MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Epidural Steroid Injections-GA MCD-MM-0217 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 assess ment 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 diagnosi s or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services me et 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 Co verage 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 refe r 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 disord er will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………… 2 B. Background ………………………….. ………………………….. ………………………….. …….. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………….. 3 E. Conditions of Coverage ………………………….. ………………………….. …………………. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………….. 5 G. Review/Revision History ………………………….. ………………………….. ……………….. 5 H. Re ferences ………………………….. ………………………….. ………………………….. ……… 6 Epidural Steroid Injections-GA MCD-MM-0217Effective 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. SubjectEpidural Steroid Injections B. BackgroundNearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent. Persistent pain is categorized as subacute when lasting between four and twelve weeks and chronic when persisting for at least three months. Comprehensive pain management care plan s are most effective in managing a patientschronic pain. These plans focus on a person-centered approach and incorporate conse rvative treatment with other modalities . These m ultidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. In addition to conservativ e therapy, additional treatment options may include nonpharmacologic or pharmacologic treatments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative treatment should be p rovided only by physicians qualified to deliver these health services . Epidural steroid injections (ESIs) are a nonsurgical, minimally-invasive intervention for chronic low back pain. ESIs may be administered through the translaminar approach (via the in terlaminar space in the spine), the transforaminal approach (through the neuroforamen dorsal to the nerve root), or the caudal approach (through the sacral hiatus at the sacral canal ). There is conflicting evidence on the efficacy of ESIs and a lack of con sensus on frequency and number of epidural steroid injections from professional organizations. However, clinical experience suggests that some patients obtain more significant relief, making it reasonable to offer a trial of steroid injections when conserv ative management has failed. Imaging studies of the symptomatic region may be performed to evaluate suspectedspecific causes of spinal pain ( eg, herniated disc, spinal stenosis, degenerative vertebral disease , rul e out fracture or tumor). However, e vidence does not support the routine use of imaging or other diagnostic tests in patients with nonspecific low back pain. Diagnostic imaging and testing are only recommended when severe or progressive neurologic deficits are present or when serious underly ing conditions are suspected on the basis of history and physical examination. C. Definitions Conservative Therapy A multimodal plan of care includ ing both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities t hat strengthen muscle groups and target key spinal structures, including physical therapy, occupational therapy , and/ or a physician supervised home exercise program (HEP) . Epidural Steroid Injections-GA MCD-MM-0217Effective 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 HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience or noncompliance without expla nation does not constitue an inability to complete. o Inactive Conservative Therapies Passive activites by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS u se, and /or pharmacotherapy (prescription or over the counter [eg, non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Epidural Steroid I njections Administration of steroids via a needle inserted in the space between the ligamentum flavum and the dura and admistered by translaminar, tranforaminal , or caudal approach es . Injections are intended to cause a short-term reduction in pa in in the affected region. D. PolicyI. Epidural steroid injections for labor and delivery in childbirth or post-surgical pain do not require medical necessity review . II. Initial (Diagnostic) InjectionA. CareSource considers an initial (diagnostic) epidural steroid injection (maximum of 2 injections) medically necessary for the management of chronic pain when ALL the following clinical criteria are met : 1. Pain is located in either the cervical, thoracic, or lumbar spine and is predominantly radiating or shooting in nature . 2. Pain is causing functional disability (at least a 6 on a scale of 0 to 10). 3. Signs or symptoms are consistent with radiculopathy, as indi cated by at least one of the following: a. diminished or absent deep tendon reflexes b. parasthesias, numbness, sensory change, or weakness in dermatomal distribution c. positive femoral nerve stretch test d. positive Spurling test e. positive straight leg raising test 4. Conservative therapy has failed to alleviate symptoms, as evidenced by ALL the following: a. documentation in the medical record of at least 6 weeks of active conservative therapy (see definition above) within the past 6 months OR Epidural Steroid Injections-GA MCD-MM-0217Effective 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 inability to complete active conservative therapy due to contraindication, increased pain, or intolerance b. documentation in the medical record of at least 6 weeks of inactive conservative therapy (see definition above) within the past 6 months 5. Imaging (eg, x-ray, CT, MRI), if performed, demonstrates that there are no conditions present that would preclude the safety of the performance of the procedure. III. Subsequent (Therapeutic) InjectionsCareSource considered therapeutic epidural steroid injections medically necessary when ALL the following criteria are met: A. The diagnostic or last therapeutic injection for current episode of pain provided significant functional pain relief of at least 50% as measured by a significant decrease in pain level, decrease in pain medications, and/or increase in physical function. B. Th e member continues to have ongoing pain or documented functional disability (at least a 6 on a scale of 0 to 10) . C. At least 3 weeks have passed since the prior injection in order to reach pharmacodynamic effect . D. No more than 3 procedures in a 12-week period of time per region are considered medically necessary . E. The member continues to engage in conservative therapy (see definition above) . IV. Limitations and ExclusionsA. The maximum number of all epidural injections a member can receive in 12 months is 6, regardless of the number of levels involved. B. For interlaminar or caudal epidural injections , no more than 1 epidural injection per treatment date should be performed . C. For transforaminal epidurals or selective nerve root blocks (SNRBs) , no more than 2 vertebral levels per treatment date, whether unilateral or bilateral, should be performed. D. Real-time image guidance and any injection of contrast are inclusive components of epidural injections and are not compensat ed for separately or unbundled for covera ge. E. Conscious sedation, if required for co-morbidities or patient/physician preference, may be provided without a medical necessity review but services will be considered part of the procedure and are not eligible for additional reimbursement if administered by a second provider. F. Monitored anesthesia is not considered medically necessary . G. Patients with indwelling implanted spinal cord stimula tors or pain pumps must have a device interrogation report and an interpretation submitted with medical records, and included in the prior authorization request for propo sed interventional pain injections. If a device is not functioning properly, an escala tion in pain may warrant evaluation and management of the implanted device. Epidural Steroid Injections-GA MCD-MM-0217Effective 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.5 H. Clinical evaluations and care of candidate patients for epidural injections should also address, at t he discretion of the physician and according to prevailing standards of medical care: 1. no acute spinal cord compression 2. selected body imaging evaluation s to evaluate the area of pain, particularly for acute pain, or to evaluate escal ations in chronic baseline pain 3. appropriate imaging to rule out red flag conditions may be indic ated if potential issues of trauma, osteomyelitis or malignancy , or other diagnoses are a concern I. Contraindications include any of the following: 1. pain related to cancer etiology 2. local or systemic infection 3. cauda equina syndrome 4. spinal trauma (eg, hematoma, hemorrhage, mass, ischemia) 5. coagulopathy V. Inconclusive or Non-Supportive EvidenceA. Evidence reported in the medical literature is inconclusive as to the use of epidural injections for long term relief or treatment of chronic pain. Long-term continuation (epidural injections beyond 1 year) may be subject to medical necessity review. B. For both cervical and lumbar transforaminal (TF) ESIs, using particulate steroid is associated with a rare risk of catastrophic neurovascular complicati ons such as stroke or death. Cervical transforaminal injections are risky because arterial supply may be densely concentrated in and around the intervertebral foramen. TF ESIs can be performed without contrast in patients with documented contraindication t o its use. In these circumstances , particulate steroids are contraindicated and only the preservative free, particulate fre e steroids which are available should be used. C. Cervical transforaminal ESIs have sparse literature for cervical radicular pain, and , if performed , should be performed by injecting contrast medium under real – time fluoroscopy and/or digital subtraction angiography (DSA) in a frontal plane, before injecting any substance potentially hazardous to the patient. Particulate steroids should no t be used for cervical TF injections as per the contraindication established by the FDA warning. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision History DATES ACTION Epidural Steroid Injections-GA MCD-MM-0217Effective 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.6 Date Issued 02/22/2018 New PolicyDate Revised 03/06/2019 05/13/202004/28/202103/16/202211/03/202203/15 /2023 01/31/202401/15 /2024Annual Update: Removed chiropractic care as a conservative therapy option. Annual Update: No policy criteria revisions. Only formatting and restructuring of policy information. Annual Update: Removed PA language. Reorganization of clinical criteria, but no content changes. Annual Review: updated formatting and references, conso lidated background and evidence, separated indications into initial and subsequent injections, frequency restrictions, and limitations/exclusions . Added contraindications Removed anti-platelet therapy as contraindication Annual review: reorganized criteria , simplified conservative therapy, added provocation tests, added pain scale to diagnostic injection criteria . Approved at Committee. Annual review: updated references and formatting, approved at Committee. Review: removed US limitation, updated references , approved at Committee. Date Effective 08/01/2025 Date Archived H. References1. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate . Updated May 15, 2024 . Accessed December 18 , 2024. www.uptodate.com 2. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med . 2017;166(7):493-505. doi:10.7326/M16-2459 3. Chou R, Hashimoto R, Friedly J, et al. Epidural corticoste roid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med . 2015;163(5):373-381. doi:10.7326/M15-0934 4. Conger A, Cushman DM, Speckman RA, et al. The effectiveness of fluroscopically guided cervical transfora minal epidural steroid injection for the treatment of radicular pain; a systematic review and meta-analysis. Pain Med. 2020;21(1):41-54. doi:410.1093/pm/pnz127 5. Goel A, Singh S, Shukla NK, et al. Efficacy of caudal epidural steroid injections in chronic low backache patients. JPharm Bioallied Sci. 2023;15(Supple 1):S669 – S672. doi:10.4103/jpbs.jpbs_89_23 6. Helm S, Harmon PC, Noe C, et al. Transforaminal epidural steroid injections: a systematic review and meta-analysis of efficacy and safety. Pain Phys ician . 2021;24:S209-S232. Accessed December 18 , 2024. www.painphysicianjournal.com Epidural Steroid Injections-GA MCD-MM-0217Effective 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.7 7. Kennedy DJ, Levin J, Rosenquist R, et al. Epidural steroid injections are safe and effective: multisociety letter in support of the safety and effectiveness of epidural steroid injections. Pain Med. 2015;16(5):833-838. doi:10.1111/pme.12667 8. Lee JH, Shin K, Bahk SJ, et al. Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: a systematic review and meta-analysis. Spine J . 2018;18(12):2343-2353. doi:10.1016/j.spinee.2018.06.720 9. Manchikanti L, Benyamin RM, Falco FJ, et al. Do epidural injections provide short – and long-term relief for lumbar disc herniation? A systematic review. Clin Orthop Relat Res. 2015;473(6):1940-1956. doi:10.1007/s11999-014-3490-4 10. Manchikanti L, Knezevic NN, Boswell MV, et al. Epidural injections for lumbar radiculopathy and spinal stenosis: a comparative systematic review and meta – analysis. Pain Physician. 2016;19(3):E365-41 0. Accessed December 18 , 2024. www.painphysicianjournal.com 11. Manchikanti L, Knezevic NN, Navani A, et al. Epidural interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) comprehensive evidence-based guidelines. Pain Physician. 2021;24(S1): S27-S208. Accessed December 18 , 2024. www.painphysicianjournal.com 12. Oliveira CB, Maher CG, Ferreira ML, et al. Epi dural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020;4(4):CD013577. doi: 10.1002/14651858.CD013577 13. Qassem A, Wilt TJ, McLean RM, et al . Noninvasive treatments for acute, subacute and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med . 2017 ;166(7):514-530 . doi:10.7326/M16-2367 14. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3729-3832. doi:10.2147/JPR.S386879 15. Taskaynatan MA, Tezel K, Yavuz F, et al. The effectiveness of transforaminal epidural steroid injection in patients with radicular low back pain due to lumbar disc herniation two years after treatment. JBack Musculoskelet Rehabil. 2015;28(3):447 – 451. doi:10.3233/BMR-140539 16. Verheijen EJA, Bonke CA, Amorij EMJ, et al . Epidural steroid compared to placebo injection for sciatica: a systematic review and meta-analysis. Euro Spine J . 2021;30:3255-3264. doi:10.1007/s00586-021-06854-9 17. Woo JH, Park HS. Cervical transforaminal epidural block using low-dose lo cal anesthetic: a prospective, randomized, double-blind study. Pain Med. 2015;16(1):61 – 67. doi:10.1111/pme.12582 18. Yang S, Kim W, Kong HH, et al. Epidural steroid injection versus conservative treatment for patients with lumbosacral radicular pain: a meta-analysis of randomized controlled trials. Med. 2020;99(30):e21283. doi:10/1097/MD. 0000000000021283 GA-MED-P-3611852 Issue Date 02/22/2018 Approved DCH 0 4/30/2025
