MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 09/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 3 H. References ………………………….. ………………………….. ………………………….. …………………….. 3 Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 Effective Dat e: 09/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPeripheral Nerve Stimulators for Treatment of Pain B. BackgroundThe role of peripheral nerves as sources of pain and avenues of treatment when conservative therapy has failed is being more extensively explored than in previous years. Neuromodulation of peripheral nerves to treat refractory pain is one such area of inte rest. The neuromodulation of peripheral nerves to reduce pain, known as peripheral nerve stimulation (PNS), has been developed as a minimally invasive pain management modality intended to manage acute and chronic pain. The proposed mechanism of action, referred to as the gate control theory, involves a method by which stimulation of large-diameter sensory neurons reduces transmission ofpainful stimuli from small nociceptive fibers to the brain. The stimulation system is placed adjacent to the nerve, a process commonly known as remote selective targeting. The lead is connected to a small, wearable stimulator. Depending on the device, the wearer may be able to adjust the level of stimulation using Bluetooth technology. C. Definitions Acute Pain Pain lasting 4 weeks or less. Chronic Pain A distressing feeling often caused by intense or damaging stimuli (pain) lasting more than 90 days , considered beyond normal healing time. Conservative Therapy A multimodality plan of care for treating pain non – surgically, including active and inactive conservative therapies. o Active A type of action or activity to strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational therapy, a physician-supervised home exercise program (HEP), and/or chiropractic care. o Inactive Lack of activity on behalf of the patient that aids in treating symptoms associated with pain but not necessarily the underlying source, including rest, ice, heat, medical devices, acupuncture, and/or prescription medications. Minimally Invasive Procedures involving entry into the body through small incisions to lessen recovery time, level of pain and risk of infection. Sub-acute Pain Pain lasting between 4 and 12 weeks. D. PolicyI. Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply used in or directly related to the diagnosis, evaluation, or treatment of a disease, injury, illness, or other health condition which CareSource determines in its sole discretion to be experimental or investigational is not covered by CareSource. II. Peripheral nerve stimulators are considered experimental and investigational and are unproven for all indications for the reduction of acute, sub-acute, and chronic pain.Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 Effective Dat e: 09/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 III. Peripheral nerve stimulators are not covered. This includes but is not limited to:A. IB-Stim B. SPRINT PNS System C. Nalu Neurostimulation System D. StimRouter Neuromodulation System E. Moventis PNS F. StimQ PNS System E. Conditions of CoverageN/A F. Related Policies/RulesMedical Necessity Determinations Experimental and Investigational Item or Service G. Review/Revision HistoryDATE ACTIONDate Issued 02/15/2023 Approved at Committee.Date Revised 01/17/2024 06/05/2024 05/07/2025 Annual Review : references updated ; Approved at Committee Revised Background, added D. III. A. Approved at Committee Annual review, references updated. Approved at Committee Date Effective 09/01/2025 Date Archived H. References1. Abd-Elsayed A, Keith MK, Cao NN, Fiala KJ, Martens JM. Temporary peripheral nerve stimulation as treatment for chronic pain. Pain Ther . 2023;12(6):1415-1426. doi:10.1007/s40122-023-00557-3 2. Albright-Trainer B, Phan T, Trainer RJ, et al. Peripheral nerve stimulation for the management of acute and subacute post-amputation pain: a randomized, controlled feasibility trial. Pain Manage . 2022;12(3):357-369. doi:10.2217/pmt-2021-0087 3. Char S, Jin MY, Francio VT, et al. Implantable peripheral nerve stimulation for peripheral neuropathic pain: a systematic review of prospective studies. Biomed . 2022;10(10)2606. doi:10.3390/biomedicines10102606 4. DSouza RS, Jin MY, Abd-Elsayed A. Peripheral nerve stimulation for low back pain: a systematic review. Curr Pain Headache Rep . 2023;27:117-128. doi:10.1007/s11916-023-01109-2 5. Evidence Analysis Research Brief: Peripheral Nerve Stimulation for the Treatment of Superior Cluneal Neuralgia. Hayes; 2024. Accessed April 10, 2024. www.evidence.hayesinc.com 6. Evolving Evidence Review: IB-Stim (NeurAxis) for Treatment of Pain Associated with Irritable Bowel Syndrome in Adolescents. Hayes; 2022. Reviewed July 17, 2024. Accessed April 10, 2025. www.evidence.hayesinc.com Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 Effective Dat e: 09/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 7. Evolving Evidence Review: SPRINT PNS System (SPR Therapeutics) for Chronic Pain. Hayes; 2021. Updated February 27, 2025. Accessed April 10, 2025. www.evidence.hayesinc.com 8. Hatheway J, Hersel A, Song J, et al. Clinical study of a micro-implantable pulse generator for the treatment of peripheral neuropathic pain: 3-month and 6-month results from the COMFORT-randomised controlled trial. Reg Anesth Pain Med . 