REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-1091 09/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………… 2 B. Background ………………………….. ………………………….. ………………………….. ………….. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………… 3 G. Review/Revision History ………………………….. ………………………….. ……………………… 4 H. Ref erences ………………………….. ………………………….. ………………………….. …………… 4 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ens ure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 Sacro iliac Jo in t Pro ceduresGEORGIA MEDICAID PY-1091 Effective Date: 09/01/2020 Joint ProceduresB. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusio n of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be ef f ective for diagnostic purposes, but provide limi ted short-term relief f rom pain resulting f rom SI joint dysf unction. C. Def initions Sacroiliac Joint Injections – corticosteroid and local anesthetic therapeutic injections into the sacroiliac joint to treat pain that hasnt responded to conservative therapies . Radiofrequency Facet Ablation (RFA) – is performed using percutaneous introduction of an electrode under f luoroscopic guidance to thermocoagulate medial bra nches of the dorsal spinal nerves. D. PolicyI. Sacroiliac Joint Procedures A. A prior authorization (PA) is required f or each sacroiliac joint procedure f or pain management. B. Sacroiliac Joint Injection Codes 1. Codes 64451 and 27096 are considered the same procedure and may not be billed together. C. Sacroiliac Joint Injections 1. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic ef f ect, repeating no more than once every seven (7) days and with at least a 75% or greater reduction in pain af ter the f irst injection. 2. Once the diagnostic injections are perf ormed and the diagnosis is established, two (2) therapeutic injections per joint may be perf ormed over a 12 month period. 3. Injections should not be repeated more frequently than every two (2) months with no more than a total of f our (4) injections (including both diagnostic and therapeutic) per joint in 12 months. A. SubjectSacroiliac 3 Sacro iliac Jo in t Pro ceduresGEORGIA MEDICAID PY-1091 Effective Date: 09/01/2020 D. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately F. Initial Radiof requency Ablation of the SI Joint 1. A maximum of one (1) radiof requency ablation f or SI Joint pain per side per rolling twelve (12) months when CareSource medical policy MM-0010 clinical criteria has been met. G. Repeat Radiof requency Ablation of the SI Joint 1. Conservative therapy an d diagnostic injections are not required if there has been a reduction in pain f or at least twelve (12) months or more f rom the initial RFA within the last thirty-six (36) months. 2. When there has not been a repeat RFA in the last thirty-six (36) months, a diagnostic injection is required. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers , if applicable. Please ref er to the individual f ee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Sacroiliac JointProcedures Description 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (f luoroscopy or CT) including arthrography when perf ormed 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography 64625 Radiof requency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography) F. Related Policies/RulesSacroiliac Joint Procedures MM-0215 G. Re view/Revision History DATE ACTIONDate Issued 12/11/2019Date Revised 05/13/2020 Revised to add coverage f or ablation of the SI Joint; added codes: 64451 64625. Date Effective 09/01/2020 Date Archived 05/31/2021 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to f ollow CMS/State/NCCI guidelines without a f ormal documented Policy. 4 H. Ref erencesSacro iliac Jo in t Pro ceduresGEORGIA MEDICAID PY-1091 Effective Date: 09/01/2020 1. Georgia Department of Community Health Fee Schedules. Retrieved May 1, 2020 f rom www.mmis.georgia.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-MED-P-131362 Date Issued 02/11/2019 DCH Ap p ro ved 06/09/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Sacroiliac Joint Fusion PY-1216 09/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ens ure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services prov ided in a particular case and may modify this Policy at any time. 2 A. SubjectSacroiliac Joint Fusion Sacro iliac Jo in t FusionGEORGIA MEDICAID PY-1216 Effective Date: 09/01/202 B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or c laims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The sacroiliac (SI) joints are f ormed by the connection of the sa crum and the right and lef t iliac bones. The sacrum is the triangular-shaped bone in the lower portion of the spine, below the lumbar spine. While most of the bones (vertebrae) of the spine are mobile, the sacrum is made up of f ive vertebrae that are f used together and do not move. The iliac bones are the two large bones that make up the pelvis. As a result, the SI joints connect the spine to the pelvis. The sacrum and the iliac bones (ileum) are held together by a collection of strong ligaments. There is relatively little motion at the SI joints. There are normally less than 4 degrees of rotation and 2 mm of trans lation at these joints. Sacroiliac Joint (SIJ) dysf unction is indicated by the abnormal movement or malalignment of the sacroiliac joint and is the main source of lower back pain in 15% to 30% of patients. The condition causes disability and pain and