, et al. Safety and efficacy of microwave ablation for lung cancer adjacent to the interlobar fissure. Thorac Cancer . 2022 ;13(18):2557-2565 . doi:10.1111/1759-7714.14589 19. Wu X, Uhlig J, Blasberg JD, et al. Microwave ablation versus stereotactic body radiotherapy for stage I non-small cell lung cancer: a cost-effectiveness analysis. J Vasc Interv Radiol . 2022;33(8):964-971.e2. doi:10.1016/j.jvir.2022.04.019 Independent med ical review September 2022GA-MED-P-4186818 Issue Date 10/12/2022 Approved DCH 08/06/2025

Noninvasive Home Mechanical Ventilation

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Noninvasive Home Mechanical Ventilation-GA MCD-MM-1700 11/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 8 Noninvasive Home Mechanical Ventilation-GA MCD-MM-1700Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNoninvasive Home Mechanical Ventilation B. BackgroundThis document outlines the medical necessity criteria for a noninvasive home ventilator for a patient with stable, chronic respiratory failure. This device does not treat the underlying cause of respiratory failure but functions as supportive therapy, which may include reducing symptoms, improving quality of life, or sustaining or extending life. It may be used intermittently during the day and/or during sleep. A noninvasive home ventilator will not be reimbursed as such when its sole purpose is to function as a respiratory assistance device, including continuous positive airway pressure (CPAP), auto-titrating PAP, and bilevel airway pressure (BiPAP).C. Definitions Apnea-Hypopnea Index (AHI) The combined average number of apneas and hypopneas that occur per hour of sleep to determine the severity of obstructive sleep apnea (OSA) . Apnea-Hypopnea Index (AHI)Adult AHI Pediatric AHIMild OSA 5-14 1-4.9Moderate OSA 15 – 30 5-9.9 Severe OSA > 30 > 10 Bi-level Positive Airway Pressure (B iPAP) Device A device that uses mild bi-level or 2 levels of air pressure to keep breathing airways open. Continuous Positive Airway Pressure (CPAP) Device A device that uses mild continuous air pressure to keep breathing airways open. Home Mechanical Ventilation (HMV) A device used in the home setting for patients with chronic respiratory failure that delivers respiratory assistance via an invasive (ie, tracheostomy) or noninvasive (ie, nose/mouth mask, mouthpiece , nasal prongs) interface. These devices possess more advanced features than a CPAP/BiPAP machine, which include monitoring, rate control, safety, and backup power features. The ventilator can custom control a ll phases of the breathing cycle . D. PolicyI. CareSource utilizes Georgia Department of Community Health (GA DCH) and MCG Health criteria to determine medical necessity for noninvasive HMV (E0466) . An initial approval for HMV is valid for a maximum of 3 months. A new medical necessity determination thereafter is required every 6 months for continued rental use. Noninvasive Home Mechanical Ventilation-GA MCD-MM-1700Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 II. Initial Rental of HMV Medical necessity for the initial coverage of noninvasive HMV is based on the following conditions in II – IV being met . A patient must have 1 of the following qualifying diagnoses: A. Congenital central hypoventilation syndrome B. Chronic lung disease of infancy (eg, bronchopulmonary dysplasia) unable to maintain acceptable pH and PCO 2 without ventilator support C. Chronic obstructive pulmonary disease (COPD) and 1 OR MORE of the following: 1. Chronic hypercapnia with PaCO 2 of 50 mm Hg (6.7 kPa) to less than 52 mm Hg (6.9 kPa) and at least 1 of the following: a. Arterial oxygen saturation 88% for 5 consecutive minutes during nocturnal oximetry while on at least 2 liters of oxygen per minute . b. Invasive or noninvasive ventilation for acute exacerbation required during 2 or more hospitalizations per year . 2. Chronic hypercapnia with PaCO 2 of 52 mm Hg (6.9 kPa) or greater 3. Palliative care for end-stage disease and advance directive states no desire for intubation D. Neuromuscular disorder accompanied by chronic respiratory failure , as indicated by the following: Documentation of respiratory failure, as indicated by ONE OR MORE : 1. Arterial O2 saturation less than 88% for 5 consecutive minutes during nocturnal oximetry 2. Daytime PCO 2 (arterial or capillary) greater than 45 mm Hg (6.0 kPa) 3. Forced vital capacity less than 50% of predicted 4. Forced vital capacity less than 80% of predicted and symptoms of respiratory failure 5. Maximum inspiratory pressure 60 cm H 2O (5884 Pa) or lower 6. Maximum sniff nasal inspiratory pressure less than 40 cm H 2O (3923 Pa) 7. Polysomnography demonstrates sleep hypoventilation, as indicated by ONE OR MORE of the following: a. Adult with sleep-related hypoventilation (ie, arterial, end-tidal, or transcutaneous PCO 2 greater than 55 mm Hg (7.3 kPa) for 10 minutes or longer, or increase in arterial, end-tidal, or transcutaneous PCO 2 of 10 mm Hg (1.3 kPa) or greater above awake supine value resulting in PCO 2 greater than 50 mm Hg (6.7 kPa) for 10 minutes or longer) . b. Child with sleep-related hypoventilation (ie, sleeping arterial, end-tidal, or transcutaneous PCO 2 of greater than 50 mm Hg (6.7 kPa) for greater than 25% of total sleep time, or peak sleep end-tidal PCO 2 of 55 mm Hg (7.3 kPa) or greater) . E. Obesity hypoventilation syndrome , as indicated by ALL of the following: 1. BMI > 30 2. CPAP unsuccessful or not appropriate , as indicated by ONE OR MORE of the following: Noninvasive Home Mechanical Ventilation-GA MCD-MM-1700Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 a. Comorbid sleep-related hypoventilation (ie, arterial, end-tidal, or transcutaneous PCO 2 greater than 55mm Hg (7.3 kPa) for 10 minutes or longer, or increase in arterial, end-tidal, or transcutaneous PCO 2 of 10 mm Hg (1.3 kPa) or greater above awake supine value resulting in PCO 2 greater than 50 mm Hg (6.7 kPa) for 10 minutes or longer ). b. Intolerance of CPAP pressures necessary to correct obstructive sleep apnea (OSA) component (ie, difficulty exhaling against fixed airway pressure) c. Lack of resolution of hypercarbia, nocturnal desaturation, and OSA despite 3 months of CPAP use d. Titration study demonstrates OSA despite CPAP 15 cm H 2O (1471 Pa) that is responsive to BiPAP 3. Daytime hypercapnia with PaCO 2 greater than 45 mm Hg (6.0 kPa) without other etiology (eg, kyphoscoliosis, lung parenchymal disease, myopathy, severe hypothyroidism) 4. Sleep-disordered breathing or hypoventilation on polysomnography, as indicated by ONE OR MORE of the following: a. Apnea-hypopnea index of 5 or greater b. Increase in PaCO 2 during sleep by more than 10 mm Hg (1.3 kPa) above value while awake c. Significant oxygen desaturation (eg, less than 90%) not explained by obstructive apneas or hypopneas 5. TSH level does not demonstrate hypothyroidism F. OSA in child or adolescent and ONE OR MORE of the following: 1. Mild OSA (ie, apnea-hypopnea index from 1 to 5) and ONE OR MORE of the following: a. achondroplasia b. behavioral problems c. cardiovascular disease (eg, elevated blood pressure, pulmonary hypertension) d. Chiari malformation e. craniofacial abnormalities f. Down Syndrome g. excessive daytime sleepiness h. impaired cognition i. inattention or hyperactivity j. mucopolysaccharidoses k. neuromuscular disorders l. Prader-Willi syndrome 2. Moderate or severe OSA (ie, apnea-hypopnea index greater than 5) 3. Residual apnea-hypo pnea index greater than 5 in pediatric patient after adenotonsillectomy G. Restrictive disorder of chest wall , as indicated by ALL of the following: 1. Appropriate chest wall disorder as indicated by ONE OR MORE of the following: Noninvasive Home Mechanical Ventilation-GA MCD-MM-1700Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 a. asphyxiating thoracic dystrophy b. kyphoscoliosis c. other chest wall disorder accompanied by chronic respiratory failure (eg, ankylosing spondylitis, fibrothorax, post-tuberculous chest wall deformity) 2. Documentation of respiratory failure as indicated by ONE OR MORE of the following : a. Arterial O 2 saturation less than 88% for 5 consecutive minutes during nocturnal oximetry b. Daytime PCO 2 (arterial or capillary) greater than 45 mm Hg (6.0 kPa) c. Forced vital capacity less than 50% of predicted d. Forced vital capacity less than 80% of predicted and symptoms of respiratory failure e. Maximum inspiratory pressure 60 cm H 2O (5884 Pa) or lower f. Polysomnography demonstrates sleep hypoventilation, as indicated by ONE OR MORE of the following: 01. Adult with sleep-related hypoventilation (ie, arterial, end-tidal, or transcutaneous PCO 2 greater than 55 mm Hg (7.3 kPa) for 10 minutes or longer, or increase in arterial, end-tidal, or transcutaneous PCO 2 of 10 mm Hg (1.3 kPa) or greater above awake supine value resulting in PCO 2 greater than 50 mm Hg (6.7 kPa) for 10 minutes or longer) . 02. Child with sleep-related hypoventilation (ie, sleeping arterial, end-tidal, or transcutaneous PCO 2 of greater than 50 mm Hg (6.7 kPa) for greater than 25% of total sleep time, or peak sleep end-tidal PCO 2 of 55 mm Hg (7.3 kPa) or greater ). III. Respiratory status is STABLE , as indicated by ALL of the following:A. Airway interface is safe with a n oninvasive interface with acceptable fit . B. Airway pressure requirement appropriate, as indicated by ONE OR MORE of the following: 1. BiPAP expiratory positive airway pressure requirement is to 10 cm H 2O (981 Pa). 2. CPAP pressure requirement in child is 15 cm H 2O (1471 Pa). 3. Ventilator positive end-expiratory pressure requirement is 10 cm H 2O (981 Pa). C. Oxygen requirement does not exceed FiO 2 of 40%. D. Settings are stable on chosen device. E. No continuous invasive monitoring is required. IV. A BiPAP or CPAP device must NOT be clinically appropriate as indicated by ONEOR MORE of the following. A. Chronic respiratory insufficiency fails to improve with simple BiPAP device. B. Infant or child does not meet the minimum body weight requirement for CPAP device. Noninvasive Home Mechanical Ventilation-GA MCD-MM-1700Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 C. Infant or child is not appropriate for simple BiPAP device due to setting or performance requirements, as indicated by ONE OR MORE of the following:1. Breath rates delivered by device not appropriate for patient . 