2024 ;0:1-7. doi:10.1136/rapm-2023-105264 9. Health Technology Assessment: Percutaneous Peripheral Nerve Stimulation for Treatment of Chronic Pain. Hayes; 2022. Reviewed May 8, 2024. Accessed April 10, 2025. www.evidence.hayesinc.com 10. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain. Hayes; 2021. Reviewed April 17, 2024. Accessed April 10, 2025. www.evidence.hayesinc.com 11. Helm S, Shirsat N, Calodney A, et al. Peripheral nerve stimulation for chronic pain: a systematic review of effectiveness and safety. Pain Ther . 2021;10(2):985-1002. doi:10.1007/s40122-021-00306-4 12. Huntoon MA, Slavin KV, Hagedorn JM, et al. A retrospective review of real-world outcomes following 60-day peripheral nerve stimulation for the treatment of chronic pain. Pain Physician . 2023;26(3):273-281. Accessed April 10, 2025. www.painphysicianjournal.com 13. Kaye AD, Ridgell S, Alpaugh ES, et al. Peripheral nerve stimulation: a review of techniques and clinical efficacy. Pain Ther . 2021;10(2):961-972. doi:10.1007/s40122 – 021-00298-1 14. Li AH, Gulati A, Leong MS, et al. Considerations in permanent implantation of peripheral nerve stimulation (PNS) for chronic neuropathic pain. an international cross-sectional survey of implanters. Pain Pract . 2022;22(5):508-515. doi:10.1111/papr.13105 15. Luna D, Hettie G, Pirrotta L, et al. Real-world long-term outcomes of peripheral nerve stimulation: a prospective observational study. Pain Manag . 2025;15(1):37-44. doi: 10.1080/17581869.2025.2451605 16. McCullough M, Kenney D, Curtin C, et al. Peripheral nerve stimulation for saphenous neuralgia. Reg Anesth Pain Med . 2024;49(6):455-460. doi:10.1136/rapm-2023 – 104538 17. Smith BJ, Twohey EE, Dean KP, DSouza RS. Peripheral nerve stimulation for the treatment of postamputation pain: a systematic review. Am JPhys Med Rehabil . 2023;102(9):846-854. doi:10.1097/PHM.0000000000002237 18. Strand N, DSouza RS, Hagedorn JM. Evidence-based clinical guidelines from the American Society of Pain and Neuroscience for the use of implantable peripheral nerve stimulation in the treatment of chronic pain. JPain Res . 2022;15:2483-2504. doi:10.2147/JPR.S362204 19. Vangeison CT, Bintrim DJ, Saha AK, et al. The role of peripheral nerve stimulation in refractory non-operative chronic knee osteoarthritis. Pain Manag . 2023;13(4):213 – 218. doi:10.2217/pmt-2023-0025 Peripheral Nerve Stimulators for Treatment of Pain-GA MCD-MM-1429 Effective Dat e: 09/01/2025 The MEDICAL Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the MEDICAL Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 5 20. West T, Hussain N, Bhatia A, et al. Pain intensity and opioid consumption after temporary and permanent peripheral nerve stimulation: a 2-year multicenter analysis.Reg Anesth Pain Med . 2024. doi:10.1136/rapm-2024-10570421. Xu J, Sun Z, Wu J, et al. Peripheral nerve stimulation in pain management: a systematic review. Pain Physician . 2021;24(2):E131-E152. Accessed April 10, 2025 .www.painphysicianjournal.comGA-MED-P-3973709Issue Date 0 2/15/2023 Approved DCH 06/18/2025
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Genetic Testing and Counseling-GA MCD-MM-0735 09/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence o f Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the cont rolling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less fav orable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Polices/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Genetic Testing and Counseling-GA MCD-MM-0735Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectGenetic Testing and Counseling B. BackgroundAdvancements in technology have contributed to the rapid expansion of identified genetic variations . S ome of these variations have been identified as disease-causing, while others are considered common variants with no clinical impact . With the ever – expanding number of genetic tests ava ilable , it can be clinically difficult to determine the most appropriate tests for a particular patient. When clinically appropriate, genetic testing may provide diagnostic and/or actional therapeutic results which can impact a patients outcome. Due to th e complexity of genetic tests and their results, consultation with m edical genetics professionals and counselors may be required to assist members. According to the National Society of Genetic Counselors of the United States, genetic counseling is meant to integrate the following goals: 1) interpretation of family and medical histories to assess the chance of disease occurrence or recurrence; 2) education about the natural history of the condition, inheritance pattern, testing, management, prevention, sup port resources, and research; 3) counseling to promote informed choices in view of risk assessment, family goals, ethical and religious value; and 4) support to encourage the best possible adjustment to the disorder in the affected family member and/or to the risk of recurrence of that disorder. Genetic counselors are healthcare professionals trained to provide this care . H owever, access issues may require other healthcare professionals to assume this role. Genetic counseling, whether provided by a certifie d genetic counselor or other qualified healthcare professional, is an integral component of genetic testing that is informative