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Facet Joint Interventions-GA MCD-MM-0974 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 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 ………………………….. ………………………….. ………………………….. …… 5 F. Related Polices /R ules ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Facet Joint Interventions-GA MCD-MM-0974Effective 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. SubjectFacet Joint Interventions B. BackgroundAn estimated 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms persist . Persistent pain is categorized as subacute when it lasts between 4 and 12 weeks and chronic when it persists for at least 3 months. Facet joint pain comprises 27 %-40% of patients with chronic low back pain (LBP) . Comprehensive pain management care plans are most effective in managing a patients chronic pain. These plans foc us on a person-centered approach and incorporateconservative treatment with other modalities. These multidisciplinary treatments promot e self-management and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved c ompletely. In addition to conservative therapy, treatment options may include nonpharmacologic or pharmacologic treatments , and nonsurgical or surgical interventions. Only physicians qualified in interventional procedures for pain unresponsive to conservat ive treatment should perform these health services. Spinal structures may be the source of LBP, including intervertebral discs, facet joints,sacroiliac joints, and nerve roots. While some of these can be diagnosed by imaging, discogenic pain without disc herniation and facet joint or sacroiliac joint pain are difficult to diagnose wit h imaging alone. M edial branch nerve blocks are a diagnostic tool to identify the cause of pain and can provid e short term pain relief with certain medications. Following a presumptive diagnosis of facet joint pain through a physical examination and plain radiography or axial imaging , the diagnosis may be confirmed by relief of pain through injection of local anesthetic to the medial branches of the posterior rami of the dorsal spinal nerves supplying the proposed facet joint(s). Medial branch nerve blocks may be performed at the targeted joint itself, one joint above and one joint below on the same side, or bilaterally per treatment session. Medial branch nerve block injections should be performed with fluoroscopy or computed tomography . A patient may rec eive a diagnostic injection of a short-acting local anesthetic agent to identify the pain generator. If pain is relieved by the injection, then a radiofrequency ablation (RFA) , which uses energy to destroy the nerve , can be performed . A successful radiofrequency facet ablation of the affected nerve (same anatomic location of the positive diagnostic block) may relieve pain for a period of months to a year or more until nerve regeneration occurs. C. Definitions Conservativ e Therapy A multimodality plan of care includ ing both active and inactive conservative therapies. Facet Joint Interventions-GA MCD-MM-0974Effective 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 o Active Conservative Therapies Actions or activities that strengthen muscle groups and target key spinal structures, i nclud ing 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 documented in the medical record after completion, or documentation of the inability t o complete a HEP due to a stated physical reason (ie, increased pain or inability to physically perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain includ ing rest, ice, heat, medical devices, acupuncture, TENS u se , and/or pharmacotherapy (prescription or over the counter [eg, NSAIDS, 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 i mpulses and/or stimulating the release of endorphins. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy. Medial Branch Nerve Block Injection A diagnostic procedure in which a short – acting anesthetic (eg, lidocaine) is injected near small medial nerves connected to a specific facet joint. It may also be performed to treat back pain caused by facet joint(s) with a longer activing anesthetic (eg, bupivacaine). o Successful Diagnostic Injection An injection that achieves greater than 80% reduction in pain within the duration of effectiveness for the anesthetic used. Radiofrequency Facet Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves . D. PolicyCareSource considers facet joint intervention s for management of chronic back pain medically necessary when the clinical criteria in this policy are met . Documentation, including dates of service for conservative therapies , are not required for medical necessity review but must be available upon request . I. Medial Branc h Nerve Block InjectionsA. Up to 2 diagnostic medial branch nerve block injections in the cervical , thoracic , or lumbar regions are considered medically necessary when ALL of the following criteria are met: 1. Initial d iagnostic block confirm s facet joint as source of spinal pain and provides 80% or greater primary pain relief and duration of relief is consistent with agent employed. 2. Second diagnostic block confirms validity of the initial injection and is injected at the same level where the i nitial produced a positive response. Facet Joint Interventions-GA MCD-MM-0974Effective 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 3. Each diagnostic block may treat up to 3 spinal levels (unilateral or bilateral)for a maximum of 6 spinal levels per spinal region per session. 4. Radiofrequency ablation is being considered as a therapeutic intervention. 5. Injections should be at least 2 weeks apart . 6. Imaging studies and physical exam ruled out other causes of spinal pain (eg, fracture, tumor, infection, herniated disk, spinal stenosis, significant deformity) . 7. Patient history with at least 3 mo nths of moderate to severe pain with functional impairment that has not adequately respond ed to a ctive and inactive conservative therapy . 8. Failure of conservative therapy as evidenced by ALL of the following: a. Documentation in the medical record of at least 6 weeks of active conservative therapy (as defined above) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance. b. Documentation i n the medical record of at least 6 weeks of inactive conservative therapy (as defined above) within the past 6 months. 9. No coagulopathy. 10. No current infection at the injection site. B. Diagnostic medial branch nerve blocks are NOT considered medically necessary when RFA is not being considered as a treatment option. II. Radiofrequency A blation (RFA) for Facet Joint PainA. Initial RFA for facet joint pain is considered medically necessary when in the past 36 months 1. The clinical criteria above (I.A.1-10 ) have been met . 2. 2 successful medial branch nerve block injections were performed at the same spinal region and achiev ed 80% or more pain relief. B. Repeat RFA for facet joint pain is considered medically necessary when in the past 36 months 1. Prior successful single or multilevel RFA in the same spinal region (cervical, thoracic, or lumbar) and side provid ed at least 50% pain relief over a minimum of 6 months . 2. The m ost recent RFA was at least 6 months prior . 3. No more than 4 RFAs per rolling 12 months ( 2 left and 2 right per spinal region ) are considered appropriate . III. SedationA. Neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks a nd are not routinely reimbursable. B. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. Facet Joint Interventions-GA MCD-MM-0974Effective 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.5 IV. Inconclusive or Non-Supportive EvidenceA. Medial branch nerve block injections are unproven for the treatment of c hronic spinal pain . R outine therapeutic injections will not be authorized for chronic pain management. B. Intra-articular facet joint injections for neck and back pain are not considered medical ly necessary as there is limited evidence and the efficacy has not been established. C. Intra-articular facet joint injections do not qualify as diagnostic information for a proposed neurotomy . V. Spinal Cord Stimulators/Pain PumpsPatients with indwelling implanted spinal cord stimulators or pain pumps should include a device interrogation report with the required medical records for medical necessity review requests. If a device is not functioning properly, an escalation in pain may warrant eval uation and management of the implanted device. E. Conditions of CoverageN/A F. Related Polices /R ulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 05/13/20 20 This policy replaces the Facet Medial Branch Nerve Block and Radiofrequency Facet Ablation policies. Added c riteria re: exclusion of repea t diagnostic injections for RFA. Date Revised 07/22/2020 11/11/202007/21/202106/22/2022 06 /21 /202305/08 /202404/09 /2025 Revisions: Medial Branch Nerve Block injection clinical criteria; requirement of one successful RFA session. Revision: RFA language revised around benefit limit for clarity. (This revision does not require a network notification or a change of the Effec tive Date). Annual Update: Removed PA language. Annual Review: updated references, background, definitions, added chiro as type of active conservative therapy, re-organized criteria, added coagulopathy and infection criteria Annual Review: revised langua ge, added RFA requirement for diagnostic injections, updated references; Approved at Committee . Annual review: updated references, approved at Committee Annual review: updated references, approved at Committee Date Effective 08/01/2025 Date Archived Facet Joint Interventions-GA MCD-MM-0974Effective 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.6 H. References 1. Ashmore ZM, Bies MM, Meiling JB, et al. Ultrasound-guided lumbar medial branch blocks and intra-articular facet joint injections: a systematic review and meta – analysis. Pain Rep. 2022;7(3):e1008. doi:10.1097/ PR9. 0000000000001008 2. Boswell MV, Manchikanti L, Kaye AD, et al. A best-evidence systematic appraisal of the diagnostic accuracy and utility of facet (zygapophysial) joint injections in chronic spinal pain . Pain Physician . 2015;18(4):E497-E533. Accessed March 20, 2025 . www.painphysicianjournal.com 3. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated May 15, 2024 . Access ed March 20, 2025 . www.uptodate.com 4. Chou R. Subacute and chronic low back pain: surgical treatment. UpToDate. Updated September 27, 2023. Access ed March 20, 2025 . www.uptodate.com 5. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic revie w for an American College of Physicians clinical practice guideline . Ann Intern Med . 2017;166(7):493-505. doi:10.7326/M16-2459 6. Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispec ialty, international working group. Reg Anesth Pain Med . 2020;45(6):424-467. doi:10.1136/rapm-2019-101243 7. Cohen SP, Moon JY, Brummett CM, et al . Medial branch blocks or intra-articular injections as a prognostic tool before lumbar facet radiofrequency denervation: a multicenter, case-control study . Reg Anesth Pain Med . 2015;40(4):376-383. doi:10.1097/AAP.0000000000000229 8. Copenhaver DJ, Pritzlaff SG, Jung M, et al. Interventional therapies for chronic pain. UpToDate. Updated January 23, 2025 . Accessed March 20, 2025 . www.uptodate.com 9. Curtis L, Shah N, Padalia D. Facet joint disease. StatPearls . StatPearls Publishing; updated January 9, 2023. Accessed April 25, 2024 . www.ncbi.nlm.nih.gov 10. Facet Joint Injection. MCG Health . 28th ed. MCG Health; 2024. Updated March 14, 2024 . Accessed March 20, 2025 . www.careweb.careguidelines.com 11. Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med . 2022;47(1):3-59. doi:10.1136/rapm-2021 – 103031 12. Isaac Z, Kelly H. Evaluation of the adult patient with neck pain. UpToDate. Updated May 31, 2023. Accessed March 20, 2025 . www.uptodate.com 13. Le DT, Alem N. Facet Joint Injection. StatPearls . StatPearls Publishing; updated June 20, 2023. Accessed April 25, 2024 . www.ncbi.nlm.nih.gov 14. Lee DW, Pritzlaff S, Jung MJ, et al. Latest Evidence-Based Application for Radiofrequency Neurotomy (LEARN): best practice guidelines from the American Society of Pain and Neuroscience (ASPN). JPain Res . 2021;14:2807-2831. doi:10.2147/JPR.S325665 15. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain : American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint interventions Facet Joint Interventions-GA MCD-MM-0974Effective 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.7 2020 guidelines . Pain Physician . 2020;23(3S):S1-S127. Accesse d March 20, 2025 .www.painphysicianjournal.com 16. Perolat R, Kastler A, Nicot B, et al. Facet joint syndrome: from diagnosis to interventional management. Insights Imaging . 201 8;9(5):773-789. doi:10.1007/s13244-018-0638x 17. Won HS, Yang M, Kim YD. Facet joint injections for management of low back pain: a cli nically focused review. Anesth Pain Med (Seoul) . 2020;15(1):8-18. doi:10.17085/apm.2020.15.1.8 GA-MED-P-3837726 Issue Date 05/13/2020 Approved DCH 0 5/07/2025
