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

Breast Reduction Surgery

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Breast Reduction Surgery-GA MCD-MM-0253 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 Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 7 F. Related Polic ies /R ules ………………………….. ………………………….. ………………………….. …….. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 Breast Reduction Surgery-GA MCD-MM-0253Effective 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. SubjectBreast Reduction Surgery B. BackgroundWomen diagnosed with macromastia (excessively large breasts) seeking breast reduction typically present with complaints of a feeling of heaviness, chronic pain , and tension in the neck, shoulders , and upper back. Macromastia commonly causes permanent grooving and ulceration of the shoulder following years of wearing support bras to try to minimize symptoms. The physical and psychological symptoms of macromastia can significantly and negatively impact an individuals life and should be taken into consideration when evaluating su rgical intervention. Reduction mamm aplasty is a surgical procedure that reduc es the weight and volume ofthe breast. As much as one to five pounds of excess breast tissue is routinely removed during a reduction mamm aplasty depdending on breast and body mass . Indications for surgery include chronic pain and skin symptoms , neuropathy, breast discomfort, physical impairment , and psychological symptoms that can be associated with poor self-esteem and loss of desire to engage in activities. Gynecomastia is the benign proliferation of glandular tissue of the breast in males. Thiscondition may be caused by androgen deficiency , medication s, chronic medical conditions , tumors , or endocrine disorders. Depending on the cause of the tissue proliferation, surgical removal may be considered cosmetic or medically necessary. C. Definitions Body Surface Area (BSA) A metric used for physiologic measurements, pharmacologic dosing, and therapeutic calculations, including the Schnur Sliding Scale for breast reduction surgery. Cosmetic Procedures Procedures performed for aesthetic purposes that do not improv e or restor e physiologic function. Functional/Physical or Physiological Impairment Impairment caus es deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired or delayed capacity to move and coordinate actions , or perform physical activities and is exhibited by difficulties in physical and motor tasks, independent movement, and performing basic life functions. Gynecomastia Enlargement of the male breast secondary to a proliferation of ductal, stromal, and/or fatty tissue. Gynecomastia Scale A qualitative classification system for gynecomastia developed by the American Society of Plastic Surgeons (ASPS). a. Grade I Small breast enlargement with localized button of tissue that is concentrated around the areola. b. Grade II Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Breast Reduction Surgery-GA MCD-MM-0253Effective 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. Grade III Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present. d. Grade IV Marked breast enlargement with skin redundancy and feminization of the breast. Intertriginous Rash Dermatitis occurring between juxtaposed folds of skin, caused by retention of moisture and warmth , and providing an environment favoring overgrowth of normal skin micro-organisms. Kyphosis Over-curvature of the thoracic vertebrae (upper back) associated with degenerative diseases , such as arthritis, developmental problems, or with osteoporotic compression fractures of vertebral bodies. Macromastia (Breast Hypertrophy) An increase in the volume and weight of breast tissue relative to the general body habitus. Mammography An imaging technique that uses low-energy X-rays to examine breast tissue for diagnosis and screening. Symptomatic Breast Hypertrophy A syndrome of persistent neck and shoulder pain, shoulder grooving from brassiere straps, chronic intertriginous rash of the infra – mammary fold and/or frequent episodes of headache, backache, and upper extremity neuropathies caused by an increase in the volume and weight of breast tissue beyond normal proportions. Schnur Sliding Scale Use d in calculating the amount of breast tissue to be removed in reduction mamm aplasty (Appendix A). D. PolicyI. CareSource considers b reast reduction surgery for macromastia medically necessary when ALL the following criteria are met and have been documented : A. Member is 18 years or older , or under 18 years with evidence that breasts have finished growing for a minimum of one year . P arental/guardian consent is required for members under age 18 . B. Breast size interferes with activities of daily living , as indicated by 1 or more of the following: 1. arm numbness consistent with brachial plexus compression syndrome 2. cervical pain 3. chronic breast pain 4. headaches 5. nipple position greater than 21 cm below suprasternal notch 6. persistent redness and erythema (intertrigo) below breasts 7. restriction of physical activity 8. severe bra strap grooving or ulceration of shoulder 9. shoulder pain 10. thoracic kyphosis 11. upper or lower back pain C. Preoperative evaluation by surgeon concludes that the amount of breast tissue to be removed (by mass or volume) will provide a reasonable expectation of symptomatic relief. Breast Reduction Surgery-GA MCD-MM-0253Effective 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 D. No evidence of breast cancer1. physical exam completed by a physician within the last year if under 40 years of age 2. women 40 to 54 years of age or older with mammogram negative for cancer performed within the year prior to the date of the planned breast reduction surgery. 