and supportive to members, both before and after they undergo testing. C. Definitions Genetic Screening The process of testing a population for a genetic disease to identify a subgroup of people who either have the disease or the potential to pass it to offspring . Genetic Testing A medical test that identifies changes in genes, chromosomes, or proteins to confirm or rule out a s uspected genetic condition , either hereditary or acquired. Human Leukocyte Antigen (HLA) Typing A test used to match patients and donors for bone marrow or cord blood transplants. Inherited Genetic Variant A type of DNA sequence change passed from parent to offspring (ie, germline). Precision Medicine A field of medicine that selects pharmacotherapies based on the patients genetics. Somatic Gene Variant A type of DNA sequence change that is not inherited from a parent but acquired during a per sons life. Genetic Testing and Counseling-GA MCD-MM-0735Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 D. PolicyI. Prior authorization may be required for genetic testing . This includes both somatic and germline genetic testing. I. CareSource will review for medical necessity using published MCG criteria when available and the Medical Necessity Determinations administrative policy. This policy does not apply to requests that have MCG or InterQual guidelines with clear genetic counsel ing requirements/recommendations. II. Proprietary panel testing requires evidence-based documentation per the MedicalNecessity Determinations administrative policy. Individual genetic testing may be requested separately based on the Medical Necessity Determi nations administrative policy for panels not meeting medical necessity requirements. III. Genetic counseling is required for all inherited genetic m utation testing , as indicated by ALL the following: A. Counseling is provided by a healthcare professional with edu cation and training in genetic issues relevant to the genetic tests under consideration . B. Counseling is provided to enable members informed decision making concerning proposed testing (eg, purpose of testing, management that may be informed by result, heri table nature informed by 3-generation family history, range of possible results, potential benefits and risks of testing (eg, psychological, social, economic). IV. Somatic genetic testing does not require genetic counseling described above.V. Human leukocyte antigen (H LA ) typing is not part of the genetic testing policy and do es not require pre-authorization. VI. While most inherited genetic testing is only necessary once in a lifetime, CareSource recognizes that a germline genetic test could be approp riate repeated in extraordinary circumstances due to changes in technology. This type of test will be considered with the proper medical necessity documentation. E. Conditions of CoverageNAF. Related Polices/RulesMedical Necessity Determinations Cystic Fibrosis Testing G. Review/Revision HistoryDATE ACTIONDate Issued 01/01/2020 New PolicyGenetic Testing and Counseling-GA MCD-MM-0735Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 Date Revised 09/02/202007/07/2021 05/25/2022 05/10/202304/10/202407/03/2024 04/23 /2025Revised title, removed MCG table, condensed backgroundReviewed, updated references Annual Review: updated background, definitions, references, re-organized criteria Annual review: updated background, definitions, and references, rephrased genetic counseling process. Approved at Committee. Review: updated references, approved at Committee. Review: clarified genetic counseling requirements, added language regarding MCG. Approved at Committee Review: updated references, approved at Committee. Date Effective 09/01/2025 Date Archived H. References1. Ambulatory care: genetic medicine. MCG Health. 28 th ed. Accessed April 8, 2025 . www.careweb.careguidelines.com 2. Cohen SA, Bradbury A, Henderson V, et al. Genetic counseling and testing in a community setting: quality, access, and efficiency. Am Soc Clin Oncol Educ Book . 2019;e34-e44. doi:10.1200/EDBK_238937 3. Crooke A, Jacobs C, Newton-John T, et al. Genetic counselin g and testing practices for late-onset neurodegenerative disease: a systematic review. JNeurol. 2022;269(2):676-692. doi:10.1007/s00415-021-10461-5 4. Georgia Department of Community Health. Part II Policies and Procedures for Independent Laboratory Services. April 1, 2024. Accessed April 8, 2025 . www.mmis.georgia.gov 5. Kohlmann W, Slavotinek A. Genetic testing. UpToDate. Updated July 22, 2024 . Accessed April 8, 2025 . www.uptodate.com 6. Mundy J, Davies HL, Radu M , et al. Research priorities in psychiatric genetic counselling: how to talk to children and adolescents about genetics and psychiatric disorders. Eur JHum Genet. 2023;31(3):262-264. doi:10.1038/s41431-022-01253-0 7. National Center for Biotechnology Information (NCBI). Genetic Testing Registry (GTR) National Library of Medicine. Accessed April 8, 2025 . www.ncbi.nlm.nih.gov 8. National Human Genome Research Institute. Coverage and Reimbursement of Genetic Tests. National Institutes of Health. Updated February 6, 2024 . Accessed April 8, 2025 . www.genome.gov 9. National Human Genome Research Institute. Regulation of Gene tic Tests. National Institutes of Health. Updated February 19, 2024 . Accessed April 8, 2025 . www.genome.gov 10. Raby BA, Kohlmann W. Genetic counseling: family history interpretation and risk assessment. UpToDate. Updated April 9, 2024 . Accessed April 8, 2025 . www.uptodate.com 11. Sarata AK. Genetic Testing: Background and Policy Issues . Congressional Research Service Report ; 2015 . RL33832. Accessed April 8, 2025 . www.sgp.fas.org Genetic Testing and Counseling-GA MCD-MM-0735Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 12. Senter L, Austin JC, Carey M, et al. Advancing the genetic counseling profession through research: identification of priorities by the National Society of GeneticCounselors research task force. JGenet Couns. 