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Breast Reconstruction Surgery-GA MCD-MM-0732 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Breast Reconstruction Surgery-GA MCD-MM-0732Effective 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. SubjectBreast Reconstruction Surgery B. BackgroundWith an estimated 272,000 new cases yearly, breast cancer continues to be the leading cause of new cancer among women in the United States and a leading cause of cancer death. Breast reconstruction is intended to reduce post-mastectomy complications , establish symmetry between the surgical breast and the contralateral breast , and improve quality of life following breast cancer surgery . Breast reconstruction procedures may include breast reduction, breast augmentation with FDA-approved breast implants, nipple reconstruction (includin g surgery, tattooing, or both), and breast contouring. Reconstruction may be performed immediately following a mastectomy or can be delayed for weeks or years until the member has undergone radiation, chemotherapy, or decides that reconstruction is wanted . Breast augmentation with an FDA-approved implant can be performed in one stage,during which the implant is inserted during the same surgical visit as the mastectomy, or in two stages using an implanted tissue expander in the first stage, followed by remov al of the expander and insertion of the permanent breast implant. Complications may occur from breast implants immediately postoperatively or years later and can include exposure, extrusion, infection, contracture, rupture, and pain. Clinically significant complications may require implant removal. Autologous tissue/muscle breast flap reconstruction is a safe and effective alternative to breast implants. Muscle, subcutaneous tissue, and skin can be transposed from the donor site either locally (eg, latissimus dorsi myocutaneous [LD] flap, pedicled transverse rectus abdominus myocutaneous [TRAM] flap) or distally (eg, free TRAM flap, deep inferior epigastric perforator [DIEP] flap, superficial inferior epigastric artery perforator [SIEP] flap, inferior or superior gluteal flap, superior gluteal artery perforatorflap, Reubens flap, transverse upper gracilis [TUG] flap). The choice of procedure can be affected by the members age and health, contralateral breast size and shape, personal preference, and expertise of the surgeon.Individuals may also select non-invasive options such as mastectomy bras and externalbreast prostheses.Refer to MCG for complete mastectomy.C. Definitions Breast Conserving Surgery ( Lumpectomy, Partial Mastectomy) Surgical removal of tumor and small amount of surrounding tissue . Contralateral Breast Unaffected/nonsurgical breast . Cosmetic Procedures Procedures completed to improve appearance and self – esteem and to reshape normal structures of the body . Breast Reconstruction Surgery-GA MCD-MM-0732Effective 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 Mastectomy Surgical removal of one or both breasts .D. PolicyI. Breast reconstruction is not gender specific . II. Surgical OptionsA. CareSource considers breast reconstructio n following treatment for breast cancer medically necessary when ANY of the following apply: 1. following mastectomy or breast conserving surgery of the affected breast 2. producing a symmetrical appearance on the contralateral breast B. Breast reconstruction surgery to improve breast function after conservatory therapy and related to significant abnormalities/deformities is considered medically necessary when ANY of the following apply : 1. malignant breast disease 2. congenital deformities that affect the member’s physical and psychological being 3. severe fibrocystic breast disease that limits the member s function 4. unintentional trauma or injuries 5. unintentional complications after breast surgery for non-malignant conditions (eg, pain, irritation , bleeding, discharge , complication s causing difficulty with lactation ) III. CareSource considers bilateral risk-reducti ng mastectomy medically necessary .Refer to MCG Guidelines Mastectomy, Complete for more information. IV. CareSource considers treatment of physical complications , including lymphedema ,following breast reconstruction medically necessary . V. Surgical Exclusions :A. CareSource does not cover any breast reconstruction procedures that are considered experimental , investigational , or unproven for this indication . B. CareSource does not cover : 1. procedures that are considered cosmetic in nature including natural changes due to aging and weight loss/gain 2. lipectomy for donor site symmetry 3. suction lipectomy or ultrasonically assisted suction lipectomy (liposuction) for correction of surgically induced donor site asymmetry (eg, trunk or extremity) that results from one or more flap breast reconstruction procedures VI. Non-Surgical AlternativesCareSource covers external breast prostheses and mastectomy bras following mastectomy or breast conserving surgery. All other indication s are considered not medically necessary. VII. Breast reconstruction with free flap procedures, regardless of technique, applies toBreast Reconstruction Surgery-GA MCD-MM-0732Effective 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 CPT code 19364. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 04/01/2020Date Revised 02/17/2021 03/16/2022 11/01/202203/01/202309/27/2023 10/23/2024 04/09/2025Updated Criteria .No changes to content. Updated reference dates. Approved at PGC. Added background, references, guidance regarding HCPCS S – codes . Updated background. Removed IV. C. Updated references. Annual review. Approved at committee. Annual review: updated risk reduction mastectomy and reorganized policy section for clarity. Review : removed breast cancer requirement from some criteria , updated risk-reducing mastectomy and references . Approved at Committee. Date Effective 08/01/2025 Date Archived H. References1. Alder L, Zaidi M, Zeidan B, et al. Advanced breast conservation and partial breast reconstruction a review of current available options for oncoplastic breast surgery. Ann RColl Surg Engl . 2022;104(5):319-323. doi:10.1308/rcsann.2021.0169 2. Breast reconstruction surgery. American Cancer Society . Updated September 19 , 2022 . Accessed March 18, 2025 . www.cancer.org 3. Breast cancer statistics. Centers for Disease Control and Prevention. Accessed March 18, 2025 . www.cdc.gov 4. Centers for Medicare and Medicaid Services. Womens Health and Cancer Rights Act (WHCRA) . Accessed March 18, 2025 . www.cms.gov 5. Colwell AS, Taylor EM. Recent advances in implant-based breast reconstruction. Plast Reconstr Surg . 2020;145(2):421e-432e. doi:10.1097/PRS.0000000000006510 6. Costanzo D, Klinger M, Lisa A, et al. The evolution of autologous breast reconstruction. Breast J . 2020;26(11):2223-2225. doi:10.1111/tbj.14025 7. Friedrich M, Kramer S, Friedrich Det al. Difficulties of breast reconstruction problems that no one likes to face. Anticancer Res . 2021;41(11):5365-5375. doi:10.21873/anticanres.15349 Breast Reconstruction Surgery-GA MCD-MM-0732Effective 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.5 8. Gradishar WJ, Moran MS, Abraham J, et al . NCCN guidelines insights: breast cancer, version 4.2023. JNatl Compr Canc Netw . 2023;21(6):594-608 . doi:10.6004/jnccn.2023.0031 9. Griffin C, Fairhurst K, Stables I, et al. Outcomes of women undergoing mastectomy for unilateral breast cancer who elect to undergo contralateral mastectomy for symmetry: a systematic review. Ann Surg Oncol . 2024;31(1):303-315. doi:10.1245/s10434-023-14294-6 10. Guliyeva G, Torres RA, Avila FR, et al. The impact of implant-based reconstruction on persistent pain after breast cancer surgery: a systematic review. JPlast Reconstr Aesthet Surg . 2022;75(2):519-527. doi:10.1016/j.bjps.2021.09.079 11. Health technology assessment : c omparative effectiveness review of human acellular dermal matrix for breast reconstruction. Hayes; 2019. Reviewed February 28, 2022. Accessed March 18, 2025 . evidence.hayesinc.com 12. Health technology assessment : a utologous fat grafting for breast reconstruction after breast cancer surgery. Hayes ; 2015 . Review ed November 1 3, 202 3. Accessed March 18, 2025 . evidence.hayesinc.com 13. Mastectomy, complete : S-860. MCG Health, 2 9th ed draft . Updated January 25, 2025. Accessed March 20 , 2025 . careweb.careguidelines.com 14. Nahabedian M. Options for autologous flap-based breast reconstruction. UpToDate. Updated April 29, 2024 . Accessed March 18, 2025 . www.uptodate.com 15. Nahabedian M. Overview of breast reconstruction. UpToDate. Updated May 24, 2023. Accessed March 18, 2025. www.uptodate.com 16. Pappalardo M, Starnoni M, Franceschini G, et al. Breast cancer-related lymphedema: recent updates on diagnosis, severity and available treatments. JPers Med . 2021;11(5):402. doi:10.3390/jpm11050402 17. Sab el MS. Breast conserving therapy. UpToDate. Updated September 11 , 2023. Accessed March 18, 2025 . www.uptodate.com 18. Tomita K, Kubo T. Recent advances in surgical techniques for breast reconstruction. Int JClin Oncol . 2023;28(7):841-846. doi:10.1007/s10147-023-02313-1 19. Toyserkani NM, Jorgensen MG, Tabatabaeifar S, et al. Autologous versus implant – based breast reconstruction: a systematic review and meta-analysis of Breast-Q patient-reported outcomes. JPlast Reconstr Aesthet Surg . 2020;73(2):278-285. doi :10.1016/j.bjps.2019.09.040 20. Zehra S, Doyle F, Barry M, et al. Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis. Breast Cancer . 2020;27(4):534-566. doi :10.1007/s12282-020-01076-1 GA-MED-P-3837726 Issue Date 04/01/2020 Approved DCH 05/07/2025
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Trigger Point Injections-GA MCD-MM-0221 08/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived fr om 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 in clude, 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 convenienc e 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 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 a s covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………. 2 B. Background ………………………….. ………………………….. ………………………….. ………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………… 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. … 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. .. 4 H. References ………………………….. ………………………….. ………………………….. …………………. 5 Trigger Point Injections-GA MCD-MM-0221Effective Dat e: 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. SubjectTrigger Point Injections B. BackgroundMyofascial trigger points are self-sustaining hyper-irritative foci in any skeletal muscle, often occurring in response to strain produce d by acute or chronic overload. There is no associated neurologic deficit, and the pain may be aggravated by hyperextension of the spine, standi ng , and walking. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS) which i s responsive to appropriate treatment. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor. The purpose of a trigger point injection (TPI) is to treat not only the symptom but also the cause through the injection of a single substance (eg, a local anesthetic) or a mixture of substances (eg, a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Interventional procedures for management of pain should be part of a comprehensivepain management care plan that incorporates an initial trial of conservative treatment utilizing appropriate medications, physical therapy modalities , and behavioral support as needed. Interventional procedures for the management of p ain unresponsive to conservativetreatment should be provided only by healthcare providers within their scope of practice who are qualified to deliver these health services.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Subacute Pain Pain that has lasted between 4 weeks and 12 weeks. Physician Supervised Home Exercise Program (HEP) A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the me dical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience or noncompliance without explanation does not consti tute an inability to complete. Trigger Point A hyper excitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. D. PolicyI. Trigger Point Injections Initial Injection A. Trigger point injections of anesthetic and/or corticosteroid for back pain, neck pain, or myofascial pain syndrome is considered medically necessary when pain has persisted despite appropriate medical management and ALL the following criteria are me t: Trigger Point Injections-GA MCD-MM-0221Effective 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 1. Patient presents with new (acute or subacute) localized pain, occurring in the last 3 months . 