3. women 55 years of age and older with negative mammograms for cancer every 2 years 4. women with family history of breast cancer with mammograms starting at least 7 years prior to when the youngest family member was diagnosed with breast cancer (as early as 30 years old) II. Breast reduction surgery following mastectomy to achieve symmetry is covered as part of the Womens Health and Cancer Rights Act (WHCRA). Please refer to theCareSource Medical policy titled Breast Reconstruction Post Mastectomy for additional information. III. CareSource considers breast reduction surgery for gynecomastia medically necessary when ALL the following clinical criteria are met and have been documented: A. Member is 18 years or older , or under 18 years with evidence that breasts have finished growing for a minimum of one year . Parental/guardian consent is required for members under age 18 . B. A physical exam has been conducted by an appropriately credentialed provider and confirms the presence of gynecomastia: 1. pubertal male (adolescent) a. gynecomastia present for more than 1 year after pathological causes ruled out b. Gynecomastia Grade II, III, or IV 2. postpubertal male a. gynecomastia present for more than 3 months after pathological causes ruled out b. Gynecomastia Grade III or IV C. The tissue being removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of drug treatment that can be discontinued. D. The gynecomastia is attributed to an underlying condition (not an all-inclusive list), including: 1. androgen deficiency 2. chronic liver disease that causes decreased androgen availability 3. Klinefelter syndrome 4. adrenal tumors that cause androgen deficiency or increased secretion of estrogen 5. brain tumors that cause androgen deficiency 6. testicular tumors that cause androgen deficiency or tumor secretion of estrogen Breast Reduction Surgery-GA MCD-MM-0253Effective 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 7. endocrine disorders (eg, hyperthyroidism)E. The gynecomastia causes functional impairment (eg, pain, chronic irritation) and breast reduction surgery is not for cosmetic reasons. F. Breast malignancy was ruled out. IV. Schnur Sliding ScaleThe S chnur Sliding Scale is one of several evalu ation tools used to de termine the appr opriate volume of tissue to be r emoved relati ve to a members total body surface area ( BSA ). This esti mation can be instr umental in determining whet her br east reducti on sur gery is being planned for cos metic reas ons or as a medical ly neces sary procedure. A. The weight of tiss ue to be r emoved from each brea st is recommended to be above t he 22nd percentile on the Sc hn ur Sliding Scale ( App endix A belo w) based on t he members BSA. B. The BSA in met ers s quar ed ( m2) is c alcula ted using the Mos teller f ormu la (square root of the result of height (inches) multiplied by weight (lbs) and divided by 3131 ). App endix A: Schnur Sliding Sca leBody Su rface Ar ea an d M inim um Re quirement for Breast Tissue R emoval Body Surface Area (m2)Gr ams per Br east of Minimum Breast T issue to be Remo ved 1.350-1.374 199 1.375-1.399 208 1.400-1.424 218 1.425-1.449 227 1.450-1.474 238 1.475-1.499 249 1.500-1.524 260 1.525-1.549 272 1.550-1.574 284 1.575-1.599 297 1.600-1.624 310 1.625-1.649 324 1.650-1.674 338 1.675-1.699 354 1.700-1.724 370 1.725-1.749 386 Breast Reduction Surgery-GA MCD-MM-0253Effective 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 1.750-1.774 4041.775-1.799 422 1.800-1.824 441 1.825-1.849 461 1.850-1.874 482 1.875-1.899 504 1.900-1.924 527 1.925-1.949 550 1.950-1.974 575 1.975-1.999 601 2.000-2.024 628 2.025-2.049 657 2.050-2.074 687 2.075-2.099 717 2.100-2.124 750 2.125-2.149 784 2.150-2.174 819 2.175-2.199 856 2.200-2.224 895 2.225-2.249 935 2.250-2.274 978 2.275-2.299 10 22 2.300-2.324 10 68 2.325-2.349 11 17 2.350-2.374 11 67 2.375-2.399 12 19 2.400-2.424 12 75 2.425-2.449 13 33 2.450-2.474 13 93 2.475-2.499 14 55 2.500-2.524 15 22 2.525-2.549 15 90 2.550 or grea ter 16 62 Breast Reduction Surgery-GA MCD-MM-0253Effective 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 E. Conditions of CoverageN/A F. Related Polic ies /R ulesBreas t Reconstruction Surgery G. Review/Revision HistoryDATE ACTIONDate Issued 04/02/2019Date Revised 04/15/2020 03/17/202103/16/202203/15/202306/21/2023 02/28/2024 03/12 /2025Annual Update: Update to MCG Health Clinical Indications; addition of Related Policies .Added male breast reduction surgery criteria. Updated references. Approved at PGC.Revised D.I, D.I.A., D.II. and D.II.A. Updated references. Approved at CommitteeRemoved II.C. Updated references. Approved at Committee. Revision: expanded policy to cover members under 18 years of age, removed definitions, and updated references. Approved at Committee. Annual review: updated background and definitions, added D.I.D.4., revised gynecomastia criteria, and updated references. Approved at Committee. Date Effective 10/01/2025 Date Archived H. References1. ASPS recommended insurance coverage criteria for third-party payers: gynecomastia. American Society of Plastic Surgeons. Accessed March 3, 2025. www.plasticsurgery.org 2. ASPS recommended insurance coverage criteria for third-party payers: reduction mammaplasty. American Society of Plastic Surgeons. Accessed March 3, 2025. www.plasticsurgery.org 3. Billa E, Kanakis GA, Goulis DG. Imaging in gynecomastia. Andrology . 2021;9(5):1444-1456. doi:10.1111/andr.13051 4. Biro F M, Chan Y M. Normal puberty. UpToDate. Updated September 24, 2024. Accessed January 31, 2025. www.uptodate.com 5. Braunstein G D, Anawalt BD. Clinical features, diagnosis, and evaluation of gynecomastia in adults. UpToDate. Updated April 26, 2023. Accessed January 31, 2025. www.uptodate.com 6. Braunstein G D, Anawalt BD . Management of gynecomastia. UpToDate. Updated September 27, 2024. Accessed January 31, 2025. www.uptodate.com 7. Briefing paper: plastic surgery for teenagers. American Society of Plastic Surgeons. Accessed January 31, 2025. www.plasticsurgery.org Breast Reduction Surgery-GA MCD-MM-0253Effective 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.8 8. Guliyeva G, Cheung JY, Avila FR, et al. Effect of reduction mammoplasty on pulmonary function tests: a systematic review. Ann Plast Surg . 