2020;29(6):884-887. doi:10.1002/jgc4.1330 13. Whit e S, Jacobs C, Phillips J. Mainstreaming genetics and genomics: a systematic review of the barriers and facilitators for nurses and physicians in secondary and tertiary care. Genet Med. 2020;22(7):1149-1155. doi:10.1038/s41436-020-0785-6 GA-MED-P-3769851 Issue date 01/01/2020 Approved DCH 06/18/ 20 25
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Non-Emergency Facility to Facility Transfers-GA MCD-MM-1447 08/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Non-Emergency Facility to Facility Transfers-GA MCD-MM-1447 Effective Dat e: 08/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNon-Emergency Facility to Facility Transfers B. BackgroundThis policy addresses the necessity of transferring a patient to a second acute care facility (receiving facility) when the individual requires care not available at the original facility. The goal of any transfer is to maintain the optimal health of the p atient. This is accomplished by transferring the patient to the nearest facility that provides the highest specialized care needed. Inter-hospital patient transfer is an important aspect of patient care, most often toimprove patient management. During such transfers, there must be continuity of medical care. Key elements include the decision to transfer and communication, pre-transfer stabilization and preparation, choosing the appropriate mode of transfer, personnel accompanying the patient, equipment and monitoring required during the transfer, and documentation and handover of the patient at the receiving facility. Transfer, admission , and subsequent care to the receiving facility is not medicallynecessary when the needed care is available at the originating facility.C. Definitions Non-Emergency A situation for which immediate response is not needed for the provision of medical treatment. Inter-Facility Transfer The transfer of patients between two healthcare facilities. Intra-Facility Transfer The transfer of patients within the same facility. Originating Facility The current facility to which an individual has been admitted for care and from which a transfer is planned. Participating (In-Network) Facility Facility that is contracted with CareSource. Non-Participating (Out-of-Network) Facility Facility that is not contracted with CareSource. Receiving Facility The facility to which a transfer is planned. D. PolicyI. The following non-emergency transfers require a prior authorization: A. a non-emergency transfer from a participating inpatient facility to a participating inpatient facility that is not within the same healthcare system B. a non-emergency transfer from a non-participating facility to a participating facility C. a non-emergency transfer from a non-participating facility to a non-participating facility II. For non-emergency transfers that require a prior authorization , the receiving facility submits the prior authorization request to CareSource. Non-Emergency Facility to Facility Transfers-GA MCD-MM-1447 Effective Dat e: 08/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 III. Requests for transfers that require a prior authorization must meet the following criteria: A. Member must be medically stable for transfer AND 1. Member requires transfer to a level of care un available at the originating facility . 2. Member requires transfer for a medically necessary diagnostic or therapeutic service which is not available at the originating facility . 3. Member requires transfer for services of a specialist to evaluate, diagnose , or treat their condition when that specialist is not available at the originating facility . 4. Member requires transfer , because member has received care at a specific prior institution for a condition not normally managed at the originating facility and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue . 5. Member requires transfer to improve the health and welfare of the member (ie, parental bonding) . 6. A t ransfer to allow a parent who gave birth to remain with the neonate is considered medically necessary when the neonate transfer meets the medically necessary criteria listed above and the parent who gave birth requires continued hospitalization due to birth complications or other medically necessary conditions . IV. The following non-emergency transfers do not require a prior authorization:A. inter-facility transfers within the same healthcare system B. intra-facility transfers within the same facility V. Non-emergency (elective) transfers are not a covered service for the following:A. The criteria above have not been met . B. The transfer is for the convenience of the member , the members family, the physician, or the originating facility . E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/15/2023 New policy. Approved at Committee.Date Revised 02/14/2024 01/15/2025Annual review. No changes. Updated references. Approved at Committee.Annual review. Updated references . Approved at Committee. Date Effective 08/01/2025 Non-Emergency Facility to Facility Transfers-GA MCD-MM-1447 Effective Dat e: 08/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 Date ArchivedH. References1. Appropriate interhospital patient transfer. American College of Emergency Physicians. January 2022. Accessed December 16, 2024. www.acep.org 2. Discharges and Transfers, 42 C.F.R. 412.4 (202 4). 