2. Patient has been refractory or intolerant of conservative therapies for at least 1 month, including at least 1 of the following: a. bed rest b. active exercise c. ultrasound d. range of motion e. heating or cooling treatments f. massage 3. TPIs are being given as a part of an overall conservative manage ment (usually short term) plan, including at least 1 of the following : a. physical therapy b. occupational therapy c. physician supervised home exercise program (HEP) d. manipulative therapy 4. Pharmacotherapies are being administered, including at least 1 of the following : a. non-steroidal anti-infammatory drugs (NSAIDS ) b. muscle relaxants c. non-narcotic analgesics d. anti-depressants 5. The patient must have a diagnosis for which the trigger point injection is an appropriate treatment; ALL the following information must be documented in the patient’s medical record: 1. proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point 2. reason (s) for select ing this therapeutic option 3. affected muscle or muscles 4. muscle or muscles injecte d and the number of injections 5. frequency of injections required 6. name of the m edication used in the injection 7. results of any p rior treatment 8. corroborating evidence that the injection is medically necessary B. Localization techniques to image or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. II. Trigger Point Injections Subsequent InjectionsA. Trigger point injections should be repeated only if doing so is reasonable and medica lly necessary. No more than 8 dates of service per calendar year per member may be reimbursed . B. Injections may be repeated only with documented positive results to the most recent trigger point injection of the same anatomic si te. Documentation should include at least 50% improvement in pain, functioning , and activity tolerance. Trigger Point Injections-GA MCD-MM-0221Effective 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 III. There is no laborat ory or imaging test for establishing the diagnosis of trigger points .Diagnosis is dependent upon a detailed history and a thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis: A. history of onset and its cause (injury, sprain, etc.) B. distribution of pain C. restriction of movement D. mild muscle specific weakness E. focal tenderness of a trigger point F. palpable taut band of muscle in which trigger point is located G. local taut respo nse to snapping palpitation H. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point IV. Payment InformationA. Certain trigger point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. B. Payment may be made for 1 unit of service of the appropriate procedure code reported on a claim for service rendered to a particular pati ent on a pa rticular date. C. A trigger point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (eg, in the form of a mod ifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. D. Dry needling is not an acceptable alternative to trigger point injections by an appropriately licensed clinician. E. Conditions of CoverageN/A F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 02/08/2018Date Revised 03/06/2019 05/13/2020 09/01/2020Annual Update: No changes Annual Update and Revision: PA is required for each trigger point injection. Revisions include: such as was changed to ONE of the following : I. B. 2. and 3. Trigger Point Injections-GA MCD-MM-0221Effective 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.5 05/26/202104/15/2022 03/29/202302/28 /202402/12 /2025Annual Update: Removed PA language.Annual Review. Updated references, formatting, split policy into initial and subsequent injections, added conservative care modalities Annual review: updated references, added definition and payment information . Approved at Committee. Annual review: editorial changes and updated references. Approved at Committee. Review: updated references, approved at Committee. Date Effective 08/01/2025 Date Archived H. References1. Appasamy M, Lam C, Alm J, Chadwick AL. Trigger point injections. Phys Med Rehabil Clin NAm . 2022;33(2):307-333. doi:10.1016/j.pmr.2022.01.011 2. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate . Updated May 15, 2024 . Accessed January 15, 2025 . www.uptodate.com 3. Gerwin R. Myofascial trigger point pain syndromes. Semin Neurol . 2016;36(5):469 – 473. doi:10.1055/s-0036-1586262 4. Hammi C, Schroader JD, Yeung B. Trigger point injection. StatPearl s. StatPearls Publishing; 2024. Updated July 24, 2023. Accessed January 15, 2025 . www.ncbi.nlm.nih.gov 5. Hamzoian H, Zograbyan V. Trigger point injections versus medical management for acute myofascial pain: a systematic review and meta-analy sis. Cureus. 2023;15(8):e43424. doi:10.7759/cureus.43424 6. Isaac Z. Management of non-radicular neck pain in adults. UpToDate . Updated November 14 , 2024. Accessed January 15, 2025 . www.uptodate.com 7. Khoury AL, Keane H, Varghese F, et al. Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief. NPJ Breast Cancer . 2021;7:123. doi:10.1038/s41523-021-00321-w 8. Meyer GW. Anterior cutaneous nerve entrapment syndrome. UpToDate . Updated December 31, 2024 . Accessed January 15, 2025 . www.uptodate.com 9. Moynihan LK, Elkadry E. Myofascial pelvic pain syndrome in females: treatment. UpToDa te. Updated January 11, 2023 . Accessed January 15, 2025 . www.uptodate.com 10. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate . Updated March 15, 2023. Accessed January 15, 2025. www.uptodate.com Independent Medical Review January 2025GA-MED-P-3677827 Issu e Date 02/08/2018 Approved DCH 04/ 29/2024
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Sacroiliac Joint Procedures-GA MCD-MM-0215 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 assess ment 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 diagnosi s or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services me et 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 Co verage 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 refe r 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 disord er will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Polices/Rules ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Sacroiliac Joint Procedures-GA MCD-MM-0215Effective 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. SubjectSacroiliac Joint Procedures B. BackgroundNearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent. Persistent pain is categorized as subacute when lasting between four and twelve weeks , and chronic when persisting for at least three months. Up to 10% to 25% of patients with persistent low back pain may have a component ofpain related to sacroiliac joints (SIJ) . Comprehensive pain management care plans are most effective in managing patients chronic pain. These plans focus on a person – centered approach and incorporate conservative treatme nt with other modalities. These multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved completely. In addition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic treatments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided onl y by physicians qualified to deliver these health services. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be effective for diagnostic purposes but provide limited short-term relief from pain resulti ng from SI Jdysfunction. Long-term use has not been adequately studied to establish standards of care. Radiofrequency ablation (RFA) is another treatment method, which uses heat to destroy nerves. RFA for the treatment of low back pain has inconsistent res ults in the peer-reviewed medical literature with limited follow – up. However, clinical experience suggests that some patients obtain more significant relief from these procedures, making it reasonable to offer SIJ injections and/or RFA when conservative ma nagement has failed. C. Definitions Conservative Therapy A multimodal plan of care includ ing both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen supporting muscle groups and target key spin al structures, including physical therapy, occupational therapy, and/or 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 the HEP due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability t o complete. Sacroiliac Joint Procedures-GA MCD-MM-0215Effective 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 o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices , TENS use , and/ or pharmacotherapy (prescription or over the counter [eg, non-ster oidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inh ibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins. Its use, frequency, duration, and sta rt dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Radiofrequency Facet Ablation (RFA) Minimally invasive treatment modalitiy that percutaneous ly introduc es an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. Sacroiliac Joint (SIJ) Injections Corticosteroid and local anesthetic therapeutic injections into the SIJ to treat pain that hasnt responded to con servative therapies. D. PolicyI. Sacroiliac Joint Injections A. Diagnostic i njections: CareSource considers up to 2 diagnostic sacroiliac joint injection s for the treatment of chronic low back pain medically necessary when ALL the following criteria are met : 1. somatic or nonradicular low back and/or lower extremity pain experienced for at least 3 months 2. pain and tenderness located in the sacroiliac joint region 3. positive response to at least one SIJ pain provocation test (eg, distraction, compression, thigh thrust , Gaenslens, Patricks test/FABER test, sacral thrust) 4. failure of conservative therapy, as evidenced by ALL the following: a. document ation in the medical record of at least 6 weeks of active conservative therapy ( as defined above ) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance b. documentation in the medical record of at least 6 weeks of inactive conservative therapy ( as defined above ) within the p ast 6 months 5. if a second diagnostic injection is requested , at least 1 week has passed since the initial injection B. Therapeutic injections: CareSource considers therapeutic sacroiliac joint injections medically necessary when ALL the following criteria are met: 1. most recent SIJ injection le d to at least a 75% pain relief and functional improvement 2. member experiences return of pain or deterior ation in function 3. injection is used in conjunction with conservative therapy (as defined above) 4. injection is repeated at a frequen cy of no greater than every 2 months Sacroiliac Joint Procedures-GA MCD-MM-0215Effective 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 5. no more than 4 injections total (diagnostic and therapeutic) have been administered at the same site in the last 12 monthsC. Exclusions/Limitations 1. Codes 64451 and 27096 may not be billed together (on the same date for the same side of the body). Only one code will be reimbursed . 2. Image guidance and/or injection of contrast is i ncluded in sacroiliac injection procedures and may not be billed separately. 3. If neural blockade is applied for different regions or different sides, injections are performed at least one week apart . 4. Pain management literature highlighting controlled stud ies of SI Jpain management has not demonstrated injections of the SI Jto be effective as a long-term management modality. Long-term continuation may be subject to medical necessity review. 5. Monitored anesthesia and conscious sedation are not medically neces sary. 6. The use of SI Jinjections for the treatment of pain as a result of Herpes Zoster is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. II. Radiofrequency Ablation of the SI JA. Initial radiofrequency ablation of the SI J Radiofrequency ablation is considered medically necessary when ALL the following have been met in the last 6 months: 1. The clinical criteria above for failed conservative therapy (I.A.4.a. and I.A. 4.b.) has been met . 2. One diagnostic injection per joint to evaluate pain and attain therapeutic effect has been performed with a reported 75% or greater reduction in pain after injection. B. Repeat radiofrequency ablation of the SI J 1. Conservative therapy and diagno stic injections are not required if there has been a reduction in pain for at least 12 months or more from the initial RFA within the last 36 months. 2. When there has not been a repeat RFA in the last 36 months, a diagnostic injection is required. 3. A maximum of 1 radiofrequency ablation for SI Jpain per side per 12 months is considered medically necessary. C. Exclusions/Limitations 1. The use of cooled RFA for SI J-mediated low back pain is considered not medically necessary due to insufficient evidence demo nstrating efficacy in the peer-reviewed published literature. 2. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated the effectiveness of RFA as a long-term management modality. Long-term continuation may be subject to medical necessity review. Sacroiliac Joint Procedures-GA MCD-MM-0215Effective 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.5 III. Spinal Cord Stimulators/Pain PumpsMembers with indwelling implanted spinal cord stimula tors or pain pumps should have a device interrogation report submitted with medical records for a prior authorization request for proposed interventional pain injections. If a device is not functioning properly, an escalation in pain may warrant evaluation and management of the implanted device. E. Conditions of CoverageNA F. Related Polices/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/22/2018 New PolicyDate Revised 08/01/2019 05/13/202004/28/202104/06/2022 03/01/202301/31/202401/29/2025Annual Update: Addition of PA clarification and documentation requirements. Revision of injection frequency.Annual Update: Added cli nical criteria for coverage of radiofrequency ablation of the SI Joint . Added coding information. Annual Update : Removed PA language. Annual Review: Updated references and background, re – organized criteria by procedure and initial vs repeat procedure Annual review: restructured conservative management and clinical criteria , added provocation tests . Approved at Committee Annual review: updated formatting and references, approved at Committee Review: updated references, approved at Committee Date Effective 08/01/2025 Date Archived H. References1. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic ther apies for low back pain: a systematic rev iew for an American College of Physicians clinical practice guideline . Ann Intern Med . 2017;166(7):493-505. doi:10.7326/M16-2459 2. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated May 15, 2024 . Accessed January 5, 202 5. www.uptodate.com 3. Cine HS, Uysal E, Demirkol M, et al . Under what conditions is the intra-articular steroid injection superior to nonsteroidal anti-inflammatory drugs for treating sacroiliac joint pain? Eur Rev Med Pharmacol Sci . 2023;27(21):10539-10546. doi:10.26355/eurrev_202311_34331 Sacroiliac Joint Procedures-GA MCD-MM-0215Effective 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.6 4. Jamjoom AM, Saeedi RJ, Jamjoom AB. Placebo effect of sham spine procedures in chronic low back pain: a systematic review. JPain Res .2021;14:3057-3065. doi:10.2147/JPR.S317697 5. Janapala RN, Knezevic E, Knezevic NN, et al. Systematic review and meta-analysis of effectiveness of therapeutic sacroilic joint injections. Pain Phys ician . 2023;26:E413-E435. Accessed January 5, 2025 . www.painphysicianjournal.com 6. Lee DW, Pritzlaff S, Jung MJ, et al. Latest evidence-based application for radiofrequ en cy neurotomy (LEARN): best practice guidelines from the American Society of Pain and Neuroscience (ASPN). JPain Res. 2021;14:2807-2831. doi:10.2147/JPR.S235665 7. Maas ET, Ostelo RWJG, Niemisto L, et al . Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev . 2015;2015(10):CD008572. doi:10.1002/14651858.CD008572.pub2 8. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint inerventions 2020 guidelines. Pain Phys. 2020;23(3S):S1-S127. Accessed January 5, 202 5. www.painphysicianjournal.com 9. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 10. Szadek K, Cohen SP, de Andres Ares J, et al. Sacroiliac joint pain. Pain Pract. 2023 ;00:1-20. doi:10.1111/papr.13338 11. Wu L, Tafti D, Varacallo M. Sacroiliac joint injection. StatPearls . StatPearls Publishing; 2023. Updated August 4, 2023. Accessed January 5, 202 5. www.ncbi.nlm.nih.gov Independent Medical Review January 2025GA-MED-P-3677827 Issue Date 02/22/2018 Approved DCH 04/29/2 025
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Neonatal Discharge Criteria-GA MCD-MM-1251 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 ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Neonatal Discharge Criteria-GA MCD-MM-1251Effective 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. SubjectNeonatal Discharge Criteria B. BackgroundInfants who require neonatal admission remain at increased risk for morbidity and mortality following discharge. These infants require comprehensive discharge planning to ensure a smooth transition from the neonatal intensive care unit (NICU) and to reduce morbidity and mortality after discharge. Despite the inability to predict the exact timing of a NICU discharge, discharge planning should begin at NICU admission in an effort to avoid overwhelming parents and hospitalstaff. This planning will aid in minimizing discharge delays and will promote safe and healthy discharges to home.Discharge may be appropriate when the establishment of physiologic competencies, including , but not limited to, thermoregulation, feeding, respiratory control, and stabilityregardless of weight or corrected gestational age, have been achieved.C. Definitions Acceptable Bilirubin Level Defined per American Academy of Pediatrics (AAP) guidelines . Bilirubin Blood test to measure liver function. Car Seat Test Eligibility An infant tolerance test for sitting usually occurring 36.4 Caxillary while clothed in an open bed/ crib . D. PolicyI. CareSource considers neonatal discharge medically appropriate for non-technology dependent infants when ALL of the following clinical criteria are met: A. Thermoregu lation Stability 1. Infant demonstrates the ability to maintain normal body temperature while clothed in an open crib. Up to 48 hours of stable body temperature is typically adequate for infants born
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Intraosseous Basivertebral Nerve Ablation-GA MCD-MM-1303 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 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 ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Re view/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Intraosseous Basivertebral Nerve Ablation-GA MCD-MM-1303Effective 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. SubjectIntraosseous Basivertebral Nerve Ablation B. BackgroundInterventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates active conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. Chronic low back pain (CLBP) is a common disabling cond ition, estimated to afflict 80%of adults at some point. Degenerative disc disease (DDD) is an important cause ofCLBP. While discs are avascular with limited nerve distribution, vertebral endplates have the potential to trigger a cascade of degenerative e vents if there is a loss of integrity. Vertebral endplates are a thin interface between bone marrow and discs and contain neural elements. Breakdown of the endplate is believed to cause v ertebrogenic chronic low back pain , a type of chronic low back pain . Endplate degeneration can be observed on MRI through Modic changes (MC). Histologically, in MC type I (MC I) lesions, the endplate is disrupted as fibrous tissuereplaces bone marrow, causing the disc-bone interface to be filled with vascularized granulat ion tissue. MC I represents bone marrow edema and inflammation. In MC t ype II (MC II) lesions, there is demonstration of fatty marrow replacement in addition to MC type I findings. MC II represents conversion of hematopoietic marrow into fatty, yellow bone marrow. MC type III (MC III) lesions are related to subchondral bone sclerosis. Analysis of Modic lesion s shows that MC I is characterized by high bone turnover, MC II is characterized by decreased bone turnover, and MC III are stable. Radiofrequency ablation is a minimally invasive, percutaneous treatment which uses heat to ablate the nerve pathway that conducts the pain signal. The goal of RFA is to interrupt the pain pathway without causing excessive sensory loss, motor dysfunction, o r other complications. Intracept is an RFA system designed to ablate the basivertebral nerve of the vertebral endplate. C. Definitions Chronic Low Back Pain Persistent pain in the lumbar region lasting for more than 12 weeks. Conservative Therapy A mult imodality 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 physician supervised home exercise program (HEP). Intraosseous Basivertebral Nerve Ablation-GA MCD-MM-1303Effective 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 HEP A 6-week program requiring an exercise prescription an d/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience or non compliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS unit, and/ or pharmacotherapy (prescription or over the counter [eg, non-steroidal anti-inflammatory drugs, acetaminophen]). Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surfa ce of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Modic Changes Vertebral bone marrow signal intensity changes that are observable on MRI and are commonly associated with degenerative disc disease. o Modic Chan ge Type I Characterized by hypo-and hyper-intense signal intensities on T1-and T2-weighted spin-echo (T1W1 and T2W1), respectively. o Modic Change Type II Characterized by hyper-intense signal intensities on both T1W1 and T2W1. o Modic Change Type III Characterized by hypo-intense signal intensities on both T1W1 and T2W1. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial or lateral branches of the dorsal spinal nerves. D. PolicyI. CareSource considers intraosseous basivertebral nerve ablati on medically necessary when ALL the following clinical criteria is met: A. member has a diagnosis and documentation of chronic low back pain of at least 6 months duration B. failure of conservative therapy, as evidenced by ALL the following: 1. documentation in th e medical record of at least 6 weeks of active conservative therapy (see definition above) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance 2. documentation in the medical re cord of at least 6 weeks of inactive conservative therapy (see definition above) within the past 6 months C. MRI demonstrates Type I or Type II modic changes at one or more vertebra l endplates from level L3 to S1 , as demonstrated by 1. hypointense T1-weighted signal and hyperintense T2-weighted signal (ie, bone marrow edema and inflammation) , or Intraosseous Basivertebral Nerve Ablation-GA MCD-MM-1303Effective 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 2. hyperintense T1-weighted signal and hyperintense T2-weighted signal (ie,bone marrow ischemia) D. device is FDA-approved (eg, Intracept System) E. member does not have any of the following contraindications: 1. severe cardiac or pulmonary compromise 2. member has a targeted ablation zone less than 10mm from a sensitive structure not intended to be ablated (including vertebral foramen) 3. active systemic infection or localized infection in the area to be treated 4. member is currently pregnant 5. skeletal immaturity 6. implantable pulse generator (eg, pacemaker, defibrillator) or other electronic implant 7. scoliosis 8. spinal instability II. Repeat or additional intraosseous basivertebral nerve ablation is not considered medically necessary, as it has not been adequately studied in the peer-reviewed medical literature. III. Monitored anesthesia and conscious sedation during intraosseous basivertebral nerve ablation ar e considered not medically necessary and will therefore not be reimbursed. IV. Coverage is limited to the above criteria. Intraosseous basivertebral nerve ablation is considered not medically necessary for all other indications.E. Conditions of Coverage NA F. Re lated Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/30/2022 New PolicyDate Revised 03/01/2023 01/31/202401/29 /2025Annual review: restructured conservative therapy, added HEP and TENS definitions. Approved at Committee. Annual review: updated references, approved at Committee. Review: updated references, approved at Committee. Date Effective 08/01/2025 Date Archived Intraosseous Basivertebral Nerve Ablation-GA MCD-MM-1303Effective 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.5 H. References1. Becker S, Hadjipavlou A, Heggeness MH. Ablation of the basivertebral nerve for treatment of back pain: a clinical study. Spine J . 2017;17(2):218-223. doi :10.1016/j.spinee.2016.08.032 2. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Low Back Pain . North American Spine Society ; 2020. Accessed January 2, 2025 . www.spine.org 3. Evolving Evidence Review: Intracept Intraosseous Nerve Ablation System (Relievant Medsystems Inc.) for Treatment of Adults with Low Back Pain. Hayes ; 2023. Reviewed April 17, 2024. Accessed January 2, 202 5. www.evidence.hayesinc.com 4. Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 2-year results from a prospective randomized double-blind sham-controlled multicenter study. Int JSpi ne Surg . 2019;13(2):110-119. doi :10.14444/6015 5. Lorio M, Clerk-Lamalice O, Beall DP, et al . ISASS guideline : intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain. Int JSpine Surg . 2020;14(1):18-25. doi:10.14444/7002 6. Lori o M, Clerk-Lamalice O, Rivera M, et al. ISASS policy statement 2022: literature review of intraosseous basivertebral nerve ablation. Int JSpine Surg . 2022;16(6):1084-1094. doi:10.14444/8362 7. McCormick ZL, Curtis T, Cooper A, et al. Low back pain-related he althcare utilization following intrasosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. Pain Med . 2024;25:20-32. doi:10.1093/pm/pnad114 8. Nwosu M, Agyeman WY, Bisht A, et al. The effectiveness of in traosseous basivertebral nerve ablation in the treatment of nonradiating vertebrogenic pain: a systematic review. Cureus . 2023;15(4):e37114. doi:7759/cureus.37114 9. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evid ence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 10. Sayed D, Naidu RK, Patel KV, et al. Best practice guidelines o n the diagnosis and treatment of vertebrogenic pain and basivertebral nerve ablation from the American Society of Pain and Neuroscience. JPain Res . 2022;15:2801-2819. doi:10.2147/JPR.S378544 11. Smuck M, Khalil J, Barrette K, et al. Prospective, randomized, m ulticenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month result. Reg Anesth Pain Med. 2021;46:683-693. doi:10.1136/rapm-2020 – 102259 12. Smuck M, McCormick, ZL, Gilligan C, et al. A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J. 2024;S 1529-9430(24)01040-4. doi:10.1016/j.spinee.2024.09.016 13. U.S. Food and Drug Administration. 510(k) Premarket Notification: Int racept Intraosseous Nerve Ablation System , 510( k) approval K 222281; 2022. Accessed January 2, 2025 . www.accessdata.fda.gov Intraosseous Basivertebral Nerve Ablation-GA MCD-MM-1303Effective 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.6 14. U.S. Food and Drug Administration. 510(k) Premarket Notification: RelievantMedsystems RF Generator , 510( k) number: K171143; 20 17. Accessed January 2, 202 5. www.accessdata.fda.gov 15. Viswanathan VK, Shetty AP, Rajasekaran S. Modic changes : an evidence-based, narrative review on its pathophysiology, clinical significance and role in chronic low back pain. JClin Orthop Trauma . 202 0;11(5):761-769. doi:10.1016/j.jcot.2020.06.025 Independent med ical review 2022 GA-MED-P-3677827 Issue Date 03/30/2022 Approved DCH 0 4/29/2025