2. Compatible ventilator circuits not appropriate for patient (eg, circuit compliance, compressed volume, dead space) . 3. Inspiratory flows delivered by device not appropriate for patient . 4. Patient does not meet ventilator minimum body weight requirements. 5. Pressure range (eg, expiratory pressure, inspiratory pressure) not appropriate for patient . 6. Tidal volume range delivered by device not appropriate for patient. 7. Ventilator inspiratory trigger delay (ie, airway pressure rise time) not appropriate for patient . 8. Ventilator inspiratory trigger sensitivity not appropriate for patient . D. The following setting or functionality is required by the patient and is not available with simple BiPAP device: 1. Alarms required by patient are not available on the device . 2. Daytime ventilation using mouthpiece is required . 3. Pressure range delivered by device is not appropriate for patient . 4. Patient requires volume-assured pressure support or volume control mode (eg, obesity hypoventilation syndrome). E. Ventilated patient requires cough assistance via volume ventilator’s breath stacking capability. F. Ventilation is required 24 hours per day. V. HMV Continued UseFor HMV continued use beyond the initial 3-month determination, medical necessity must be reestablished every 6 months thereafter . The following is to be provided for continued use: A. Re-evaluation by the treating medical professional must be completed no earlier than 61 days after initiating therapy. B. Documentation of the persistence of the disease process for which HMV has been prescribed. C. Medical records must document that the patient is compliant with and benefitting from HMV. D. At least 30 consecutive days of device data, beginning after 31 days of initiation, demonstrating that the patient is utilizing the device an average of 6 hours per 24-hour period. NOTE: Failure of the patient to consistently use HMV for an average of 6 hours per 24-hour period would demonstrate non-compliant utilization of the device for its intended purpose and expectation of benefit, which would constitute a denial in continued coverage as not reasonable and necessary . E. Additional information as requested. VI. In accordance with GA DCH policy, DME 1112.10 , for each claim, the provider cannot legitimately receive payment until necessary supporting documents have Noninvasive Home Mechanical Ventilation-GA MCD-MM-1700Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 been obtained and placed in the providers files. These documents include the following items: A. A detailed written order including the type of equipment ordered, the length of need, and the qualifying diagnosis from D. II. B. A copy of the patient s history and physical examination from the ordering physician. C. The patient was an inpatient for at least 14 consecutive days prior to home ventilation. D. The patient is dependent on a ventilator for life support for at least 6 hours per day. E. The home ventilator replaces the need for inpatient respiratory care services that would be reimbursed by Medicaid. F. The patient has adequate support services or caregiver which would allow sufficient use of the ventilator in the home. 1. A checklist documenting the patient s environment from the vendor. 2. A comprehensive list of all items required for the patient to use the home ventilator (ie, back-up unit, suction equipment, and supplies). 3. The patient receives services under the direction of a pulmonary physician who is familiar with the technical and medical components of home ventilator support and has determined that in-home care is safe and feasible for the patient . G. Practitioner order and chart notes , which support the determination of medical necessity , including ventilator settings . VII. Regardless of its authorized length, a rental period ends when the rented item is no longer medically necessary. A certified respiratory technician (RT) is responsible for equipment set up, training/education on the proper usage of the equipment, and monthly visits to the home. VIII. ExclusionsA. Any application for HMV (E0466) not meeting the criteria above will be denied as being not medically necessary, including but not limited to when its sole purpose is to function as a respiratory assistance device, including CPAP, auto-titrating PAP, BiPAP /BPAP , average volume assured pressure support (AVAPS) with or without auto EPAP (A E), or intelligent volume assured pressure support (iVAPS). B. The HMV rental (E0466) includes all associated supplies that are required for appropriate use of the device and are not separately reimbursed. Servicing, repairs, and labor are included in the monthly rental fee and may not be submitted for separate reimbu rsement.E. Conditions of CoverageI. Claims for ventilators being utilized to provi de CPAP or BiPAP therapy for conditions described above and are submitted with HCPCS code E0466, will be denied as not being reasonable and necessary. If a HMV is dispensed to a patient for CPAP or Noninvasive Home Mechanical Ventilation-GA MCD-MM-1700Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 BiPAP therapy, the claim must be coded in accordance with CareSource policy,Positive Airway Pressure Devices for Pulmonary Disorders Continued Rental , and Georgia Department of Community Health policy, DME 1112.3 . All requirements in D. I. -V. of this policy must be satisfied for HMV to be considered medically necessary. II. CareSource may verify the use of equipment through post-payment review andrequest additional supporting medical record documentation. If the use of a more appropriate code or piece of equipment is warranted, CareSource may request recoupment.F. Related Policies/RulesGA DCH DME 1112.10 Positive Airway Pressure Devices for Pulmonary Disorders Continued Rental Overpayment Recovery G. Review/Revision HistoryDATE ACTIONDate Issued 09/11/2024 Approved at CommitteeDate Revised 05/21/2025 07/30/2025 Annual review-added E. II. Approved at Committee Revision D.VIII. Exclusions updated. Approved at Committee. Date Effective 11/01/2025 Date Archived H. References1. Coleman JM, Wolfe LF, Kalhan R. Noninvasive ventilation in chronic obstructive pulmonary disease. Ann Am Thorac Soc . 2019;16(9):1091-1098. doi: 10.1513/AnnalsATS.201810-657CME 2. Dudgeon D. Assessment and management of dyspnea in palliative care. UpToDate. Updated April 5, 2025 . Accessed May 5, 2025 . www.uptodate.com 3. Ferrell BR, Twaddle ML, Melnick A, et al. National Consensus Project clinical practice guidelines for quality palliative care guidelines, 4th edit. JPalliative Med . 2018;21(12): 1684-1689. doi:10.1089/jpm.2018.04311684 4. Freedman N. Treatment of obstructive sleep apnea: choosing the best positive airway pressure device. Sleep Med Clin . 2020;15(2):205-218. doi:10.1016/j.jsmc.2020.02.007 5. Gay PC. Nocturnal ventilatory support in COPD. UpToDate. Updated February 5, 2025 . Accessed May 5, 2025 . www.uptodate.com 6. Gay PC, Owens RL; ONMAP Technical Expert Panel. Executive summary: optimal NIV Medicare access promotion: a technical expert panel report from the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society. Chest . 2021;160(5):1808-1821. doi: 10.1016/j.chest.2021.05.074 Noninvasive Home Mechanical Ventilation-GA MCD-MM-1700Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.9 7. Hansen-Flaschen J, Ackrivo J. Practical guide to management of long-term noninvasive ventilation for adults with chronic neuromuscular disease. Resp Care . 2023;68(8):1123-1157. doi:10.4187/respcare.10349 8. Hill NS, Kramer NR. Noninvasive ventilation in adults with chronic respiratory failure from neuromuscular and chest wall diseases: patient selection and alternative modes of ventilatory support. UpToDate. Updated November 13 , 2024. Accessed April 16, 2025 . www.uptodate.com 9. Home Ventilator (Invasive or Noninvasive Interface): ACG A-0893. MCG Health . 2 8th ed. Accessed May 5, 202 5. www.careweb.careguidelines.com 10. Khan A, Frazer-Green L, Amin R, et al. Respiratory management of patients with neuromuscular weakness: an American College of Chest Physicians clinical practice guideline and expert panel report. Chest . 2023;164(2):394-413. doi:10.1016/j.chest.2023.03.011 11. Kline LR. Clinical presentation and diagnosis of obstructive sleep apnea in adults. UpToDate. Updated October 9, 202 4. Accessed May 5, 2025 . www.uptodate.com 12. Macrea M, Oczkowski S, Rochwerg B, et al. Long-term noninvasive ventilation in chronic stable hypercapnic chronic obstructive pulmonary disease: an official American Thoracic Society clinical practice guideline. Am JResp Crit Care Med . 2020;202(4):e74-e87. doi: 10.1164/rccm.202006-2382ST 13. Martin TJ. Noninvasive positive airway pressure therapy for obesity hypoventilation syndrome. UpToDate. Updated March 4, 2024. Accessed May 5, 2025 . www.uptodate.com 14. Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolargtngology Head Neck Surg. 2019;160(1S):S1-S42. doi: 10.1177/0194599818801757 15. Raveling T, Vonk J, Struik FM, et al. Chronic non-invasive ventilation for chronic obstructive pulmonary disease: review. Cochrane Database Syst Rev . 2021;8:CD002878. doi:10.1002/14651858.CD002878.pub3 16. Respiratory services: 1254 ventilators. Policies and Procedures for Durable Medical Equipment Services . Georgia Dept of Community Health; 202 5. Accessed May 5, 2025 . mmis.georgia.gov 17. Restrepo RD, Walsh BK. Humidification during invasive and noninvasive mechanical ventilation 2012: AARC clinical practice guideline. Respir Care . 2012;57(5):782-788. doi:10.4187/respcare.01766 18. van den Biggelaar RJM, Hazenberg A, Cobben NAM, et al. A randomized trial of initiation of chronic noninvasive mechanic ventilation at home vs in-hospital in patients with neuromuscular disease and thoracic cage disorder. Chest . 2020;158(6):2493-2501. doi: 10.1016/j.chest.2020.07.007 Independent Medical Review 05/08/24GA-MED-P-4284804 Issue date 09/11/2024 Approved DCH 08/19/2025