3. Heaton JK. EMS inter-facility transport. In: StatPearls . StatPearls Publishing; 2022. 4. Obstetric Care Consensus Number 9. Levels of Maternal Care. American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine; 20 23 . Accessed December 16, 20204 . www.acep.org Independent med ical review 02/21/2023GA-MED-P-3611852 Issue Date 03/15/2023 Approved DCH 04/30/2025
MEDICAL POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Inhaled Nitric Oxide-GA MCD-MM-1187 08/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 7 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 8 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 9 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 9 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 9 H. References ………………………….. ………………………….. ………………………….. …………………….. 9 Inhaled Nitric Oxide-GA MCD-MM-1187Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectInhaled Nitric Oxide (iNO) B. BackgroundInhaled Nitric oxide (iNO) is a lipophilic gas that is naturally produced in numerous cells in the body and is readily absorbed across pulmonary membranes in the ventilated lung after inhalation. In the body, nitric oxide is involved in oxygen transport to the tissues, the transmission of nerve impulses, and other physiological activities. When administered via inhalation, it is a potent endogenous vasodilator that induces relaxation of vascular and bronchial smooth muscle, vasodilation of blood vessels, and can increase the partial pressure of arterial oxygen. iNO was initially approved by the U.S. Food and Drug Administration (FDA) in 1999. A compl ete nitric oxide delivery system is comprised of a nitric oxide administration apparatus, a nitric oxide gas analyzer, and a nitrogen dioxide gas analyzer. Additional warnings and precautions were added in 2013, including rebound hypertension following abr upt discontinuation, hypoxia from methemoglobinemia, and airway injury from nitrous dioxide. Dilation of pulmonary vessels in well-ventilated lung areas redistributes blood flow awayfrom lung areas where ventilation/perfusion ratios are poor. iNO has been used in conjunction with ventilator support as a treatment of hypoxic respiratory failure associated with persistent pulmonary hypertension of the newborn (PPHN), in infants who are at term or near-term (greater than 34 weeks gestation) to improve oxygenation,and to decrease the need for extracorporeal membrane oxygenation (ECMO). Respiratory failure is a clinical state that is defined either by the inability to rid the bodyof carbon dioxide or establish an adequate blood oxygen level. Acute respiratory failure is the most common clinical problem seen in term, near-term (born at 34 or more weeks of gestation), and pre-term (less than 34 weeks of gestation) infants admitted to neonatal intensive care units. Acute respiratory failure is frequently associated with meconium aspiration syndrome, sepsis, pulmonary hypoplasia, and/or primary pulmonary hypertension of the newborn. Management of infants with respiratory failure includes administration of high concentrations of oxygen, hyperventilation, high-frequency ventilation, neuromuscularblockade, antenatal steroids for the prevention of respiratory distress syndrome, use of po st-natal steroids to decrease inflammation, as well as iNO therapy.Clinical studies have shown that iNO is a selective pulmonary vasodilator withoutsignificant effects on the systemic circulation. There is scientific evidence that iNO therapy improves oxygenation and ventilation, reduces the need for extracorporeal membrane oxygenation (ECMO), and lowers the incidences of chronic lung disease and death among infants with respiratory failure. Moreover, the literature indicates that iNO does not appear to increase the incidence of adverse neurodevelopmental, behavioral, or medi cal sequelae in these high-risk neonat es. Infants with congenital diaphragmatic hernia (CDH) have not been shown to benefit from iNO therapy. Clark, et al (2000) Inhaled Nitric Oxide-GA MCD-MM-1187Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 concluded iNO does not lead to reduced ECMO use and Putnam, et al (2016) concluded iNO use in CDH may be associated with increased mortality.In preterm infants, the most common cause of acute respiratory failure is respiratory distress syndrome as a result of surfactant deficiency. According to the available literature, treatment of preterm infants usually entails exogenous surfactant administr ation. A systematic review of the evidence (Barrington and Finer, 2003)concluded: “The currently published evidence from randomized trials does not support the use of inhaled nitric oxide in preterm infants with hypoxic respiratory failure.” Carey, et al (2018) also