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 05/10/2025 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 standar ds, 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 determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………. 4 D. Policy ………………………….. ………………………….. ………………………….. ……………….. 4 E. Conditions of Coverage ………………………….. ………………………….. …………………. 14 F. Related Policies/Rules ………………………….. ………………………….. …………………… 16 G. Review/Revision History ………………………….. ………………………….. ………………… 16 H. References ………………………….. ………………………….. ………………………….. ……… 16 Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectApplied Behavior Analysis for Autism Spectrum Disorder B. BackgroundThe Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition, Text Revised (DSM-5-TR) classifies Autism Spectrum Disorder (ASD) as a neurodevelopmental disorder vary ing widely in severity and symptoms, depending on the developmental level and chronological age of the individual . ASD is characterized by specific developmental deficits that affect socialization, communication, academic , and personal functioning. Individuals are typically diagnosed before entering grade school, and symptoms are noticed across multiple contexts, including social reciprocity, nonverbal communicative behaviors, and skills in developing, maintaining , and understanding relationships. Restricted, repetitive patterns of behavior, interests , or activities are also often present. Currently, there is no cure for ASD, nor is there any single treatment for the disorder.The diagnosis may be managed through a combination of therapies, including behavioral, cognitive, pharmacological, and educational interventions with a goal of minimiz ing the severity of ASD symptoms, maximiz ing learning, facilitat ing social integration, and improv ing quality of life for members and families/caregivers. Applied behavior analysis (ABA) , one such therapy, may be provided in centers or at home and provides an evidence-based practice for the treatment of ASD . ABA is based on the science of behavior, which was founded on the premise that understanding behavior functioning, how it is affected by the environment, and how learning to change behavior can improve the human condition. It is a flexible treatment in tha t it should always be adapted to the needs of the individual, teaches skills that areuseful and generalizable, and involves individual, group and family training. Qualified and trained practitioners provide and/or oversee ABA programs and are accountable to state boards for registration, certification, or licensure requirements. Clinical decisions on telehealth service delivery models should be selected based on the individual needs, strengths, preference of service modality, caregiver availability and environmental support available. CareSource follows the Georgia Department of Community Health (DCH) Division of Medicaid and applicable state and federal laws in the provision of ABA services, which are based on a diagnosis from the DSM-5-TR. Severity levels are divided into 2 domainsand are defined as follows:Severity Levels for Autism Spectrum DisorderSeverity Level Social Communication Restricted, Repetitive Behaviors Level 3 Requiring very Severe deficits in verbal & nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, Inflexibility of behavior, extreme difficulty coping with change, or other restricted/ repetitive behaviors markedly interfere with Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 substantial support and minimal response to social overtures from others. functioning in all spheres. Great distress/difficulty changing focus or action. Level 2 Requiring substantial support Marked deficits in verbal and nonverbal social communication skills, social impairments apparent even with supports in place, limited initiation of social interactions, and reduced or abnormal responses to social overtures from others. Inflexibility of behavior, difficulty coping with change, or other restricted/ repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing f ocus or action. Level 1 Requiring support Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence. Social skills instruction is an important component of management of the diagnosis.Although additional studies are necessary, a 2012 meta-analysis of five randomized trials (196 participants) found evidence that participation in social skills groups improved overall social competence and friendship quality in the short term . A 2020 study demonstrated efficacy of a modified group cognitive behavioral therapy program in children delivered in a community context . A 2021 study demonstrated benefits of group cognitive behavioral treatment in adolescents diagnosed with autism and intellectual disabilities. As children near entry in a public or private school system, research supports the use of group therapy for school readiness and improved social skills. Training must be an integral component of the management of the underlying disorder and include clearly defined goals, teach desired behaviors, provide prompting for natural display of desired behaviors, provide reinforcement of demonstrated behaviors, an d include practice of desired behaviors with goals of generalizability outside the therapeu tic setting (eg, impairments in social-emotional reciprocity, restrictive or obsessional interests, aggressive behaviors). As the child becomes eligible for school-based services (the age varies depending uponthe state), the public school system becomes responsible for the provision of services and education. The services provided are outlined in an individualized education program (IEP), which is reviewed at a minimum of once a year , for children eligible . DCH reiterates that ASD services d o not include education services otherwise available through a program funded under 20 US Code Chapter 3, section 1400 of the Individuals with Disabilities Education Act (IDEA). Congress reauthorized the IDEA in 2004 and most recently amended the IDEA through Public Law 114-95, Every Student Succeeds Act, in December 2015. Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 C. Definitions Applied Behavior Analysis The design, implementation, and evaluation or systematic instructional and environmental modifications by a behavior analyst to produce socially significant improvements in behavior. Behavioral Assessmen t Separate from the initial diagnostic evaluation , the administration of an industry-standard assessment tool for skill acquisition and/or behavior reduction required to substantiate future tre atment services. Caregiver/Family Training Training taught by a therapist to parents/caregivers on how to implement methods utilized in a clinical setting into other environments, such as the home or community, to maximize outcomes furthering generalization of skills, and maximizing and reinforcing methods being taught. Direction Includes, but is not limited to, the QHCP observing implementation of a members protocols with member and providing instructions and corrective feedback as needed and/or demonstrating correct implementation of a new or modified protocol with the member whi le the QHCP observes and provides feedback. Plan of Care (POC ) A document submitted for authorization of treatment services that includes member goals, background, parent/caregiver training and other criteria associated with treatment. Qualified Health Care Professional (QHCP) An individual licensed, certified, or permitted to provide ASD services and enrolled with Georgia Medicaid , including physicians, psychologists, BCBA-D, or a BCBA . Supervisio n The direct clinical review, for the purpose of training or teaching, by a physician, psychiatrist, BCBA-D, or BCBA to promote the development of the practitioners clinical skills and may include, without being limited to, the review of case presentations, audiotapes, videotapes, and direct observation . D. PolicyI. General Guidelines The members treatment record (eg, plans of care, treatment plans, behavior support plans, functional assessments) must be completed by the provider or practitioner, signed by the parent or legal guardian (if minor age) or by the member , if applicable , and submitted to CareSource at the time the provider requests a medical necessity review for behavioral assessment or treatment services. Guardianship documentation must be provided for any member 18 and over, as applicable. A. Medical review must be submitted with appropriate documentation as indicated in this policy and align with the States definition of medical necessity includ ing that treatment is not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results. Along with this policy, CareSource utilizes the following resources for the provision of ABA therapy: 1. Autism Spectrum Disorder Services Manual provided by Georgia Department of Community Health Division of Medicaid 2. MCG Health B. The following providers are authorized to deliver ABA services: Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 1. Licensed physician may supervise BCaBAs and RBTs2. Licensed psychologist may supervise BCaBAs and RBTs 3. Board Certified Behavioral Analyst Doctoral Level (BCBA-D) may supervise BCaBAs, RBTs and other implementing ABA interventions 4. Board Certified Behavior Analyst (BCBA) may supervise BCaBAs and RBTs 5. Board Certified Assistant Behavior Analyst (BCaBA ) must be supervised by a physician, psychologist, or BCBA /BCBA-D but may supervise RBTs and may not be the enrolled QHCP 6. Registered Behavior Technician must be supervised by a BCBA/BCBA-D or BCaBA and may not be the enrolled QHCP C. Eligibility 1. Member is under the age of 21 and must be able to participate in sessions. 2. Behaviors must be exhibited and present as clinically significant health or safety risks to self or others or significantly interfe re with basic selfcare, communication, or social skills . 3. Parent/c aregivers must be able to participate in ABA therapy and have the ability to implement ABA techniques in the home environment. If unwilling or unable, consideration will be given to other modalities of treatment . D. Diagnos tic Evaluation s Evaluations should be comprehensive with multiple informants covering multiple domains and completed prior to requesting a review of medical necessity for behavioral assessment or treatment services . Primary hearing deficits, speech disorder, and heavy metal poisoning must be ruled out as causal reasons for behavior. The following guidelines apply to diagnostic evaluation s: 1. Documentation must be established by a licensed physician . psychologist or other licensed professional as designated by Medical Composite Board . 2. Completion of 1 acceptable evidence-based tool and 1 caregiver tool (a list can be located in the Georgia Autism Spectrum Disorder Services Policies and Procedures Manual ). 3. Results should be submitted in report format with a summary of each individual evaluation instrument, developmental history, and present concerns , include the following information: a. date completed b. minimum of 2 assessment tools , including 1 clinician tool and 1 caregiver tool with a summary of each individual assessment c. any t ests administered with scores d. evaluators name , signature, and credentials E. Diagnostic Reevaluations In certain conditions as outlined in the Georgia Autism Spectrum Disorder Services Policies and Procedures Manual , a diagnostic reevaluation must include, at a minimum, 1 clinician observational assessment (school psychoeducation assessments are not acceptable) that re confirm s the diagnosis : 1. The diagnosis of ASD is provisional. Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 2. No formal neuropsychological evaluation was completed.3. The initial diagnosis is at least 5 years old with no evidence of ongoing assessment and treatment. II. Review of Medical NecessityCareSource considers ABA services , both the behavioral assessment and treatment services, medically necessary when the following criteria are met . Reviews of medical necessity are to be completed separately : A. Behavioral Assessment (BA) Prior Authorization (PA) 1. Authorization may be requested in 3-month increments and completed 1 time during the 6-month treatment authorization period no more than 2 months prior to the effective date of the next treatment authorization . 2. Review must be requested by the enrolled QHCP . 3. The BA is c onducted by a n independent practitioner who also develop s a treatment plan before services are provided . Comprehensive BAs are not to exceed 8 hours every 6 months unless additional justification is provided. 