Myoelectric Lower Extremity Prosthetic Technology

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Myoelectric Lower Extremity Prosthetic Technology-GA MCD-MM-1222 11/01/2025 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 suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 4 E. Conditions of Coverage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Myoelectric Lower Extremity Prosthetic Technology-GA MCD-MM-1222Effective Date: 11/01/2025 The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMyoelectric Lower Extremity Prosthetic Technology B. Background The policy addresses the computerized limb prosthesis that is a nonstandard, external prosthetic device incorporating a microprocessor for movement control. These devices are equipped with a sensor that detects when the knee is in full extension and adjusts the swing phase automatically, permitting a more natural walking pattern of varying speeds. C. Definitions Myoelectric Lower Extremity Prosthetic Technology Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type. Classification Level Rehabilitation potential as described by Centers for Medicare & Medicaid Services: Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility a. The individual does not have sufficient cognitive ability to safely use a prosthesis with or without assistance. b. The individual requires assistance from equipment or caregiver in order to transfer and use of a prosthesis does not improve mobility or independence with transfers. c. The individual is wheelchair dependent for mobility and use of a prosthesis does not improve transfer abilities. d. The individual is bedridden and has no need or capacity to ambulate or transfer. Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence, typical of the limited and unlimited household ambulator. a. The individual has sufficient cognitive ability to safely use a prosthesis with or without an assistive device and/or the assistance/supervision of one person. b. The individual is capable of safe but limited ambulation within the home with or without an assistive device and/or with or without the assistance/supervision of one person. c. The individual requires the use of a wheelchair for most activities outside of their residence. d. The individual is not capable of most of the functional activities designated in Level 2. Level 2: Has the ability or potential for ambulation with the ability to transverse low level environmental barriers such as curbs, stairs or uneven surfaces. This level is typical of the a. The individual can ambulate with or without an assistive device (which may include one or two handrails) and/or with or without the assistance/supervision of one person: i. Perform the level 1 tasks designated above ii. Ambulate on a flat, smooth surface iii. Negotiate a curb iv. Access public or private transportation v. Negotiate 1-2 stairs vi. Negotiate a ramp built to ADA specifications Myoelectric Lower Extremity Prosthetic Technology-GA MCD-MM-1222Effective Date: 11/01/2025 The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 limited community ambulator.b. The individual may require a wheelchair for distances that are beyond the perimeters of the yard/driveway, apartment building, etc. c. The individual is only able to increase his/her generally observed speed of walking for short distances or with great effort. d. The individual is generally not capable of accomplishing most of the tasks at Level 3 (or does so infrequently with great effort). Level 3: Has the ability or potential for ambulation with variable cadence, typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. a. With or without an assistive device (which may include one or two hand rails), the individual is independently capable (i.e. requires no personal assistance or supervision) of performing the Level 2 tasks above and can i. Walk on terrain that varies in texture and level (eg, grass, gravel, uneven concrete) ii. Negotiate 3-7 consecutive stairs iii. Walk up/down ramps built to ADA specifications iv. Open and close doors v. Ambulate through a crowded area (eg, grocery store, big box store, restaurant) vi. Cross a controlled intersection within his/her community within the time limit provided (varies by location) vii. Access public or private transportation viii. Perform dual ambulation tasks (eg, carry an item or meaningfully converse while ambulating) b. The individual does not perform the activities of Level 4. Level 4: Has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress or energy levels typical of the prosthetic demands of the child, active adult, or athlete. With or without an assistive device (which may include one or two hand rails), this individual is independently capable (i.e. requires no personal assistance or supervision) of performing high impact domestic, vocational or recreational activities such as: a. Running b. Repetitive stair climbing c. Climbing of steep hills d. Being a caregiver for another individual e. Home maintenance (eg, repairs, cleaning) NOTE: Consideration is given to bilateral amputees who often cannot be strictlybound by the Classification Levels.Myoelectric Lower Extremity Prosthetic Technology-GA MCD-MM-1222Effective Date: 11/01/2025 The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 D. PolicyI. CareSource considers myoelectric lower limb prosthetic technology medically necessary when the following criteria are met: A. The member is 18 years of age or older. B. Has a lower extremity prosthesis(s). C. Documentation submitted supports medical necessity and includes the following: 1. A written order/prescription from a treating practitioner for the additional technology. 2. Sufficient documentation of the rehabilitation potential including, but not limited to, clear documentation supporting the expected potential classification level that is K3 or above. 3. Member exhibits the following characteristics: a. emotionally readiness b. ability and willingness to participate in training c. ability to care for the technology d. physically ability to use the equipment e. adequate cardiovascular and pulmonary reserve for ambulation at faster than normal walking speed NOTE: Documentation for Durable Medical Equipment, Prosthetics, Orthotics,and Supplies is followed. E. Conditions of CoverageN/A F. Related Policies/Rules Medical Record Documentation Standards for Practitioners G. Review/Revision History DATE ACTIONDate Issued 07/21/2022 New PolicyDate Revised 07/19/2023 08/28/2024 07/30/2025 Updated references. Approved at Committee Updated references. Approved at Committee Updated references. Approved at Committee Date Effective 11/01/2025 Date Archived H. References1. Centers for Medicare & Medicare Services Health Technology Assessment. Lower Limb Prosthetic Workgroup Consensus Document . September 2017. Accessed June 30, 2025. www.cms.gov 2. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items and services having special DME review considerations. Medicare Program Integrity Myoelectric Lower Extremity Prosthetic Technology-GA MCD-MM-1222Effective Date: 11/01/2025 The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 Manual . US Centers for Medicare and Medicaid Services; 2025. Accessed June 30,2025. www.cms.gov 3. Liu W, Fleming A, Lee IC, Huang HH. Direct myoelectric control modifies lower limb functional connectivity: a case study. Annu Int Conf IEEE Eng Med Biol Soc . 2021;2021:6573-6576. doi:10.1109/EMBC46164.2021.9630844 4. Lower limb prosethesis: A-0487 (AC). MCG Health. 28th ed. Accessed June 30, 2025. www.careweb.careguidelines.com 5. Schulte RV, Prinsen EC, Buurke JH, et al. Adaptive lower limb pattern recognition for multi-day control. Sensors (Basel) . 2022;22(17):6351. doi:10.3390/s22176351 Independent medical review May 2021 GA-MED-P-4284804 Issue Date 07/21/2022 Approved DCH 08/19/2025

Autonomic Nerve Testing

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Autonomic Nerve Testing-GA MCD-MM-1767 10/01/2025 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 suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Autonomic Nerve Testing-GA MCD-MM-1767Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectAutonomic Nerve Testing B. Background The autonomic nervous system (ANS) coordinates multiple reflex actions which are essential for life. It controls the heart rate, blood pressure, digestion, respiration, pupillary reactivity, sweating, urination, sexual arousal, and regulates the functions of internal organs. This system provides the homeostasis of the cells, tissues, and organs throughout the body and protects against the disturbances imposed by the external and internal stressors. The ANS has three main divisions: the sympathetic nervous system (SNS), the parasympathetic nervous system (PNS), and the enteric nervous system. In general, the SNS and PNS have opposing effects. Each region belonging to the 'pain matrix' interacts with ANS. The descending system regulates pain and creates a regulatory effect by the contribution of aminergic neurotransmitters. Disorders of the ANS can affect any system of the body; they can originate in the peripheral or central nervous system and may be primary or secondary to other disorders. Symptoms suggesting autonomic dysfunction include orthostatic hypotension, heat intolerance, nausea, constipation, urinary retention or incontinence, nocturia, impotence, and dry mucous membranes. If a patient has symptoms suggesting autonomic dysfunction, cardiovagal, adrenergic, and sudomotor tests are usually done to help determine severity and distribution of the dysfunction. Autonomic testing using automated devices, in which software automatically generates an interpretation, has not been validated. Most of these devices generate reports automatically and do not allow physician interpretation of the raw data, which is a serious design flaw when evaluating patients who have, for example, cardiac rhythm abnormalities that mislead the testing results. C. Definitions Autonomic Nervous System The part of the nervous system that controls involuntary visceral actions. Cardiovagal Innervation A test that provides a standardized quantitative evaluation of vagal innervation to parasympathetic function of the heart. Responses are based on the interpretation of changes in continuous heart recordings in response to standardized maneuvers and include heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio heart rate responses to standing. A tilt table may be used but is not required. Vasomotor Adrenergic Innervation A test that evaluates adrenergic innervation of the circulation and of the heart in autonomic failure. The following tests are included: beat-to-beat blood pressure and R-R interval response to Valsalva Autonomic Nerve Testing-GA MCD-MM-1767Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 maneuver, sustained hand grip, and blood pressure and heart rate responses to tilt-up or active standing and must be performed with a tilt table. Sudomotor Function testing is used to evaluate and document neuropathic disturbances that may be associated with pain. The quantitative sudomotor axon reflex test (QSART), thermoregulatory sweat test (TST), sympathetic skin responses, and silastic sweat imprints are tests of sympathetic cholinergic sudomotor. Sympathetic Skin Response A test to measure a provoked change in the electrical potential of the skin. D. PolicyI. CareSource considers autonomic nerve testing medically necessary to evaluate autonomic nerve function and aid in the diagnosis of ANY of the following conditions: A. distal small fiber neuropathy B. postural tachycardia syndrome C. reflexive sympathetic dystrophy D. recurrent variants of syncope E. One or more of the following progressive autonomic neuropathies: 1. diabetic autonomic neuropathy 2. amyloid neuropathy 3. Sjogrens syndrome 4. idiopathic neuropathy 5. pure autonomic failure 6. multiple system atrophy II. LimitationsProperly trained physicians with the necessary expertise should perform and interpret these tests. Training can be obtained through accredited residency/fellowship programs or AMA-approved continuing medical education courses. III. ExclusionsA. Autonomic nerve function testing to aid in the diagnosis of ANY other condition not listed above is not covered or reimbursable. B. Screening patients without signs or symptoms of autonomic dysfunction, including patients with diabetes, hepatic, or renal disease. C. Testing results that are not used in clinical decision-making or patient management D. The use portable automated devices for autonomic nerve testing, including ANSAR ANX 3.0, VitalScan ANS, ANSiscope or any similar device is considered experimental, investigational and non-covered. E. Conditions of CoverageNA Autonomic Nerve Testing-GA MCD-MM-1767Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 F. Related Policies/RulesExperimental or Investigational Item or Service G. Review/Revision History DATE ACTIONDate Issued 05/21/2025 New policy. Approved at Committee.Date Revised Date Effective 10/01/2025 Date Archived H. References1. Baker JR, Hira R, Uppal J, et al. Clinical assessment of the autonomic nervous system. Card Electrophysiol Clin . 2024;16(3):239-248. doi:10.1016/j.ccep.2024.02.001 2. Cheshire WP, Freeman R, Gibbons CH, et al. Electrodiagnostic assessment of the autonomic nervous system: a consensus statement endorsed by the American Autonomic Society, American Academy of Neurology, and the International Federation of Clinical Neurophysiology. Clin Neurophysiol . 2021;132(2):666-682. doi:10.1016/j.clinph.2020.11.024 3. Gutirrez J. Electrophysiological assessment of peripheral and central autonomic disorders. Handb Clin Neurol . 2023;195:301-314. doi:10.1016/B978-0-323-98818- 6.00015-7 4. Illigens BMW, Gibbons CH. Autonomic testing, methods and techniques. Handb Clin Neurol . 2019;160:419-433. doi:10.1016/B978-0-444-64032-1.00028-X 5. Lee HJ, Lee KH, Moon JY, Kim YC. Prevalence of autonomic nervous system dysfunction in complex regional pain syndrome. Reg Anesth Pain Med . 2021;46(3):196-202. doi:10.1136/rapm-2020-101644 6. Novak P. Quantitative autonomic testing. JVis Exp . 2011;(53):2502. doi:10.3791/2502 7. Panigrahi B, Srivastava AK, Garg D, et al. Examination of the autonomic nervous system at the bedside. Acta Neurol Belg . Published online December 5, 2024. doi:10.1007/s13760-024-02654-2 GA-MED-P-4051450 Issue Date: 05/21/2025 Approved DCH 07/14/2025