2021;87(6):694-698. doi:10.1097/SAP.0000000000002834 9. Hansen J, Chang S. Overview of breast reduction. UpToDate. Updated April 19, 2023. Accessed January 31, 2025. www.uptodate.com 10. Holzmer SW, Lewis PG, Landau MJ, et al. Surgical management of gynecomastia: a comprehensive review of the literature. Plast Reconstr Surg Glob Open . 2020;8(10):e3161. doi:10.1097/GOX.0000000000003161 11. Kanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines – gynecomastia evaluation and management. Andrology . 2019;7(6):778-793. doi:10.1111/andr.12636 12. Kimia R, Magee L, Caplan HS, et al. Trends in insurance coverage for adolescent reduction mammaplasty. Am JSurg . 2022;224(4):1068-1073. doi:10.1016/j.amjsurg.2022.07.030 13. Klement KA, Hijjawi BJ, Neuner J, et al. Discussion of preoperative mammography in women undergoing reduction mamm aplasty. Breast J . 2019;25(3):439-44. doi:10.1111/tbj.13237 14. Knox JA, Nelson DA, Latham KP, et al. Objective effects of breast reduction surgery on physical fitness. Ann Plast Surg . 2018;80(1):14-17. doi:10.1097/SAP.0000000000001167 15. Lewin R, Liden M, Lundberg J, et al. Prospective evaluation of health after breast reduction surgery using the Breast-Q, Short-Form 36, Breast-Related Symptoms Questionnaire, and Modifed Breast Evaluation Form. Ann Plast Surg . 2019;83(2):143-151. doi:10.1097/SAP.0000000000001849 16. Magny SJ, Shikhman R, Keppke AL. Breast Imaging Reporting and Data System. StatPearls Publishing; 2024. Accessed January 31, 2025 . www.ncbi.nlm.nih.gov 17. Mastectomy for gynecomastia. MCG. 28 th ed draft. Updated March 14, 2024. Accessed March 3, 2025. www.careweb.careguidelines.com 18. Morrison KA, Vernon R, Choi M, et al. Quantifying surgical complications for reduction mammaplasty in adolescents. Plast Reconstr Surg . 2023;151(3):376e – 383e. doi:10.1097/PRS.0000000000009905 19. NCCN guidelines for patients 2022: breast cancer screening and diagnosis. NCCN. www.nccn.org 20. Nuzzi LC, Firriolo JM, Pike CM, et al. The effect of reduction mammaplasty on quality of life in adolescents with macromastia. Pediatrics . 2017;140(5):e20171103. doi:10.1542/peds.2017-1103 21. Nuzzi LC, Pramanick T, Walsh LR, et al. Optimal timing for reduction mammaplasty in adolescents. Plast Reconstr Surg . 2020;146(6):1213-1220. doi:10.1097/PRS.0000000000007325 22. Patel K, Corcoran J. Breast reduction surgery in adolescents. Pediatr Ann . 2023;52(1):e31-e35. doi:10.3928/19382359-20221114-06 23. Perdikis G, Dillingham C, Boukovalas S, et al. American Society of Plastic Surgeons evidence-based clinical practice guideline revision : reduction mammaplasty. Plast Reconstr Surg . 2022;149(3):392e-409e. doi:10.1097/PRS.0000000000008860 Breast Reduction Surgery-GA MCD-MM-0253Effective 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.9 24. Perez-Panzano E, Gascon-Catalan A , Sousa-Dominguez R, et al. Reduction mamm aplasty improves levels of anxiety, depression and body image satisfaction in patients with symptomatic macromastia in the short and long term. JPsychosom Obstet Gynaecol . 2017;38(4):268-275. doi:10.1080/0167482X.2016.1270936 25. Reduction mammaplasty. MCG. 28 th ed draft. Updated March 14, 2024. Accessed January 31, 2025. www.careweb.careguidelines.com 26. Reeves RA, Kaufman T. Mammography. StatPearls Publishing; 2023. Updated July 24, 2023. Accessed January 31, 2025 . www.ncbi.nlm.nih.gov 27. Sears ED, Lu YT, Swiatek PR, et al. Use of preoperative mammography during evaluation for nononcologic breast reduction surgery. JAMA Surg . 2019;154(4):356 – 358. doi:10.1001/jamasurg.2018.4875 28. Taylor SA. Gynecomastia in children and adolescents. UpToDate. Updated July 12, 2024. Accessed January 31, 2025. www.uptodate.com 29. Womens Health and Cancer Rights Act (WHCRA). Centers for Medicare and Medicaid Services . Accessed January 31, 2025. www.cms.gov 30. Xia TY, Scomacao I, Duraes E, Cakmakoglu C, Schwarz G. Aesthetic, quality-of-life, and clinical outcomes after inferior pedicle oncoplastic reduction mammoplasty. Aesthetic Plast Surg . 2023;47(3):905-911. doi:10.1007/s00266-023-03257-7 31. Zeiderman MR, Kelishadi SS, Tutela JP, et al. Reduction mammoplasty: intraoperative weight versus pathology weight and its implications . Eplasty . 2017;17:e32. Accessed January 31, 2025 . www.pubmed.ncbi.nlm.nih.gov GA-MED-P-3769851 Issue Date 04/02/2019 Approved DCH 0 7/02/2025

Peripheral Nerve Stimulators for Treatment of Pain

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 09/01/2025 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 ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 3 H. References ………………………….. ………………………….. ………………………….. …………………….. 3 Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 Effective Dat e: 09/01/2025 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 Stimulators for Treatment of Pain B. BackgroundThe role of peripheral nerves as sources of pain and avenues of treatment when conservative therapy has failed is being more extensively explored than in previous years. Neuromodulation of peripheral nerves to treat refractory pain is one such area of inte rest. The neuromodulation of peripheral nerves to reduce pain, known as peripheral nerve stimulation (PNS), has been developed as a minimally invasive pain management modality intended to manage acute and chronic pain. The proposed mechanism of action, referred to as the gate control theory, involves a method by which stimulation of large-diameter sensory neurons reduces transmission ofpainful stimuli from small nociceptive fibers to the brain. The stimulation system is placed adjacent to the nerve, a process commonly known as remote selective targeting. The lead is connected to a small, wearable stimulator. Depending on the device, the wearer may be able to adjust the level of stimulation using Bluetooth technology. C. Definitions Acute Pain Pain lasting 4 weeks or less. Chronic Pain A distressing feeling often caused by intense or damaging stimuli (pain) lasting more than 90 days , considered beyond normal healing time. Conservative Therapy A multimodality plan of care for treating pain non – surgically, including active and inactive conservative therapies. o Active A type of action or activity to strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational therapy, a physician-supervised home exercise program (HEP), and/or chiropractic care. o Inactive Lack of activity on behalf of the patient that aids in treating symptoms associated with pain but not necessarily the underlying source, including rest, ice, heat, medical devices, acupuncture, and/or prescription medications. Minimally Invasive Procedures involving entry into the body through small incisions to lessen recovery time, level of pain and risk of infection. Sub-acute Pain Pain lasting between 4 and 12 weeks. D. PolicyI. Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply used in or directly related to the diagnosis, evaluation, or treatment of a disease, injury, illness, or other health condition which CareSource determines in its sole discretion to be experimental or investigational is not covered by CareSource. II. Peripheral nerve stimulators are considered experimental and investigational and are unproven for all indications for the reduction of acute, sub-acute, and chronic pain.Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 Effective Dat e: 09/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 III. Peripheral nerve stimulators are not covered. This includes but is not limited to:A. IB-Stim B. SPRINT PNS System C. Nalu Neurostimulation System D. StimRouter Neuromodulation System E. Moventis PNS F. StimQ PNS System E. Conditions of CoverageN/A F. Related Policies/RulesMedical Necessity Determinations Experimental and Investigational Item or Service G. Review/Revision HistoryDATE ACTIONDate Issued 02/15/2023 Approved at Committee.Date Revised 01/17/2024 06/05/2024 05/07/2025 Annual Review : references updated ; Approved at Committee Revised Background, added D. III. A. Approved at Committee Annual review, references updated. Approved at Committee Date Effective 09/01/2025 Date Archived H. References1. Abd-Elsayed A, Keith MK, Cao NN, Fiala KJ, Martens JM. Temporary peripheral nerve stimulation as treatment for chronic pain. Pain Ther . 2023;12(6):1415-1426. doi:10.1007/s40122-023-00557-3 2. Albright-Trainer B, Phan T, Trainer RJ, et al. Peripheral nerve stimulation for the management of acute and subacute post-amputation pain: a randomized, controlled feasibility trial. Pain Manage . 2022;12(3):357-369. doi:10.2217/pmt-2021-0087 3. Char S, Jin MY, Francio VT, et al. Implantable peripheral nerve stimulation for peripheral neuropathic pain: a systematic review of prospective studies. Biomed . 2022;10(10)2606. doi:10.3390/biomedicines10102606 4. DSouza RS, Jin MY, Abd-Elsayed A. Peripheral nerve stimulation for low back pain: a systematic review. Curr Pain Headache Rep . 2023;27:117-128. doi:10.1007/s11916-023-01109-2 5. Evidence Analysis Research Brief: Peripheral Nerve Stimulation for the Treatment of Superior Cluneal Neuralgia. Hayes; 2024. Accessed April 10, 2024. www.evidence.hayesinc.com 6. Evolving Evidence Review: IB-Stim (NeurAxis) for Treatment of Pain Associated with Irritable Bowel Syndrome in Adolescents. Hayes; 2022. Reviewed July 17, 2024. Accessed April 10, 2025. www.evidence.hayesinc.com Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 Effective Dat e: 09/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 7. Evolving Evidence Review: SPRINT PNS System (SPR Therapeutics) for Chronic Pain. Hayes; 2021. Updated February 27, 2025. Accessed April 10, 2025. www.evidence.hayesinc.com 8. Hatheway J, Hersel A, Song J, et al. Clinical study of a micro-implantable pulse generator for the treatment of peripheral neuropathic pain: 3-month and 6-month results from the COMFORT-randomised controlled trial. Reg Anesth Pain Med . 2024 ;0:1-7. doi:10.1136/rapm-2023-105264 9. Health Technology Assessment: Percutaneous Peripheral Nerve Stimulation for Treatment of Chronic Pain. Hayes; 2022. Reviewed May 8, 2024. Accessed April 10, 2025. www.evidence.hayesinc.com 10. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain. Hayes; 2021. Reviewed April 17, 2024. Accessed April 10, 2025. www.evidence.hayesinc.com 11. Helm S, Shirsat N, Calodney A, et al. Peripheral nerve stimulation for chronic pain: a systematic review of effectiveness and safety. Pain Ther . 2021;10(2):985-1002. doi:10.1007/s40122-021-00306-4 12. Huntoon MA, Slavin KV, Hagedorn JM, et al. A retrospective review of real-world outcomes following 60-day peripheral nerve stimulation for the treatment of chronic pain. Pain Physician . 2023;26(3):273-281. Accessed April 10, 2025. www.painphysicianjournal.com 13. Kaye AD, Ridgell S, Alpaugh ES, et al. Peripheral nerve stimulation: a review of techniques and clinical efficacy. Pain Ther . 2021;10(2):961-972. doi:10.1007/s40122 – 021-00298-1 14. Li AH, Gulati A, Leong MS, et al. Considerations in permanent implantation of peripheral nerve stimulation (PNS) for chronic neuropathic pain. an international cross-sectional survey of implanters. Pain Pract . 2022;22(5):508-515. doi:10.1111/papr.13105 15. Luna D, Hettie G, Pirrotta L, et al. Real-world long-term outcomes of peripheral nerve stimulation: a prospective observational study. Pain Manag . 2025;15(1):37-44. doi: 10.1080/17581869.2025.2451605 16. McCullough M, Kenney D, Curtin C, et al. Peripheral nerve stimulation for saphenous neuralgia. Reg Anesth Pain Med . 2024;49(6):455-460. doi:10.1136/rapm-2023 – 104538 17. Smith BJ, Twohey EE, Dean KP, DSouza RS. Peripheral nerve stimulation for the treatment of postamputation pain: a systematic review. Am JPhys Med Rehabil . 2023;102(9):846-854. doi:10.1097/PHM.0000000000002237 18. Strand N, DSouza RS, Hagedorn JM. Evidence-based clinical guidelines from the American Society of Pain and Neuroscience for the use of implantable peripheral nerve stimulation in the treatment of chronic pain. JPain Res . 2022;15:2483-2504. doi:10.2147/JPR.S362204 19. Vangeison CT, Bintrim DJ, Saha AK, et al. The role of peripheral nerve stimulation in refractory non-operative chronic knee osteoarthritis. Pain Manag . 2023;13(4):213 – 218. doi:10.2217/pmt-2023-0025 Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 Effective Dat e: 09/01/2025 The MEDICAL Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the MEDICAL Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 5 20. West T, Hussain N, Bhatia A, et al. Pain intensity and opioid consumption after temporary and permanent peripheral nerve stimulation: a 2-year multicenter analysis.Reg Anesth Pain Med . 2024. doi:10.1136/rapm-2024-10570421. Xu J, Sun Z, Wu J, et al. Peripheral nerve stimulation in pain management: a systematic review. Pain Physician . 2021;24(2):E131-E152. Accessed April 10, 2025 .www.painphysicianjournal.comGA-MED-P-3973709Issue Date 0 2/15/2023 Approved DCH 06/18/2025