4. The BA will assess the following: a. sk ill acquisition, which may include: 01. Verbal Behavior Milestones and Assessments Placement Program (VB-MAPP) 02. Assessment of Basic Language and Learning Skills-Revised (ABLLS-R) 03. Assessment of Functional Living Skills (AFLS) 04. Promoting the Emergence of Advanced Knowledge Generalization (PEAK) 05. other direct s kills assessment b. maladaptive behavior, which may include: 01. functional behavioral assessment s 02. traditional functional analyses 03. Interview-Informed Synthesized Contingency Analysis (IISCAs) / Practical Functional Assessment (PFA) 5. Summarized re sults will be used to develop interventions in the form of a plan of care (POC) , a required document for treatment service authorization that must be signed by the parent , guardian , or member (if 18 and over ) and submitted to CareSource at the time of the review request 6. With appropriate consent, behavior analysts s hould conduct record reviews of available data when receiving members from other facilities; however, BAs and treatment plans must be developed by the current provider. a. A behavior analyst should not submit BAs and treatment plans that are the work product of another behavior analyst to obtain a PA. b. If a member transfers to another provider within the same company during a period covered under an active PA, the behavior analyst receiving the transferred member must review and attest that the treatment plan has been approved and signed by the parent, guardian or member, as applicable . Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 7. Medical necessity review documentation should include the following , as applicable : a. diagnostic evaluation b. Letter of Medical Necessity (LMN) c. individualized Family Service Plan d. Individual Education Plan (IEP) e. previous hospitalization or out-of-home placement documents f. Medicaid Cover Page (see Georgia Autism Spectrum Disorder Services Policies and Procedures M anual ) g. any other clinical documentation needed to support the plan of care as supported by best practices (eg, behavioral, psychological or medical history, evidence of previous therapies with results, history of symptom intensity that demonstrates how the members ability to function in various setting is impacted) B. Treatment Services Prior Authorization (PA) 1. Authorization may be requested in 6-month increments . 2. Documentation should include the following , as applicable : a. diagnostic evaluation b. Letter of Medical Necessity (LMN) c. descriptive results of the BA conducted/dated no more than 2 months prior to the treatment services PA effective date d. proposed Plan of Care (POC) signed by the parent, guardian or member, as applicable e. updated data collected during previous treatment authorizations if not initial request f. individualized Family Service Plan g. Individual Education Plan (IEP) h. previous hospitalization or out-of-home placement documents i. progress notes , if requested by CareSource j. Medicaid Cover Page (see Georgia Autism Spectrum Disorder Services Policies and Procedures Manual ) k. any other clinical documentation needed to support the POC as supported by best practices 3. Medical necessary will determine approved hours per week (eg, typically 10 – 30 hours) but should be c ommensurate with skill deficit or behavioral excesses as identified in the BA. 4. Active parent/caregiver participation and involvement is required to increase behavior improvement in behaviors identified as causing limitations or deficits in functional skills . C. Follow-up service medical necessity reviews following the initial treatment PA must include the following: 1. a summary of previous goals and progress 2. results of a recent BA within the previous 2 month s, including any graphs and current measurements 3. individualized goals for the member and parent/ caregivers as described in Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 the practice guidelines for treatment of ASD developed by the Behavior Analyst Certification Board (BACB)III. Plan of Care (POC)The POC must be submitted for review , be signed by the parent/caregiver and authoriz e treatment services and must comply the following: A. It should include a clear connection between the results of the BA to specific goals developed for the member. B. Goals should highlight areas in need of remediation, focusing on functional skills related to core deficits of ASD. C. Baseline data, current progress data, measurement , graphs and mastery criteria should be included and address core deficits as described in the practice guidelines for treatment set forth by the BACB . D. Treatment must 1. demonstrate that interventions are not custodial or maintenance-oriented in nature 2. include coordination across all providers, supports, and resources, particularly that applicable community resources have been identified and engaged 3. include c riteria and specific behavioral goals and interventions for lesser intensity of care and discharge 4. identify parent, guardian, and/or caregiver involvement in prioritizing target behaviors and training in behavioral techniques to provide additional supportive interventions 5. provide evidence/support for reasonable expectation that the member can benefit from services provided IV. Parent/Caregiver TrainingTraining will evolve as goals are met. Parent/caregiver(s) must actively work on at least 1 unmet goal with the provider documenting and tracking 2-4 goals. The plan of care must include documentation of the following: A. understanding /agreement to comply with the requirements of treatment B. how the parent/caregiver (s) will be trained in skills g eneraliza ble to the home and other environments , how the treatment goas are addressed when providers are not present, and overall skill abilities C. methods by which the parent/caregiver (s) will demonstrate trained skills (presence during sessions is not sufficient for a goal or method of training ) D. barriers to parent involvement and how those are being addressed ( eg, parents having the skills to assist with generalization of skills developed by the member) E. training and time involvement, including any materials or meetings occurring on a routine basis V. Discontinuation of ABA TherapyTitration and/or discontinuation of ABA therapy should occur when the following conditions are met (not an all-inclusive list): Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.9 A. Treatment ceases to produce significant meaningful progress or maximum benefit has been reached . B. Member behavior does not demonstrate meaningful progress for two successive 6-month authorization periods as demonstrated via standardized assessments. C. ABA therapy is making symptoms, behaviors or impairments worse. D. Symptoms have stabilized allowing member transition to a less intensive type of treatment or level of care to manage symptoms. E. Parent/caregiver(s) have refused treatment recommendations, are unable to participate in the treatment program and/or do not follow through on treatment recommendations to an extent that compromises the effectiveness of the services for member progress. VI. Documentation RequirementsThe State of Georgia and DCH enacts regulations and establishes guidelines related to requirements for documentation expectations for client records. Each dated entry in the record is to be maintained for a t least 5 years after the last date of service or not less than the length of time required by other regulations if longer , including those outlined by Centers for Medicare and Medicaid Services (CMS) and Health Insurance Portability and Accountability Act (HIPAA) . All written, electronic and other record s will be stored and disposed of in a manner that ensure s confidentiality. DCH outlines the following minimum standards for records, including: A. complete medical file with sufficient information to validate the diagnosis and establish the basis for treatment , including, at a minimum, the following: 1. member name or other information related to identification ( eg, social security number, medicaid identification number, date of birth) 2. date and time of admission 3. admitting, and then, verified diagnosis 4. name, address, telephone number of emergency contact 5. appropriate authorizations and consents for procedures and treatment 6. medical necessity of the service(s) being provided 7. results of any testing and/or assessments, including previous testing 8. records or reports from previous or current providers 9. documented correlation between assessed need and care plan 10. documentation of treatment that supports billing and clear evidence that the services billed are the services provided 11. financial and insurance information 12. pertinent medical information with physician, nursing, other practitioner, and case management progress notes 13. any treatment and medication orders 14. date and time o f discharge or death and/or condition on discharge B. plan of care that includes clear and specific coordination with all providers involved in treatment with individualized expectations and the following: 1. individualized expectations 2. prescribed services 3. service frequency Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.10 4. scope and duration of treatment5. measurable goals to be achieved C. progress notes that are legible, detailed, complete, signed and dated, including 1. signatures must be legible, original , and belonging to the person creating the signature 2. if illegible, the name should be printed as well as signed 3. signatures must be dated the actual date signed 4. rubber stamps are not acceptable but electronic signatures are acceptable in certain circumstances (see Part I Policies and Procedures for Medicaid/Peachcare for Kids , Section 106, General Conditions of Participation) D. corrections should be made by striking one line through the error, writing the correction, and including the initials of the person making the correction along with the date the correction is made (whiteout or any such product is unacceptable) E. back-dated records are not allowed, as records should be documented in real – time VII. Codes of ConductCodes of conduct to protect members by establishing, disseminating, and managing professional standards. Additionally, the State of Georgia mandates requirements for providers to comply with and train in standards and ethics . The ethics code written by the BACB includes the following standards (not all-inclusive): A. Family oversight must occur by/with the BCBA or BCaBA. An RBT may be present during a family training session to provide assistance with interventions, but the training or supervision of interventions cannot be completed by the RBT. B. Providers will create a contract for consent to services ( eg, Declaration of Professional Practices and Procedures) at the onset of services that defines and documents, in writing, the professional role with relevant parties. C. Appropriate effort will be made to involve members and stakeholders in treatment, including selecting goals, designing assessments and interventions, and conducting continual progress monitoring. D. Providers will identify and address environmental conditions ( eg, behavior of others, hazards to client or staff) that may interfere with service delivery, including the identification of effective modifications to interventions and appropriate documentation of conditions, actions taken, and eventual outcomes. E. Continuity of services will be facilitated to avoid interruption or disruption of services for members, including documentation of actions taken and eventual outcomes. F. Providers will address any possible circumstances when relevant stakeholders are not complying with the behavior-change intervention(s) despite documented and appropriate efforts to address barriers to treatment. Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.11 VIII. Supervision ExpectationsThe State of Georgia and DCH enacts guidelines with requirements for supervision and documentation. The QHCP must supervise non-enrolled practitioners under the enrolled provider identification number of the QHCP and/or facility. However, supervision must be performed in acco rdance with the supervision guidelines of the BACB. Supervision is not separately reimbursable as it is build into the direct service code rates. Time reported and billed MUST be face-to-face time with the patient. QHCP billing of protoc ol modification is not appropriate in instances when documentation supports only supervision or services being performed at a time when the member is not present. If there are any discrepancies with supervision documentation, the associated claims are subject to recoupment. At a minimum, supervision must include the following and records maintained by the supervisor and supervisee to be submitted for auditing upon r equest: A. GA DCH requirements (at a minimum): 1. duration and type of supervision session 2. brief summary of pertinent activity for each session B. The BACB outlines the following minimum provisions for supervision documentation: 1. RBTs must document the following during supervision (not all-inclusive): a. days and times behavior-analytic services were provided b. dates and duration of supervision c. supervision format (individual, group) d. dates of direct observation e. names of supervisors providing supervision f. noncertified RBT supervisor form, if applicable g. proof of supervisors relationship to the client h. additional documentation in the event of discrepant records (session notes) 2. Supervisors must document the following for any supervision hours conducted (not an all-inclusive list): a. date with start and stop times b. fieldwork type c. supervision type (group, individual) d. activity category (restricted or unrestricted) e. summary of supervision activity, including 01. discussion of activities completed during independent hours and any feedback provided 02. progress toward individual member goals 03. outcome of supervision, including any modification to treatment interventions or plans of care 04. collaboration of care among providers f. dated signatures of supervisor and supervisee, including credentials 3. Observations must include the following (at a minimum): a. date with start and stop times b. fieldwork type Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.12 c. setting name d. supervisor name e. activity category (restricted or unrestricted) C. QHCPs are required to follow DCH guidance regarding delegation of work, including the following: 1. QHCP s are responsible for all delegated work performed by any supervisee. 