Peripheral Nerve Blocks for Treatment of Pain

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 10/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 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: 10/01/2025 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. Various areas of pain require different types of nerve blocks that can be administered in numerous parts of the body with some of the mos t common blocks being sympathetic, peripheral, and occipital. Sacroiliac and facet joint interventions, epidural steroid injections, and trigger point injections 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 Conservative 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 inconvenience 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: 10/01/2025 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 Procedures 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 ad dress 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 neuropathy 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 indication 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: 10/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 III. Chronic 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 criteria 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 to 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 provide d. 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 medications 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: 10/01/2025 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/Rules Epidural 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 02/26/2025 Annual review . Updated references. Approved at Committee . Annual review, references updated. Approved at Committee. Date Effective 10/01/2025 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 . 2021;61(7):1021-1039. doi:10.1111/head.14153 2. Allen SM, Mookadam F, Cha SS, 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 quality 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 cervicogenic 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 May 15, 2024 . Accessed February 9, 202 5. 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 : Greater Occipital Nerve Blocks for Treatment of Occipital Neuralgia . Hayes; 2023. Accessed February 9, 2025. www.evidence.hayesinc.com 10. Evidence Analysis Research Brief : Pudendal Nerve Decompression Surgery for Treatment of Pudendal Neuralgia. Hayes; 2022. Accessed February 9, 202 5. www.evidence.hayesinc.com Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 Effective Dat e: 10/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 11. Evidence Analysis Research Brief: Radiofrequency Ablation of Cluneal Nerves for Treatment of Chronic Low Back Pain. Hayes; 2023. Accessed February 7, 2025.12. Evolving Evidence Review: Middle Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2022. Reviewed March 13, 2024 . Accessed February 9, 202 5. www.evidence.hayesinc.com 13. Evolving Evidence Review: Superior Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2021. Revie wed December 18, 2024 . Accessed February 9, 202 5. www.evidence.hayesinc.com 14. Frank FT, Sawsan A. Chronic pelvic pain in adult females: treatment. UpToDate. Updated August 16, 2024 . Accessed February 9, 202 5. www. uptodate.co m 15. Garza I, Schwedt TJ. Chronic migraine. UpToDate. Updated October 3, 202 4. Accessed February 9, 202 5. www. uptodate.com 16. Garza I. Occipital neuralgia. UpToDate. Updated December 17, 2024 . Accessed February 9, 202 5. www.uptodate.com 17. Gautam S, Gupta N, Khuba S, et al . Evaluation of the efficacy 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 18. 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 19. Health Technology Assessment: Genicular Nerve Block for Treatment of Knee Osteoarthritis . Hayes; 202 3. Reviewed December 19, 2024 . Accessed February 9, 202 5. www.evidence.hayesinc.com 20. Health Technology Assessment: Local Injection Therapy for Cervicogenic Headache and Occipital Neuralgia. Hayes; 2017. Reviewed November 15, 2021. Accessed February 9, 202 5. www.evidence.hayesinc.com 21. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain . Hayes; 2021. Reviewed April 17, 2024 . Accessed February 9, 202 5. 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, Unal-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 pain. 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 January 10, 2025 . Accessed February 9, 202 5. www.uptodate.com 26. 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 27. 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 Peripheral Nerve Blocks for Treatment of Pain-GA MCD-MM-1432 Effective Dat e: 10/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 28. 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 29. Ornello R, Lambru G, Caponnetto V, et al. Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic review and meta – analysis. Expert Rev Neurotherapeutics . 2020;20(11):1157-1167. doi:10.1080/14737175.2020.1809379 30. Piltsis JG, Khazen O. Occipital neuralgia . American Academy of Neurological Surgeons. Accessed February 9, 2024 . www.aans.or g 31. 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):655 – 662. doi: 10.1002/pmrj.12258 32. 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 . Anesthesiology . 2010;112(4):810-833. doi: 10.1097/ALN.0b013e3181c43103 33. 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;144(4):943-952. doi :10.1097/PRS.0000000000006059 34. Tu F F, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate. Updated August 16, 2024 . Accessed February 9, 202 5. www. uptodate.com 35. Watson JC. Cervicogenic headache. UpToDate. Updated March 12, 2024 . Accessed February 9, 202 5. www.uptodate.com 36. Wray JK, Dixon B, Przkora R. Radiofrequency ablation. StatPearls. StatPearls Publishing; 202 5. Accessed February 7, 2025 . www.ncbi.nlm.nih.gov GA-MED-P-3769851 Issue Date 02/15/2023 Approved DCH 07/02/2025