concluded, Off-label prescription of iNO is not associated with reduced in-hospital mortality among premature infants with respiratory distress syndrome (RDS). In an Agency for Healthcare Research and Qualitys assessment on Inhaled Nitric Oxidein Preterm Infants , Allen, et al (2010) systematically reviewed the evidence on the use of iNO in preterm infants born at or before 34 weeks gestation age who receive respiratory support. They searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Studies (CENTRAL) and PsycInfo in June 2010. They also searched the proceedings o f the 2009 and 2010 Pediatric Academic Societies Meeting and ClinicalTrials.gov. T hey identified additional studies from reference lists of eligible articles and relevant reviews, as well as from technical experts. Questions were developed in collaboration with technical experts, including the chair of the upcoming National Institutes o f Health Office of Medical Applications of Research Consensus Development Conference. These researchers limited their review to randomized controlled trials (RCTs) for the question of survival or occurrence of bronchopulmonary dysplasia (BPD), and for the question on short-term risks. All study designs were considered for long-term pulmonary or neurodevelopmental outcomes, and for questions about whether outcomes varied by subpopulation or by intervention characteristics. Two investigators independently screened search results and abstracted data from eligible articles. These investigators identified a total of 14 RCTs, reported in 23 articles, and 8 observational studies. Chronic Lung Disease (CLD) or BPD studies have shown that there is in sufficient evidence to support iNO for the treatment of CLD or BPD. Mortality rates in the neonatal intensive care unit (NICU) did not differ for infants treatedwith iNO versus those not treated with iNO (RR 0.97 (95 % CI: 0.82 to 1.15)). Broncho-pulmonary dysplasia at 36 weeks for iNO and control groups also did not differ (RR 0.93 (0.86, 1.003) for survivors). A small difference was found between iNO and control infants in the composite outcome of death or BPD (RR 0.93 (0.87, 0.99)). There was inconsistent evidence about the risk of brain injury from individual RCTs, bu t meta – analyses showed no difference between iNO and control groups. These researchers found no evidence of differences in other short-term risks. There was no evidence to suggest a difference in the incidence of cerebral palsy (RR 1.36 (0.88, 2.10)), neu rodevelopmental impairment (RR 0.91 (0.77, 1.12)), or cognitive impairment (RR 0.72 (0.35, 1.45)). Evidence was limited on whether the effect of iNO varies by subpopulation or by characteristics of the therapy (timing, dose and duration, mode of delivery, or concurrent therapies). The authors concluded that there was a 7% reduction Inhaled Nitric Oxide-GA MCD-MM-1187Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 in the risk of the composite outcome of death or BPD at 36 weeks PMA for infants treated with iNO compared to controls, but no reduction in death or BPD alone. They stated that further studies are needed to explore subgroups of infants and to assess long-term outcomes including function in childhood. There is currently no evidence to support the use of iNO in preterm infants with respiratory failure outside the context of rigorously conducted RCTs. To provide health care professionals, families, and the general public with a responsible assessment of currently available data regarding the benefits and risks of iNO in premature infants, the Eunice Kennedy Shriver National Institute of Child Health andHuman Development, the National Heart, Lung, and Blood Institute, and the Office of Medical Applications of Research of the National Institutes of Health (Cole, et al, 2011) convened a consensus-development conference. Findings from a substantial body of experimental work in developing animals and other model systems suggest that iNO may enhance lung growth and reduce lung inflammation independently of its effects on blood vessel resistance. Although this work demonstrates biological plausibility and the results of RCTs in term and near-term infants were positive, combined evidence from the 14 RCTs of iNO treatment in premature infants of gestation of 34 weeks or less shows equivocal effects on pulmonary outcomes, survival, and neurodevelopmental outcomes. A National Institutes of Health Consensus Development Conference for inhaled nitricoxygen in premature infants (Cole, et al, 2010) recommended the following:1. Taken as a whole, the available evidence does not support use of iNO in early routine, early rescue, or later rescue regimens in the care of premature infants