Genetic Testing and Counseling

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Genetic Testing and Counseling-GA MCD-MM-0735 09/01/2025 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 o f Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the cont rolling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less fav orable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Polices/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Genetic Testing and Counseling-GA MCD-MM-0735Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectGenetic Testing and Counseling B. BackgroundAdvancements in technology have contributed to the rapid expansion of identified genetic variations . S ome of these variations have been identified as disease-causing, while others are considered common variants with no clinical impact . With the ever – expanding number of genetic tests ava ilable , it can be clinically difficult to determine the most appropriate tests for a particular patient. When clinically appropriate, genetic testing may provide diagnostic and/or actional therapeutic results which can impact a patients outcome. Due to th e complexity of genetic tests and their results, consultation with m edical genetics professionals and counselors may be required to assist members. According to the National Society of Genetic Counselors of the United States, genetic counseling is meant to integrate the following goals: 1) interpretation of family and medical histories to assess the chance of disease occurrence or recurrence; 2) education about the natural history of the condition, inheritance pattern, testing, management, prevention, sup port resources, and research; 3) counseling to promote informed choices in view of risk assessment, family goals, ethical and religious value; and 4) support to encourage the best possible adjustment to the disorder in the affected family member and/or to the risk of recurrence of that disorder. Genetic counselors are healthcare professionals trained to provide this care . H owever, access issues may require other healthcare professionals to assume this role. Genetic counseling, whether provided by a certifie d genetic counselor or other qualified healthcare professional, is an integral component of genetic testing that is informative and supportive to members, both before and after they undergo testing. C. Definitions Genetic Screening The process of testing a population for a genetic disease to identify a subgroup of people who either have the disease or the potential to pass it to offspring . Genetic Testing A medical test that identifies changes in genes, chromosomes, or proteins to confirm or rule out a s uspected genetic condition , either hereditary or acquired. Human Leukocyte Antigen (HLA) Typing A test used to match patients and donors for bone marrow or cord blood transplants. Inherited Genetic Variant A type of DNA sequence change passed from parent to offspring (ie, germline). Precision Medicine A field of medicine that selects pharmacotherapies based on the patients genetics. Somatic Gene Variant A type of DNA sequence change that is not inherited from a parent but acquired during a per sons life. Genetic Testing and Counseling-GA MCD-MM-0735Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 D. PolicyI. Prior authorization may be required for genetic testing . This includes both somatic and germline genetic testing. I. CareSource will review for medical necessity using published MCG criteria when available and the Medical Necessity Determinations administrative policy. This policy does not apply to requests that have MCG or InterQual guidelines with clear genetic counsel ing requirements/recommendations. II. Proprietary panel testing requires evidence-based documentation per the MedicalNecessity Determinations administrative policy. Individual genetic testing may be requested separately based on the Medical Necessity Determi nations administrative policy for panels not meeting medical necessity requirements. III. Genetic counseling is required for all inherited genetic m utation testing , as indicated by ALL the following: A. Counseling is provided by a healthcare professional with edu cation and training in genetic issues relevant to the genetic tests under consideration . B. Counseling is provided to enable members informed decision making concerning proposed testing (eg, purpose of testing, management that may be informed by result, heri table nature informed by 3-generation family history, range of possible results, potential benefits and risks of testing (eg, psychological, social, economic). IV. Somatic genetic testing does not require genetic counseling described above.V. Human leukocyte antigen (H LA ) typing is not part of the genetic testing policy and do es not require pre-authorization. VI. While most inherited genetic testing is only necessary once in a lifetime, CareSource recognizes that a germline genetic test could be approp riate repeated in extraordinary circumstances due to changes in technology. This type of test will be considered with the proper medical necessity documentation. E. Conditions of CoverageNAF. Related Polices/RulesMedical Necessity Determinations Cystic Fibrosis Testing G. Review/Revision HistoryDATE ACTIONDate Issued 01/01/2020 New PolicyGenetic Testing and Counseling-GA MCD-MM-0735Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 Date Revised 09/02/202007/07/2021 05/25/2022 05/10/202304/10/202407/03/2024 04/23 /2025Revised title, removed MCG table, condensed backgroundReviewed, updated references Annual Review: updated background, definitions, references, re-organized criteria Annual review: updated background, definitions, and references, rephrased genetic counseling process. Approved at Committee. Review: updated references, approved at Committee. Review: clarified genetic counseling requirements, added language regarding MCG. Approved at Committee Review: updated references, approved at Committee. Date Effective 09/01/2025 Date Archived H. References1. Ambulatory care: genetic medicine. MCG Health. 