Metabolic and Bariatric Surgery-Revision

MEDICAL POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Metabolic and Bariatric Surgery-Revision-GA MCD-MM-1060 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 suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Metabolic and Bariatric Surgery-Revision-GA MCD-MM-1060Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMetabolic and Bariatric Surgery: Revision B. Background Revision procedures are typically completed because of complications from or a failure of the initial surgical procedure. Complications may include surgical or anatomical complications, as well as nutritional or metabolic complications. A failure of the initial bariatric surgery may result in an inadequate weight loss or a weight regain. C. Definitions Revisional Bariatric Surgery (RBS) Surgery to address patients whose original operation was unsuccessful in achieving satisfactory weight loss goals or complications from the original operation have occurred. Inadequate Weight Loss Less than 50% expected weight loss and/or weight remains greater than 40% over ideal body weight (normal body weight Body Mass Index [BMI] parameter = 18.5-24.9). D. Policy I. CareSource considers surgical revision of a bariatric surgery procedure a covered service when medically necessary. II. An inadequate weight loss due only to non-compliance with dietary, behavior or exercise recommendations is not a medically necessary indication for a revision procedure. III. A revision procedure is medically necessary when all of the following criteria are met and documented in the medical record: A. surgery/procedure selected is a proven procedure and not considered experimental/investigational and B. a technical failure or major complication has occurred from the initial procedure that cannot be managed medically. Technical failure and major complication examples include the following: 1. persistent pain and recurrent bleeding occur 2. chronic stenosis remains after multiple dilations 3. faulty component or malfunction that cannot be repaired 4. candy cane roux syndrome 5. complications that cannot be corrected with band manipulation, adjustments or replacement including band slippage and port leakage or 6. obstruction confirmed by imaging studies. NOTE: Stretching of a stomach pouch formed by a previous bariatric surgery due to overeating is not considered a complication and therefore is not considered an indication for revision. Metabolic and Bariatric Surgery-Revision-GA MCD-MM-1060Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 IV. In the absence of a technical failure or major complication, individuals with weight loss failure 2 years following the initial bariatric surgery procedure must meet the medical necessity criteria for an initial bariatric surgery. E. Conditions of Coverage N/A F. Related Policies/Rules Metabolic and Bariatric Surgery Experimental or Investigational Item or Service G. Review/Revision History DATE ACTIONDate Issued 07/22/2020 New policy Separated out from policies listed in Related policies/rulesDate Revised 06/23/2021 06/22/202206/19/202302/26/2025 PA language replaced by medical necessity criteria. PA enforced by inclusion on the PA list. Updated references. Reworded language in section IV, Updated references. Added definition of Revisional bariatric surgery (RBS). Updated references. Approved at Committee Annual review. Approved at Committee. No changes. Annual review. Approved at Committee. Date Effective 10/01/2025 Date Archived H. References1. Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federal for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis. 2022;18(12):1345-1356. Accessed January 14, 2025. www.soard.org 2. Ellsmere J. Bariatric operations: late complications with subacute presentations. Updated July 18, 2023. Accessed June 17, 2024. www.uptodate.com 3. Gastric Restrictive Procedure with Gastric Bypass (S-512). MCG. 28th ed. 2024. Accessed January 14, 2025. www.careweb.careguidelines.com 4. Mechanisk J, Apovian C, et al. Clinical practice Guidelines for the Perioperative Nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures 2020 Update: Cosponsored by American Association of Clinical Endocrinologist/American college of Endocrinology, The obesity society, American Society for metabolic & Bariatric surgery, Obesity medicine Association, and American Society of Anesthesiologists. Obesity . 2020;28(4):01-58. doi:10.1002/oby.22719 5. Palep J. Reoperative bariatric surgery. Recent Advances in Minimal Access Surgery . JP Medical Ltd; 2019:14-151. Metabolic and Bariatric Surgery-Revision-GA MCD-MM-1060 Effective Date: 10/01/2025 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 4 6.Weight-Loss and Weight-Management Devices . Federal Drug Administration; 2020. Accessed January 17, 2025. www.fda.gov7. Yung-Chieh Y, Huang C, Tai C. Psychiatric aspects of bariatric surgery. Curr OpinPsychiatry . 2014;27(5):374-379. doi:10.1097/YCO.00000000000000085. Independent medical review 7/2020 GA-MED-P-3769851 Issue Date 07/22/2020 Approved DCH 07/24/2025