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 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. Accessed February 26, 2025 . www.uptodate.com 5. Augustyn M. Autism spectrum disorder (ASD) in children and adolescents: terminology, epidemiology, and pathogenesis. UptoDate. Updated January 24, 2024. Accessed February 26, 2025 . www.uptodate.com 6. Augustyn M, Von Hahn E. Autism spectrum disorder in children and and adolescents: clinical features. UptoDate. Updated May 17, 2023. Accessed February 26, 2025 . www.uptodate.com 7. Autism spectrum disorder. American Academy of Pediatrics. Updated April 5, 2023. Accessed February 26, 2025 . www.aap.org 8. Autism Spectrum Disorder In Young Children: Screening . U SPreventive Services Task Force; 2016. Accessed February 26, 2025 . www.uspreventiveservicestaskforce.org 9. Autism Spectrum Disorders: M-7075. MCG. 28th ed. Updated March 14, 2024 . Accessed February 26, 2025 . www.careweb.careguidelines.com 10. Autism Spectrum Disorders: B-012-HC. MCG. 28th ed. Updated March 14, 2024 . Accessed February 26, 2025 . www.careweb.careguidelines.com 11. Autism Spectrum Disorders, Adult, Inpatient Care: B-012-IP. MCG. 28th ed. Updated March 14 , 2024 . Accessed February 26, 2025 . www.careweb.careguidelines.com 12. Autism Spectrum Disorders, Child or Adolescent: B-019-IP. MCG. 28th ed. Updated March 14, 2024 . Accessed February 26, 2025 . www.careweb.careguidelines.com 13. Autism Spectrum Disorders, Intensive Outpatient Program: B-012-IOP. MCG. 28th ed. Updated March 14, 2024 . Accessed February 26, 2025 . www.careweb.careguidelines.com 14. Autism Spectrum Disorders, Outpatient Care: B-012-AOP. MCG. 28th ed. Updated March 14, 2024 . Accessed February 26, 2025 . www.careweb.careguidelines.com 15. Autism Spectrum Disorders, Partial Hospitalization Program: B-012-PHP. MCG. 28th ed. Updated March 14, 2024 . Accessed February 26, 2025 . www.careweb.careguidelines.com 16. Autism Spectrum Disorders, Residential Care: B-012-RES. MCG. 28th ed. Updated March 14, 2024 . Accessed February 26, 2025 . www.careweb.careguidelines.com 17. BACB Newsletter . Behavior Analyst Certfication Board; September 2023. Accessed February 26, 2025 . www.bacb.com 18. BACB Newsletter: Introducing the 2026 RBT Examination and Certification Requirements . Behavior Analyst Certification Board; December 2023. Accessed February 26, 2025 . www.bacb.com 19. Bak M, Plavnick J, Dueas A, et al. The use of automated data collection in applied behavior analytic research: a systematic review. Behavior Analysis: Res Practice. 2021;21(4), 376 405. https://doi.org/10.1037/bar0000228 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.18 20. Bearss K, Burrell T, Challa S, et al. Feasibility of parent training via telehealth for children with autism spectrum disorder and disruptive behavior: a demonstration pilot. JAutism Dev Dis . 2018;48:1020-3. doi: 10.1007/s10803-017-3363-221. Blakeley-Smith A, Meyer A, Boles R, et al. Group cognitive behavioral treatment for anxiety in autistic adolescents with intellectual disability: a pilot and feasibility study. JApp Res Intell Disab. 2021;34(3):777-788. doi:10.111/jar.12854 22. Board Certified Behavior Analyst Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed February 26, 2025 . www.bacb.com 23. Board Certified Assistant Behavior Analyst Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed February 26, 2025 . www.bacb.com 24. Buckley A, Hirtz D, Oskoui M, et al.; Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Practice guideline: treatment for insomnia and disrupted sleep behavior in cihldre n and adolescents with autism spectrum disorder. Neurology . 2020;94(9):392-404. doi:org/10.1212/WNL0000000000009033 25. Chun T, Mace S, Katz E; American Academy of Pediatrics; Committee on Pediatric Emergency Medicine and American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Evaluation and management of children and adolescents with acute mental health or behavioral health problems: part I, common clinical challenges of patients with mental health or behavioral emergencies. Pediatr. 2016;138(3):e20161570. doi:org/10.1542/peds.2016-1570 26. Chun T, Mace S, Katz E; American Academy of Pediatrics; Committee on Pediatric Emergency Medicine and American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Evaluation and management of children and adolescents with acute mental health or behavioral health problems: part II, recognition of clinically challenging mental health related conditions presenting with medical or uncertain symptoms. Pediatr. 2016;138(3):e20161573. doi:org/10.1542/peds.2016-1573 27. Coverage for Autism, GA. CODE ANN . 33-24-59.10 (2023). 28. Crockett, JL, Fleming RK, Doepke K, et al. Parent training: acquisition and generalization of discrete trials teaching skills with parents of children with autism. Res Dev Disabilities . 2007; 28 (1):23-36. doi.org/10.1016/j.ridd.2005.10.003 29. Declaration of Purpose, GA. CODE ANN . 37-2-1 (2023). 30. Dubreucq J, Haesebaert F, Plasse J, et al. A systematic review and meta-analysis of social skills training for adults with autism spectrum disorder. JAutism Dev Disorders. 2022;52(4):1598-1609. doi:10.1007/s10803-021-05058 31. Ellison K, Guidry J, Picou P, et al. Telehealth and autism prior to and in the age of COVID-10: a systematic and critical review of the last decade. Clin Child Family Psych Rev . 2021;24:599-630. doi:10.1007/s10567-021-00358-0 32. Ethics Code for Behavior Analysts. Behavior Analyst Certification Board; 2020. Updated January 1, 202 2. Accessed February 26, 2025 . www. bacb.com 33. Evidence analysis research brief: intensive behavioral intervention for treatment of Autism Spectrum Disorder. Hayes; 2024. Accessed February 24, 2025. www.evidence.hayesinc.com 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.19 34. Gates JA, Kang E, Lerner MD. Efficacy of group social skills interventions for youth with autism spectrum disorder: a systematic review and meta-analysis. Clin PsychRev . 