2. QHCPs will not delegate professional responsibilities to a person not qualified to provide those services. Responsibilities, even with appropriate levels of supervision, must be within the supervisees scopes of practice. 3. QHCP must have education completion and training on supervision rules, professional ethics, standards of practice, and certification guidelines. 4. QHCPs are responsible for determining competency of supervisee and will provide specific instructions regarding limits of the supervisees role. 5. Any QHCP contracts for independent contractors must maintain compliance with DCH policies, including Medicaid enrollment requirements. D. The BACB publishe s ethical codes related to supervision includ ing 1. Behavior analysts are knowledgeable about and comply with all applicable supervisory requirements (eg, BACB rules, licensure requirements, funder and organization policies), including those related to supervision modalities and structure (eg, in person, vi deo conference, individual, group). 2. Behavior analysts supervise and train others only within an individual ly identified scope of competence. 3. Behavior analysts take on only the number of supervisees that allows effective supervision and training. When a threshold volume for providing effective supervision has been met , document ation of self-assessment and communicat ion of results to employer(s) and relevant parties must occur. 4. Behavior analysts are accountable for supervisory practices and professional activities (eg, client services, supervision, training, research activity, public statements) of supervisees occurring as part of th at re lationship. 5. Behavior analysts ensure that documentation and the documentation of supervisees or trainees is accurate and complete. 6. Behavior analysts deliver supervision and training in compliance with applicable requirements (eg, BACB rules, licensure requirements, funder and organization policies) and design and implement supervision and training procedures that are evidence based, focus on positive reinforcement, and are individualized for each supervisee and circumstances. 7. Behavior analysts actively engage in continual evaluation of supervisory practices using feedback from others and client and supervisee outcomes. Self-evaluations are documented and timely adjustments made to supervisory and training practices as indicated. IX . Special Provisions Related to RBTsA. Current Standards for RBTs1. RBT services must be supervised by a qualified RBT supervisor (BCBA,BCBA-D, or BCaBA) . RBTs may not be the enrolled QHCP and must obtain Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.13 ongoing supervision for a minimum of 5% of the hours spent providing ABAservices per month. Additionally, the BACB publishes information regarding the structure o f supervision and parameters for group and individual supervision in the RBT Handbook . 2. An RBT certified by the BACB may provide ABA under the supervision of an independent practitioner if enrolled in the Medicaid program and affiliated with the organization under which the provider is employed or contracted. If the independent practitioner leaves the affiliated organization and no longer provides supervision, the RBT may not continue to provide services under that independent practitioner. Additionally, if the RBT leaves the affiliated organization and no longer receives mandated supervision, the RBT may not continue to provide services to the member. 3. RBTs must use appropriate modifiers that indicate qualifications of staff delivering services. B. Upcoming RBT Changes from the Behavior Analyst Certification Board 1. Effective January 1, 2026 : In the interest of consumer protection, the BACB Board of Directors approved a recommendation that RBT supervisors must hold BCBA or BCaBA certification. Noncertified supervisors will not be allowed to provide BACB-required supervision to RBTs. During th is transition, RBT Requirements Coordinators who currently attest to the qualifications of noncertified supervisors should make preparations to ensure continuity of care for clients. 2. Effective January 1, 2026 : New rules regarding eligibility for and maintenance of certification for RBTs were adopted by the BACB Board of Directors and can be located in the BACB Newsletter: December 2023 at www.bacb.com. X. Telehealth GuidanceThe provision of ABA services is allowed via telehealth per GA DCH. Part II Policies and Procedures for Autism Spectrum Disorder Services publishes applicable codes, modifiers and allowable provider types. Additionally, Part II Policies and Procedures for Telehealth Guidance provides information for telehealth billing requirements , which is only billable if the provider is in GA or within 50 miles of the GA border when services are rendered. Providers utilizing telehealth for the delivery of services must make decisions that are consistent with best, currently available evidence and clinical consensus. Clinical rationale must consider assessed needs, strengths, preferences, and availableresources of members and caregivers. The same professional ethics governing in-person care must be followed and limitations considered, including interstate licensure challenges, state regulatory issues, member or caregiver discomfort with technology, technology limitations, and cultural acceptance of virtual visits. Providers must identify protocols for clinical appropriateness (eg, risk assessment, safety planning, patient/caregiver characteristics), ensure the rapeutic benefit for recipients, and ensure provider competence of delivering care via telehealth modalities. Peer Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.14 reviewed studies and other best evidence literature provides guidance on appropriate screeners and questionnaires for use in the determination of appropriateness of telehealth services for particular clients.XI. ExclusionsAB A is not covered in the following circumstances: A. rehabilitative services (eg, community psychiatric supportive treatment, therapeutic behavioral service, and psychosocial rehabilitation service ) for the provision of ABA B. reimbursement is not permitted under any of the following situations: 1. any services not documented in the treatment plan 2. behavioral methods or mode s considered experimental 3. education al-related services or activities described under Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. 1400 (IDEA) , amended through Public Law 114-95, the Every Student Succeeds Act 4. vocational services in nature or those available through program s funded under Section 110 of the Rehabilitation Act of 1973 5. component s of adult day care programs C. treatment solely for the benefit of the family, caregiver or therapist D. treatment solely focused on recreational or educational outcomes E. goals focused on academic targets ( eg, treatment should address autistic symptoms impeding deficits in the home environment, such as reduction of frequency of self-stimulatory behavior to follow through with toilet training or completing a mathematic sorting task) F. treatment un expected to cause measurable , functional improvement or improvement is not documented G. duplicative therapy services addressing the same behavioral goals using the same techniques as the treatment plan, including services under an IEP H. services provided by family or household members I. care primarily custodial in nature and not requiring trained/professional ABA staff J. shadow ing , para-professional, or companion services in any setting K. personal training or life coaching L. services more costly than an alternative service (s) , which are as likely to produce equivalent diagnostic or therapeutic results for the member M. program s or service s performed in nonconventional settings , even if performed by a licensed provider, including spas/resorts , vocational or recreational settings , Outward Bound , and wilderness camp or ranch programs E. Conditions of CoverageI. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. II. When a member has other insurance, Medicaid is always the payer of last resort. CareSource will not pay more than the Medicaid rate totals for service. The p rimaryApplied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.15 payer must provide evidence of determinations for consideration of Medicaid coverage for services. III. CareSource reserves the right to request supervision documentation.A. Level 4 and 5 practitioners work under the supervision of higher-level practitioners. Providers are required to bill at the appropriate practitioner level and service code for the service rendered. To enroll as a Medicaid provider, the provider must either physically be located in Georgia or located within 50 miles of the Georgia border. B. Adaptive behavior treatment with protocol modification administered by an authorized provider type (ie, physician, psychiatrist, psychologist, BCBA-D, BCBA) with 1 client for the first 30 minutes utilizes patient face-to-face time. Additional 30-minute increments requirement authorization in accordance with medical necessity. IV. Providers a gree to bill Medicaid for only those services rendered by the provider or by a QHP under the provider s direct supervision . Under no circumstances may a provider bill for services rendered by another practitioner who is enrolled or eligible to enroll as a provider. All services are to be billed with modifiers specific for practitioner level and service delivery setting/modality , as follows: Practioner Level Legend Physician, Psychiatrist U1 Level 1 Psychologist, BCBA-D U2 Level 2 BCBA U3 Level 3 BCaBA U4 Level 4 RBT U5 Level 5 V. Providers a gree to bill the procedure code(s) which best describes the servicerendered and not to bill under separate procedure codes for services included under a single procedure code. Coding of both diagnoses and procedures is required for all claims and must be to the highest level. VI. Providers cannot submit multiple dates of service on a single claim line. Each claim line must be specific to a single date of service and the units provided on that single date of service.VII. Both codes and modifiers can be found in the Georgia Autism Spectrum DisorderServices Policies and Procedures Manual. The maximum daily units per procedure code as mandated by CMS and published by the State of GA is as follows: Procedure Code Max Units Per Day 97151 32 97152 16 97153 32 97154 18 Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.16 97155 2497156 16 97157 16 97158 16 0362T 16 0373T 32 F. Related Policies/RulesI. Health Insurance Po rtability and Accountability Act (HIPAA) of 1996 II. Diagnostic, screening, preventive, and rehabilitative services, 42 C .F.R. 440.130(c) (2023) III. Definitions, 42 U.S.C. 1396d (2019) G. Review/Revision HistoryDATE ACTIONDate Issued 11/29/2017Date Revised 04/19/2018 04/01/202004/28/202112/01/202104/27/202204/12/2023 03/13/2024 04/24/202407/31 /202409/25/202403/12/2025Addition of qualified healthcare profession re: final diagnosis criteria . Section III. Diagnosis Updated policy. Annual review. Updated medical necessity criteria, exclusions, discontinuation criteria, and added in language from GAMMIS. Clarified documents referenced. Title change Removed telehealth exclusion Changed assessment from 3 to 5 years; removed Appendix G; added note D.2.k. Updated definitions. Reorganized. Approved at Committee. Annual review. Expanded background. Added sections VII-X. Added sections VII X & MUE information to Cond of Coverage section. Updated H. Approved at Committee. Added II.A.5. GAMMIS update 4/1/24. Approved at Committee. Added direction (GAMMIS update 7/1/24), D.III.E., VIII.D., IX.A.1.a. – b., X., E.III.A-C., updated references. Approved at Committe e. Out of cycle review. Added documentation submission prior to claim submission. Out of cycle review. Removed parent guardian signature on daily progress notes prior to claims submission. Approved by Committee. Date Effective 05/10/2025 Date Archived H. References1. 202 5 NCCI MUE Edits-Practitioner Services . Centers for Medicare and Medicaid Services. Updated January 1, 2025 . Accessed February 26, 2025 . www.cms.gov 2. Anglim M, Conway EV, Barry M, et al. An initial examination of the psychometric properties of the Diagnostic Instrument for Social and Communication Disorders Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.17 (DISCO-11) in a clinical sample of children with a diagnosis of autism spectrum disorder. Ir JPsychol Med . 2022;39(3):251-260. doi:10.1017/ipm.2020.100 3. Applied Behavior Analysis: B-806-T. MCG. 28th ed. Updated March 14, 2024 . Accessed February 26, 2025 . www.careweb.careguidelines.com 4. Augustyn M. Autism spectrum disorder in children and adolescents: evaluation and diagnosis. UptoDate. Updated May 16, 2022. 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Early behavioral interventions for children and adolescents with autism spectrum disorder in routine clinical care: a Applied Behavior Analysis for Autism Spectrum Disorder-GA MCD-MM-0212 Effective Dat e: 05/10 /2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.21 systematic review and metaanalysis. Clin Psychol . 2022;29(4):400-414. doi:org/10.1037/cps0000106 62. Witwer A, Walton K, Held M. Taking an evidence-based child-and family-centered perspective on early autism intervention. Clin Psychol . 2022;29(4):420-422. doi:org/10.1037/cps0000122 GA-MED-P-3325183 Issue Date 11/29/2017 Approved DCH 03/0 6/2025
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