Metabolic and Bariatric Surgery

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Metabolic and Bariatric Surgery-GA MCD-MM-0792 10/01/2025 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 suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definition…………………………………………………………………………………………………………….. 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 5 F. Related Polices/Rules …………………………………………………………………………………………… 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 6 Metabolic and Bariatric Surgery-GA MCD-MM-0792Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMetabolic and Bariatric Surgery B. Background Obesity continues to be a major health threat in the United States affecting an increasingly larger proportion of adults and children. The Centers for Disease Control and Prevention (CDC) estimates that over 40.3% of adults in the United States older than the age of 20 are obese (2021-2023). Obesity in adults aged 40 to 59 is higher (46.4%) than those under aged 40 (35.5%). Statistics indicate that there has been a significant increase in obesity from 1999 through 2020. Only tobacco has a higher modifiable risk factor in adult mortality. If continuing to trend at the current rate, obesity will become the number one modifiable risk factor in adult mortality. Obesity-related health problems include hypertension, type II diabetes, hyperlipidemia, atherosclerosis, heart disease, stroke, diseases of the gallbladder, osteoarthritis, sleep apnea, and certain cancers. The primary goals in achieving optimal health outcomes for CareSource members are to provide noninvasive approaches to reduce or prevent obesity by promoting healthy lifestyles that will improve long-term outcomes. For individuals not able to manage severe obesity though non-surgical interventions, metabolic and bariatric surgery options may be an effective intervention. C. Definition Body Mass Index (BMI) for Adults A persons weight in kilograms divided by the square of height in meters. Substance Use Disorder (SUD) A cluster of cognitive, behavioral, and physiological symptoms indicating continued use of substances despite significant substance-related problems, encompassing 10 separate classes of drug criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition . Behavioral Health Provider A provider of behavioral health services (minimum masters level), including a psychologist, psychiatrist, and psychiatric nurse practitioner. Weight Loss Surgery Surgery also known as bariatric and metabolic surgery. These terms are used in order to reflect the impact of these operations on patients weight and the health of their metabolism (breakdown of food into energy). In addition to their ability to treat obesity, these operations are very effective in treating diabetes, high blood pressure, sleep apnea and high cholesterol, among many other diseases. D. PolicyI. Metabolic and bariatric surgery is considered medically necessary when all the following criteria are met: A. primary diagnosis of obesity B. member is 13 years of age or older Metabolic and Bariatric Surgery-GA MCD-MM-0792Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 C. One of the following BMI requirements are met:1. BMI 35 kg/m 2 or greater 2. BMI 30 to 34.9 kg/m 2 and at least one serious obesity related condition, such as: a. high risk for Type II diabetes (insulin resistance, prediabetes, and/or metabolic syndrome) b. osteoarthritis of knee or hip c. improving outcomes of knee or hip replacement d. obstructive sleep apnea (CPAP should be considered prior to undergoing surgery) e. non-alcoholic fatty liver disease f. non-alcoholic steatohepatitis g. pseudotumor cerebri h. gastroesophageal reflux disease i. severe urinary stress incontinence j. poorly controlled hypertension on multiple drug therapy 3. BMI >30 kg/m2 with Type II diabetes mellitus (DM) if documentation is provided that Type II DM is inadequately controlled despite optimal medical treatment by either oral or injectable medications, including insulin. D. Mandatory participation in a preoperative weight loss regimen prior to weight loss surgery is not required. II. Written clinical documentation and supporting information from the attending surgeon must include all of the following: A. Evidence of informed consent. B. Letter from the Primary Care Physician (PCP) or appropriate specialist, including the following content: 1. medical necessity for procedure 2. health-related behaviors addressed, such as smoking history or adherence C. Evidence that the member is receiving treatment in a multi-disciplinary program that can provide ALL of the following: 1. preoperative medical consultation 2. preoperative mental health consultation 3. nutritional counseling 4. exercise counseling 5. patient support programs D. Substance use screening results. E. Evidence that harm reduction related to substance use was discussed. F. Evidence that risks of nicotine were discussed. G. Evidence that vitamin Bdeficiencies were monitored and treated as needed prior to surgery. H. Evidence that member is free of endocrine disease as supported by an endocrine study consisting of a T3, T4, blood sugar, and a 17-Keto Steroid or Plasma Cortisol. Metabolic and Bariatric Surgery-GA MCD-MM-0792Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 I. Documentation illustrating the member has been evaluated within the past 6months by the treating behavioral health provider, including consideration of all of the following: 1. list of co-existing psychiatric conditions 2. family and social support 3. evidence that the member understands the surgical procedure and can make a responsible decision 4. evidence that the member is stable enough to a. understand the risks and benefits b. change lifestyle through diet moderation and strategic eating c. follow through with the extensive aftercare plan d. withstand the rigors of surgery e. not display signs of suicidality or significant decompensation if the procedure is unsuccessful J. Complete history and physical, including an assessment, listing of diagnoses, height, weight, BMI, and treatment plan, must be provided. The exclusion or diagnosis of genetic or syndromic obesity, such as Prader-Willi Syndrome, must also be documented. K. For women with reproductive capacity, appropriate conception counseling was discussed and documented, including the following: 1. Clear documentation that supports that the member has agreed to avoid pregnancy for at least 1 year postoperatively. 