2017;52:164-81. doi:10.1016/j.cpr.2017.01.006 35. Gilmore R, Ziviani J, Chatfield MD, et al. Social skills group training in adolescents with disabilities: a systematic review. Res Dev Disab . 2022;125:online. doi:10.1016/j.ridd.2022 .104218 36. Gonzlez MC, Vsquez M, Hernndez-Chvez M. Autism spectrum disorder: clinical diagnosis and ADOS Test. Rev Chil Pediatr . 2019;90(5):485-491. doi:10.32641/rchped.v90i5.872 37. Health tech nology assessment: comparative effectiveness review of intensive behavioral intervention for treatment of autism spectrum disorder. Hayes; 2019. Updated February 10, 2022. Accessed February 26, 2025 . www.evidence.hayesinc.com 38. Hyman S, Levy S, Myers S; Council on Children with Disabilities. Developmental and behavioral pediatrics: identification, evaluation, and management of children with autism spectrum disorder. Pediatr. 2020;145(1):e20193447. doi:org/10.1542/peds.2019-3447 39. Information on autism spectrum disorder for healthcare providers. Centers for Disease Control and Prevention (CDC). Updated December 6, 2022. Accessed February 26, 2025 . www.cdc.gov 40. Kreyenbuhl J, Buchanan RW, Dickerson FB ; Schizophrenia Patient Outcomes Research Team (PORT). The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations. Schizophrenia Bull . 2010;36(1):94 – 103. doi: 10.1093/schbul/sbp130 41. Lebersfeld JB, Swanson M, Clesi CD, et al. Systematic review and meta-analysis of the clinical utility of the ADOS-2 and the ADI-R in diagnosing autism spectrum disorders in children. JAutism Dev Disord . 2021;51(11):4101-4114. doi:10.1007/s10803-020-04839-z 42. Lefort-Besnard J, Vogeley K, Schilbach L, et al. Patterns of autism symptoms: hidden structure in the ADOS and ADI-R instruments. Transl Psychiatry . 2020;10(1):257. doi:10.1038/s41398-020-00946-8 43. Lim N, Russell-George A. Home-based early behavioral interventions for young children with autism spectrum disorder. Clin Psychol . 2022;29(4):415-416. doi:org/10.1037/cps0000117 44. Marino F, Chila P, Failla C, et al. Tele-assisted behavioral intervention for families with children with autism spectrum disorders: a randomized control trial. Brain Sci . 2020;10(9):649. doi:10.3390/brainsci10090649 45. Medica re Claims Processing Manual. Centers for Medicare and Medicaid Services; Publication # 100-04. Updated October, 2024. Accessed February 26, 2025 . www.cms.gov 46. MeiMei L, Zenghui M. A systematic review of telehealth screening, assessment, and diagnosis of autism spectrum disorder. Child Adol Psychiatry Mental Health. 2022;16(79):1-15. doi: 10.1186/s13034-022-00514-6 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.20 47. Moody CT, Laugeson EA. Social skills training in autism spectrum disorder across the lifespan. Child Adol Psychiatric Clinics NAmer 2020;29(2):359-371. doi :10.1016/j.chc.2019.11.001 48. Policies a nd Procedures for Autism Spectrum Disorder Services, Part II . Georgia Dept. of Community Health, Division of Medicaid. Revised January 1, 2025 . Accessed February 26, 2025 . www.mmis.georgia.gov 49. Practice of Applied Behavior Analysis, GA. CODE ANN . 43-7A-1 to 11 (2023) . 50. Registered Behavior Technician Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed February 26, 2025 . www.bacb.com 51. Sneed L, Little S, Akin-Little A. Evaluating the effectiveness of two models of applied behavior analysis in a community-based setting for children with autism spectrum disorder. Behav Anal: Res Pract . 2023;23(4):238-253. doi:org/10.1037/bar0000277 52. Solish A, Klemencic N, Ritzema A , et al. Effectiveness of a modified group cognitive behavioral therapy program for anxiety in children with ASD delivered in a community context. Molecular Autism 2020; 11 (34 ):1-11. doi.10.1186/s13229020003416 53. Unholz-Bowden E, McComas J, McMaster K, et al. Caregiver training via telehealth on behavioral procedures: a systematic review. JBeh Educ . 2020;29:246-281. doi:10.1007/s10864-020-09381-7 54. Volkmar F, Siegel M, Woodbury-Smith M, et al.; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. JAm Acad Child Adolesc Psychiatry . 2014;53(2):237-57. doi: 10.1016/j.jaac.2013.10.013 55. Weissm an L. Autism spectrum disorders in children and adolescents: behavioral and educational interventions . UptoDate. Updated October 22, 2024 . Accessed February 26, 2025 . www.uptodate.com 56. Weissman L. Autism spectrum disorder in children and adolescents: overview of management. UptoDate. Updated September 8, 2023. Accessed February 26, 2025 . www.uptodate.com 57. Weissman L. Autism spectrum disorder in children and adolescents: pharmacologic interventions. UptoDate. Updated October 8 , 2024 . Accessed February 26, 2025 . www.uptodate.com 58. Weissman L. Autism spectrum disorder in children and adolescents: screening tools. UptoDate. Updated January 24, 2024. Accessed February 26, 2025 . www.uptodate.com 59. Weissman L. Autism spectrum disorder in children and adolescents: surveillance and screening in primary care. UptoDate. Updated November 25, 2024 . Accessed February 26, 2025 . www.uptodate.com 60. Weissman L, Harris H. Autism spectrum disorder in children and adolescents: complementa ry and alternative therapies. UptoDate. Updated June 20, 2022. Accessed February 26, 2025 . www.uptodate.com 61. Wergeland J, Posserud M, Fjermestad K, et al. 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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