28 th ed. Accessed April 8, 2025 . www.careweb.careguidelines.com 2. Cohen SA, Bradbury A, Henderson V, et al. Genetic counseling and testing in a community setting: quality, access, and efficiency. Am Soc Clin Oncol Educ Book . 2019;e34-e44. doi:10.1200/EDBK_238937 3. Crooke A, Jacobs C, Newton-John T, et al. Genetic counselin g and testing practices for late-onset neurodegenerative disease: a systematic review. JNeurol. 2022;269(2):676-692. doi:10.1007/s00415-021-10461-5 4. Georgia Department of Community Health. Part II Policies and Procedures for Independent Laboratory Services. April 1, 2024. Accessed April 8, 2025 . www.mmis.georgia.gov 5. Kohlmann W, Slavotinek A. Genetic testing. UpToDate. Updated July 22, 2024 . Accessed April 8, 2025 . www.uptodate.com 6. Mundy J, Davies HL, Radu M , et al. Research priorities in psychiatric genetic counselling: how to talk to children and adolescents about genetics and psychiatric disorders. Eur JHum Genet. 2023;31(3):262-264. doi:10.1038/s41431-022-01253-0 7. National Center for Biotechnology Information (NCBI). Genetic Testing Registry (GTR) National Library of Medicine. Accessed April 8, 2025 . www.ncbi.nlm.nih.gov 8. National Human Genome Research Institute. Coverage and Reimbursement of Genetic Tests. National Institutes of Health. Updated February 6, 2024 . Accessed April 8, 2025 . www.genome.gov 9. National Human Genome Research Institute. Regulation of Gene tic Tests. National Institutes of Health. Updated February 19, 2024 . Accessed April 8, 2025 . www.genome.gov 10. Raby BA, Kohlmann W. Genetic counseling: family history interpretation and risk assessment. UpToDate. Updated April 9, 2024 . Accessed April 8, 2025 . www.uptodate.com 11. Sarata AK. Genetic Testing: Background and Policy Issues . Congressional Research Service Report ; 2015 . RL33832. Accessed April 8, 2025 . www.sgp.fas.org Genetic Testing and Counseling-GA MCD-MM-0735Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 12. Senter L, Austin JC, Carey M, et al. Advancing the genetic counseling profession through research: identification of priorities by the National Society of GeneticCounselors research task force. JGenet Couns. 2020;29(6):884-887. doi:10.1002/jgc4.1330 13. Whit e S, Jacobs C, Phillips J. Mainstreaming genetics and genomics: a systematic review of the barriers and facilitators for nurses and physicians in secondary and tertiary care. Genet Med. 2020;22(7):1149-1155. doi:10.1038/s41436-020-0785-6 GA-MED-P-3769851 Issue date 01/01/2020 Approved DCH 06/18/ 20 25

Non-Emergency Facility to Facility Transfers

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Non-Emergency Facility to Facility Transfers-GA MCD-MM-1447 08/01/2025 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 ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Non-Emergency Facility to Facility Transfers-GA MCD-MM-1447 Effective Dat e: 08/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNon-Emergency Facility to Facility Transfers B. BackgroundThis policy addresses the necessity of transferring a patient to a second acute care facility (receiving facility) when the individual requires care not available at the original facility. The goal of any transfer is to maintain the optimal health of the p atient. This is accomplished by transferring the patient to the nearest facility that provides the highest specialized care needed. Inter-hospital patient transfer is an important aspect of patient care, most often toimprove patient management. During such transfers, there must be continuity of medical care. Key elements include the decision to transfer and communication, pre-transfer stabilization and preparation, choosing the appropriate mode of transfer, personnel accompanying the patient, equipment and monitoring required during the transfer, and documentation and handover of the patient at the receiving facility. Transfer, admission , and subsequent care to the receiving facility is not medicallynecessary when the needed care is available at the originating facility.C. Definitions Non-Emergency A situation for which immediate response is not needed for the provision of medical treatment. Inter-Facility Transfer The transfer of patients between two healthcare facilities. Intra-Facility Transfer The transfer of patients within the same facility. Originating Facility The current facility to which an individual has been admitted for care and from which a transfer is planned. Participating (In-Network) Facility Facility that is contracted with CareSource. Non-Participating (Out-of-Network) Facility Facility that is not contracted with CareSource. Receiving Facility The facility to which a transfer is planned. D. PolicyI. The following non-emergency transfers require a prior authorization: A. a non-emergency transfer from a participating inpatient facility to a participating inpatient facility that is not within the same healthcare system B. a non-emergency transfer from a non-participating facility to a participating facility C. a non-emergency transfer from a non-participating facility to a non-participating facility II. For non-emergency transfers that require a prior authorization , the receiving facility submits the prior authorization request to CareSource. Non-Emergency Facility to Facility Transfers-GA MCD-MM-1447 Effective Dat e: 08/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 III. Requests for transfers that require a prior authorization must meet the following criteria: A. Member must be medically stable for transfer AND 1. Member requires transfer to a level of care un available at the originating facility . 