2. Discussion of potential birth defects from nutritional deficiencies that can occur if becoming pregnant during the weight stabilization period following surgery. III. Contraindications/noncovered procedures includeA. Surgery is contraindicated in the following: 1. a medically correctable cause of obesity 2. current or planned pregnancy within one year of procedure 3. active suicidality or self-harm 4. active psychosis 5. active substance use disorder or ongoing abuse of substances within the previous year 6. severe coagulopathy 7. uncontrolled and untreated eating disorders 8. inability to comply with postoperative long-term follow-up care B. The intended procedure is not covered if it is experimental or investigational. These include, but are not limited to: 1. endoscopic sleeve gastroplasty (ESG) 2. aspiration therapy (AT). IV. The following members should be referred to an accredited comprehensive center A. BMI >55kg/m 2 B. Members with the following issues: Metabolic and Bariatric Surgery-GA MCD-MM-0792Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 1. organ failure 2. organ transplant 3. significant cardiac or pulmonary impairment 4. on a transplant list or 5. non-ambulatoryE. Conditions of CoverageN/A F. Related Polices/Rules Metabolic and Bariatric Surgery: Revision G. Review/Revision HistoryDATE ACTIONDate Issued 02/24/2015 IssuedDate Revised 04/05/2016 06/05/2019 07/22/2020 01/08/202106/23/202106/22/202206/21/202306/19/2024 02/26/2025Included MCG 23 rd Ed. Revisions to content and Table A.Included MCG 20 th Ed. Revisions to Table A Updated conservative approaches prior to surgery & BMI requirements; added SUD, health related behaviors, Vitamin B, and nicotine requirements; updated psychological evaluation, conception counseling & contraindications/noncovered procedures, separated revision criteria into a separate policy; updated referral to comprehensive center. Clarified high risk type II diabetes PA language replaced by medical necessity criteria. PA enforced by inclusion on the PA list. Updated references. Updated background. Removed documentation requirement from III. J. member not currently pregnant. Added E&I devices to IV. B. Title changed to Metabolic and Bariatric Surgery in Adults 19 and Older to reflect state law. Added definition for Weight Loss Surgery. Added new MCG criteria, changed title and combined adolescent and adult in all markets. Updated references. Approved at Committee. Updated references. Approved at Committee Removed I.C., added D. Mandatory participation in a preoperative weight loss is not required. (Health Equity consideration). Removed II.B.2. Documentation that member has been evaluated by a nutritionist/dietician during supervised weight loss. Updated references. Removed endoscopic bariatric and metabolic therapies, such as Intragastric balloon (IGB) from E&I section to reflect coverage in DCH Physicians Services provider manual. Approved at Committee. Updated references. Approved at Committee. Date Effective 10/01/2025 Metabolic and Bariatric Surgery-GA MCD-MM-0792Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 Date ArchivedH. References1. AAP Updates Recommendations on Obesity Prevention: It's Never Too Early to Begin Living a Healthy Lifestyle. Accessed January 13, 2025. www.aap.org 2. Abdul Wahab R, Al-Ruwaily H, Coleman T, et al. The relationship between percentage weight loss and World Health Organization-Five Wellbeing Index (WHO-5) in patients having bariatric surgery. Obes Surg . 2022;32(5):1667-1672. doi:10.1007/s11695-022-06010-2 3. Adult obesity facts. Centers for Disease Control and Prevention. Accessed January 13, 2025. www.cdc.gov 4. American Diabetes Association. Obesity management for the treatment of Type 2 Diabetes: standards of medical care in diabetes 2020. Diabetes Care. 2020;43(1). doi:10.2337/dc20-S008 5. American Society for Metabolic and Bariatric Surgery. Bariatric surgery procedures. Accessed January 13, 2025. www.asmbs.org 6. Bariatric Surgery. NIDDK. Accessed January 6, 2025. www.niddk.nih.gov 7. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery. JAMA . 2004;292(14):1724. doi:10.1001/jama.292.14.1724 8. Center for Disease Control and Prevention. Prevalence of Obesity in the United States. 2024. Accessed January 13, 2025. www.cdc.gov 9. Chapman A. Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery . 2004;135(3):326-351. doi:10.1016/s0039- 6060(03)00392-1 10. Coverage of weight loss surgery. Medicaid Provider Manual: Hospital . Michigan Dept of Health and Human Services; 2024: 3.35.A. Accessed January 6, 2025. www. mdch.state.mi.us 11. Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG- 00250R). U.S. Dept. of Health and Human Services, Centers for Medicare and Medicaid Services. February 21, 2006. 12. Ellesmere JC. Bariatric operations: late complications with subacute presentations. UpToDate. Updated July 18, 2023. Accessed January 13, 2025. www.uptodate.com 13. Federal Drug Administration. Weight-Loss and Weight-Management Devices . April 27, 2020. Accessed January 13, 2025. www.fda.gov 14. Gastric Restrictive Procedure with Gastric Bypass: S-512. MCG Health; 2024. 28th ed. Accessed January 6, 2025. www.careweb.careguidelines.com 15. Guidelines for Clinical Application of Bariatric Surgery . Accessed January 13, 2025. www.sages.org 16. Health Technology Assessment: Comparative Effectiveness Review of Bariatric Surgeries for Treatment of Obesity in Adolescents. July 21, 2019. Reviewed January 20, 2022. Accessed January 6, 2025. www.hayesinc.com 17. Kalarchian M. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am JPsychiatry . 2007;164(2):328. doi:10.1176/appi.ajp.164.2.328 Metabolic and Bariatric Surgery-GA MCD-MM-0792Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 18. Lim RB. Bariatric procedures for the management of severe obesity: descriptions.UpToDate. Updated April 13, 2023. Accessed January 13, 2025. www.uptodate.com 19. Marcus M, Kalarchian M, Courcoulas A. Psychiatric evaluation and follow-up of bariatric surgery patients. Am JPsychiatry . 2009;166(3):285291. doi:10.1176/appi.ajp.2008.08091327 20. Mechanisk J, et al. AACE/TOS/ASMBS/OMA/ASA 2019 Guidelines. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures 2020 update: cosponsored by American Association of Clinical Endocrinologist/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity . 2020;28(4). Accessed January 6, 2025. www.onlinelibrary.wiley.com 21. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of Obesity Among Adults and Youth: United States, 20112014 . NCHS data brief no. 219. National Center for Health Statistics; 2015. 22. Potential Candidates for Bariatric Surgery. National Institute of Diabetes and Digestive and Kidney Diseases. Accessed January 13, 2025. www.niddk.nih.gov 23. Prevalence of Obesity Among Adults and Youth: United States, 2017-2018. NCHS Data Brief no. 360. February 2020. Accessed January 13, 2025. www.cdc.gov 24. Repeat Bariatric Surgery for Patients Who Have Not Reached Weight-loss Goals after Previous Surgery. Accessed January 6, 2025. www.ecri.org 25. Shekelle, P. Mental health assessment and psychological interventions for bariatric surgery. Accessed January 13, 2025. www.hsrd.research.va.gov 26. The Practical Guide to Identification and Treatment of Overweight and Obesity in Adults . Health and Human Services Dept; 2000. Accessed January 13, 2025. www.nhlbi.nih.gov 27. Updated Guidelines for Bariatric Surgery. Accessed January 13, 2025. www.hayesinc.com 28. Yung-Chieh Y, Huang C, Tai C. Psychiatric aspects of bariatric surgery. Curr Opinion Psychiatry . 2014;27(5). doi:10.1097/YCO.0000000000000085 Independent medical review 7/2020 GA-MED-P-3769851 Issue Date 02/24/2015 Approved DCH 07/02/2025

Mechanical Stretching Devices

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Mechanical Stretching Devices-GA MCD-MM-1381 10/01/2025 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 suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 4 Mechanical Stretching Devices-GA MCD-MM-1381Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMechanical Stretching Devices B. Background Mechanical stretching devices are intended to restore range of motion (ROM) for joint stiffness or contracture by stretching joints. These devices provide passive stretching to an adjustable degree for a selected duration for multiple sessions. A variety of mechanical stretching devices are available for extension or flexion of the shoulder, elbow, wrist, fingers, knee, ankle, and toes. These devices can provide stretching for longer periods than a physical therapist and are generally used as adjunct treatment to physical therapy and/or exercise. Mechanical Stretching Devices (also known as dynamic splinting systems) include: Low-load prolonged duration stretch devices (LLPS) Static progressive stretch (SPS) splint devices Patient actuated serial stretch (PASS) devices C. Definitions Low-Load Prolonged Duration Stretch Devices (LLPS) These devices permit resisted active and passive motion (elastic traction) within a limited range. LLPS devices maintain a set level of tension by means of incorporated rubber bands or springs. Patient Actuated Serial Stretch (PASS) Devices These devices hold the joint in a set position but allow for manual modification of the joint angle and may allow for active motion without resistance (inelastic traction). This type of device itself does not exert a stress on the tissue unless the joint angle is set at the maximum ROM. Static Progressive Stretch Devices (SPS) These devices hold the joint in a set position but allow for manual modification of the joint angle and may allow for active motion without resistance (inelastic traction). D. Policy I. CareSource considers dynamic splinting devices medically necessary durable medical equipment (DME) as an adjunct treatment to physical therapy, massage and/or exercise for an existing joint contracture when the following clinical criteria is met: A. medically necessary only for the following joints: knee, elbow, wrist, finger, ankle and toe B. after three weeks of exercise and skilled therapy in the initial subacute injury or post-operative period in members with: 1. signs and symptoms of persistent joint stiffness or contracture, and 2. limited range of motion that poses a meaningful functional limitation as judged by a physician C. may be used for an initial period of 4 weeks, a subsequent 4-week period with reevaluation, and then up to 4 months based on continued improvement. Mechanical Stretching Devices-GA MCD-MM-1381Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 II. In the acute post-operative period for members who have undergone additional surgery to improve the range of motion of a previously affected joint, CareSource considers use of an LLPS device medically necessary for: A. an initial four-week period B. an additional four-week period, if improvement was noted after the initial four weeks, for up to 4 months. III. Non-Covered ServicesA. CareSource considers the use of dynamic splinting experimental and investigational for the following indications, including but not limited to: 1. adhesive capsulitis 2. carpal tunnel syndrome 3. cerebral palsy 4. foot drop associated with neuromuscular diseases, 5. hallux valgus 6. head and spinal cord injuries 7. improvement of outcomes following botulinum toxin injection for treatment of limb spasticity 8. injuries of the ankle and shoulder 9. multiple sclerosis 10. muscular dystrophy 11. plantar fasciitis 12. rheumatoid arthritis 13. stroke 14. trismus B. CareSource considers the following devices experimental and investigational due to insufficient scientific evidence of efficacy: 1. patient actuated serial stretch (PASS) devices (for example, ERMI Knee Extensionater and ERMI Shoulder Extensionater) 2. static progressive stretch devices (SPS) (for example, Joint Active Systems (JAS) splints (for example, JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and JAS Pronation-Supination) E. Conditions of CoverageAll claims for LLPS are subject to post-payment review by CareSource. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 11/09/2023 New PolicyMechanical Stretching Devices-GA MCD-MM-1381Effective Date: 10/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 Date Revised 02/15/2023 06/07/2023 05/22/2024 03/12/2025e-voted addition of ankle and toe to policy to match fee schedule and MCG. Annual review. Added examples of PASS and SPS devices. Annual review. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee Date Effective 10/01/2025 Date Archived H. References1. Furia JP, Willis FB, Shanmugam R, et al. Systematic review of contracture reduction in the lower extremity with dynamic splinting. Adv Ther . 2013;30(8):763-770. 2. Georgia Medicaid Orthotic & Prosthetic (O&P) Services Fee Schedule. Georgia Dept of Community Health. April 1, 2024. Accessed January 29, 2025. www.mmis.georgia.gov 3. Dynamic Joint Extension and Flexion Devices: ACG A-0882. MCG. 28th ed. 2024. Accessed January 29, 2025. www.careweb.careguidelines.com 4. Glasgow C, Tooth LR, Fleming J, et al. Dynamic splinting for the stiff hand after trauma: predictors of contracture resolution predictors of contracture resolution. J Hand Ther . Accessed January 29, 2025. www.jhandtherapy.org 5. Harvey LA, Katalinic OM, Herbert RD, et al. Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews. 2017. Accessed January 29, 2025. www.pubmed.ncbi.nlm.nih.gov 6. Medical Technology Directory. Mechanical Stretching Devices for the Treatment of Joint Contractures of the Extremities. Hayes, Inc. 2022. Accessed January 29, 2025. www.hayesinc.com 7. Jongs RA, Harvey LA, Gwinn T, et al. Dynamic splints do not reduce contracture following distal radial fracture: a randomised controlled trial. JPhysiother . 2012;58(3):173-180. Accessed January 29, 2025. www.reader.elsevier.com 8. Zatarain LA, Smith DK, Deng J, et al. A randomized feasibility trial to evaluate use of the jaw dynasplint to prevent trismus in patients with head and neck cancer receiving primary or adjuvant radiation-based therapy. Integr Cancer Ther . 2018. ;17(3):960- 967. doi:10.1177/1534735418784363. GA-MED-P-3769851 11/09/2023 Approved DCH 07/02/2025Independent medical review 12/21

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