2. Member requires transfer for a medically necessary diagnostic or therapeutic service which is not available at the originating facility . 3. Member requires transfer for services of a specialist to evaluate, diagnose , or treat their condition when that specialist is not available at the originating facility . 4. Member requires transfer , because member has received care at a specific prior institution for a condition not normally managed at the originating facility and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue . 5. Member requires transfer to improve the health and welfare of the member (ie, parental bonding) . 6. A t ransfer to allow a parent who gave birth to remain with the neonate is considered medically necessary when the neonate transfer meets the medically necessary criteria listed above and the parent who gave birth requires continued hospitalization due to birth complications or other medically necessary conditions . IV. The following non-emergency transfers do not require a prior authorization:A. inter-facility transfers within the same healthcare system B. intra-facility transfers within the same facility V. Non-emergency (elective) transfers are not a covered service for the following:A. The criteria above have not been met . B. The transfer is for the convenience of the member , the members family, the physician, or the originating facility . E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/15/2023 New policy. Approved at Committee.Date Revised 02/14/2024 01/15/2025Annual review. No changes. Updated references. Approved at Committee.Annual review. Updated references . Approved at Committee. Date Effective 08/01/2025 Non-Emergency Facility to Facility Transfers-GA MCD-MM-1447 Effective Dat e: 08/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 Date ArchivedH. References1. Appropriate interhospital patient transfer. American College of Emergency Physicians. January 2022. Accessed December 16, 2024. www.acep.org 2. Discharges and Transfers, 42 C.F.R. 412.4 (202 4). 3. Heaton JK. EMS inter-facility transport. In: StatPearls . StatPearls Publishing; 2022. 4. Obstetric Care Consensus Number 9. Levels of Maternal Care. American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine; 20 23 . Accessed December 16, 20204 . www.acep.org Independent med ical review 02/21/2023GA-MED-P-3611852 Issue Date 03/15/2023 Approved DCH 04/30/2025

Inhaled Nitric Oxide

MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Inhaled Nitric Oxide-GA MCD-MM-1187 08/01/2025 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 Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 7 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 8 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 9 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 9 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 9 H. References ………………………….. ………………………….. ………………………….. …………………….. 9 Inhaled Nitric Oxide-GA MCD-MM-1187Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectInhaled Nitric Oxide (iNO) B. BackgroundInhaled Nitric oxide (iNO) is a lipophilic gas that is naturally produced in numerous cells in the body and is readily absorbed across pulmonary membranes in the ventilated lung after inhalation. In the body, nitric oxide is involved in oxygen transport to the tissues, the transmission of nerve impulses, and other physiological activities. When administered via inhalation, it is a potent endogenous vasodilator that induces relaxation of vascular and bronchial smooth muscle, vasodilation of blood vessels, and can increase the partial pressure of arterial oxygen. iNO was initially approved by the U.S. Food and Drug Administration (FDA) in 1999. A compl ete nitric oxide delivery system is comprised of a nitric oxide administration apparatus, a nitric oxide gas analyzer, and a nitrogen dioxide gas analyzer. Additional warnings and precautions were added in 2013, including rebound hypertension following abr upt discontinuation, hypoxia from methemoglobinemia, and airway injury from nitrous dioxide. Dilation of pulmonary vessels in well-ventilated lung areas redistributes blood flow awayfrom lung areas where ventilation/perfusion ratios are poor. iNO has been used in conjunction with ventilator support as a treatment of hypoxic respiratory failure associated with persistent pulmonary hypertension of the newborn (PPHN), in infants who are at term or near-term (greater than 34 weeks gestation) to improve oxygenation,and to decrease the need for extracorporeal membrane oxygenation (ECMO). Respiratory failure is a clinical state that is defined either by the inability to rid the bodyof carbon dioxide or establish an adequate blood oxygen level. Acute respiratory failure is the most common clinical problem seen in term, near-term (born at 34 or more weeks of gestation), and pre-term (less than 34 weeks of gestation) infants admitted to neonatal intensive care units. Acute respiratory failure is frequently associated with meconium aspiration syndrome, sepsis, pulmonary hypoplasia, and/or primary pulmonary hypertension of the newborn. Management of infants with respiratory failure includes administration of high concentrations of oxygen, hyperventilation, high-frequency ventilation, neuromuscularblockade, antenatal steroids for the prevention of respiratory distress syndrome, use of po st-natal steroids to decrease inflammation, as well as iNO therapy.Clinical studies have shown that iNO is a selective pulmonary vasodilator withoutsignificant effects on the systemic circulation. There is scientific evidence that iNO therapy improves oxygenation and ventilation, reduces the need for extracorporeal membrane oxygenation (ECMO), and lowers the incidences of chronic lung disease and death among infants with respiratory failure. Moreover, the literature indicates that iNO does not appear to increase the incidence of adverse neurodevelopmental, behavioral, or medi cal sequelae in these high-risk neonat es. Infants with congenital diaphragmatic hernia (CDH) have not been shown to benefit from iNO therapy. Clark, et al (2000) Inhaled Nitric Oxide-GA MCD-MM-1187Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 concluded iNO does not lead to reduced ECMO use and Putnam, et al (2016) concluded iNO use in CDH may be associated with increased mortality.In preterm infants, the most common cause of acute respiratory failure is respiratory distress syndrome as a result of surfactant deficiency. According to the available literature, treatment of preterm infants usually entails exogenous surfactant administr ation. A systematic review of the evidence (Barrington and Finer, 2003)concluded: “The currently published evidence from randomized trials does not support the use of inhaled nitric oxide in preterm infants with hypoxic respiratory failure.” Carey, et al (2018) also concluded, Off-label prescription of iNO is not associated with reduced in-hospital mortality among premature infants with respiratory distress syndrome (RDS). In an Agency for Healthcare Research and Qualitys assessment on Inhaled Nitric Oxidein Preterm Infants , Allen, et al (2010) systematically reviewed the evidence on the use of iNO in preterm infants born at or before 34 weeks gestation age who receive respiratory support. They searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Studies (CENTRAL) and PsycInfo in June 2010. They also searched the proceedings o f the 2009 and 2010 Pediatric Academic Societies Meeting and ClinicalTrials.gov. T hey identified additional studies from reference lists of eligible articles and relevant reviews, as well as from technical experts. Questions were developed in collaboration with technical experts, including the chair of the upcoming National Institutes o f Health Office of Medical Applications of Research Consensus Development Conference. These researchers limited their review to randomized controlled trials (RCTs) for the question of survival or occurrence of bronchopulmonary dysplasia (BPD), and for the question on short-term risks. All study designs were considered for long-term pulmonary or neurodevelopmental outcomes, and for questions about whether outcomes varied by subpopulation or by intervention characteristics. Two investigators independently screened search results and abstracted data from eligible articles. These investigators identified a total of 14 RCTs, reported in 23 articles, and 8 observational studies. Chronic Lung Disease (CLD) or BPD studies have shown that there is in sufficient evidence to support iNO for the treatment of CLD or BPD. Mortality rates in the neonatal intensive care unit (NICU) did not differ for infants treatedwith iNO versus those not treated with iNO (RR 0.97 (95 % CI: 0.82 to 1.15)). Broncho-pulmonary dysplasia at 36 weeks for iNO and control groups also did not differ (RR 0.93 (0.86, 1.003) for survivors). A small difference was found between iNO and control infants in the composite outcome of death or BPD (RR 0.93 (0.87, 0.99)). There was inconsistent evidence about the risk of brain injury from individual RCTs, bu t meta – analyses showed no difference between iNO and control groups. These researchers found no evidence of differences in other short-term risks. There was no evidence to suggest a difference in the incidence of cerebral palsy (RR 1.36 (0.88, 2.10)), neu rodevelopmental impairment (RR 0.91 (0.77, 1.12)), or cognitive impairment (RR 0.72 (0.35, 1.45)). Evidence was limited on whether the effect of iNO varies by subpopulation or by characteristics of the therapy (timing, dose and duration, mode of delivery, or concurrent therapies). The authors concluded that there was a 7% reduction Inhaled Nitric Oxide-GA MCD-MM-1187Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 in the risk of the composite outcome of death or BPD at 36 weeks PMA for infants treated with iNO compared to controls, but no reduction in death or BPD alone. They stated that further studies are needed to explore subgroups of infants and to assess long-term outcomes including function in childhood. There is currently no evidence to support the use of iNO in preterm infants with respiratory failure outside the context of rigorously conducted RCTs. To provide health care professionals, families, and the general public with a responsible assessment of currently available data regarding the benefits and risks of iNO in premature infants, the Eunice Kennedy Shriver National Institute of Child Health andHuman Development, the National Heart, Lung, and Blood Institute, and the Office of Medical Applications of Research of the National Institutes of Health (Cole, et al, 2011) convened a consensus-development conference. Findings from a substantial body of experimental work in developing animals and other model systems suggest that iNO may enhance lung growth and reduce lung inflammation independently of its effects on blood vessel resistance. Although this work demonstrates biological plausibility and the results of RCTs in term and near-term infants were positive, combined evidence from the 14 RCTs of iNO treatment in premature infants of gestation of 34 weeks or less shows equivocal effects on pulmonary outcomes, survival, and neurodevelopmental outcomes. A National Institutes of Health Consensus Development Conference for inhaled nitricoxygen in premature infants (Cole, et al, 2010) recommended the following:1. Taken as a whole, the available evidence does not support use of iNO in early routine, early rescue, or later rescue regimens in the care of premature infants

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