may b e caused by prior lumbar sacral f usion, trauma, inf lammatory arthritis, sacral tumors, osteoarthritis or pregnancy. Patients may present with low back, groin and/or gluteal pain. SI joint pain can of ten appear to be disogenic or radicular back pain. This c an lead to the potential f or inaccurate diagnosis and treatment, reviews caution dif f icult diagnosis and evidence for ef f icacy. Open SIJ f usion typically involves opening the SIJ, denuding of cartilage, and bone graf ting. To stabilize the SIJ, the iliac crest bone and the sacrum are typically held together by plates or screws or an interbody f usion cage until the 2 bones fuse. C. Def initions Conservative Therapy – is a multimodality plan of care. Multimodality care plans include ALL of the f ollowing: o Active Conservative Therapies – such as physical therapy, occupational therapy or a physician supervised home exercise program (HEP) Home Exercise Program (HEP) – inclu des two components that are both required to meet CareSource policy for completion of conservative therapy: 3 Sacro iliac Jo in t FusionGEORGIA MEDICAID PY-1216 Effective Date: 09/01/2020 An exercise prescription and/or plan documented in the medical record. A f ollow up documented in the medical record regarding completion of a HEP (af ter suitable six (6) week period), or inability to complete a HEP due to a stated physical reason-i.e. increased pain, inability to physic ally perf orm exercises. (Patient inconvenience or noncompliance without explanation does not constitute inability to complete). o Passive Conservative Therapies – such as rest, ice, heat, medical devices, TENS unit and prescription medications D. PolicyI. Sacroiliac Joint Fusion A. Prior authorization is required f or minimally invasive f usion/stabilization of the sacroiliac joint (SIJ) f or the treatment of back pain when the medically necessary criteria in the Sacroiliac Jo int Fusion Medical policy, MM-0838, has been met. II. ExclusionsA. Percutaneous SIJ f usion for SIJ pain is NOT indicated in the presence of : 1. Systemic arthropathy such as ankylosing spondylitis or rheumatoid arthritis; 2. Generalized pain behavior (e.g. somatof orm disorder) or generalized pain disorder (e.g. fibromyalgia); 3. Inf ection, tumor, or f racture; 4. Acute, traumatic instability of the SIJ; 5. Neural compression as seen on an MRI or CT that correlates with the patients sym ptoms or other more likely source f or their pain. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graf t when performed, and placement of transf ixing device 4 F. Related Policies/RulesSacroiliac Joint Fusion MM-0838 G. Review/Revision HistorySacro iliac Jo in t FusionGEORGIA MEDICAID PY-1216 Effective Date: 09/01/2020 DATE ACTIONDate Issued 05/13/2020 New PolicyDate Revised Date Effective 09/01/2020 Date Archived 05/31/2021 No longer ef f ective as of 05/31/2021. This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to f ollow CMS/Sta te/NCCI guidelines without a f ormal documented Policy. H. Ref erences1. Georgia Department of Community Health Fee Schedules. Retrieved on April 15, 2020 f rom gammis.georgia.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-MED-P-131362 Date Issued 05/13/2020 DCH Ap p ro ved 06/09/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Overpayment Recovery PY-1112 09/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t 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 lowes t 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 federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 09/01/2020 2 A. SubjectOverpayment Recovery B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies a re not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actu al services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the sub mitting provider to submit the most accurate andappropriate CPT/HCPCS code(s) for the product or s ervice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Retrospective review of claims paid to providers assist CareSource with ensuringac curacy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified . Fraud, waste and abuse investigations ar e an exception to this policy. In theseinvestigations, the look back period may go beyond 2 years.C. Definitions Overpayment – A payment that exceeds amounts properly payable to a provider. These commonly are discovered during a post-payment review . Examples include but a re not limited to incorrect coding, non-covered services, and billing discrepancies . Coordination of benefits (COB) – A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the me mber. Retroactive eligibility – A payment for a member who was retroactively terminated from the state . Member is not eligible for benefits. Improper payment – A payment that should not have been made or an overpayment was made. Examples include but are not limited to payment made for the ineligible member, ineligible service, payment made for a service not received, and duplicate payments. D. Policy I. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider : A. The name a nd patient account number of the member to whom the service (s) were provided ; B. The date(s) of services provided ; Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 09/01/2020 3 C. The amount of overpayment;D. The reason for the re coupment ; and E. That the provider has a ppeal rights . II. Overpayment RecoveriesA. Lookback period is 12 months from the last date of service or discharge . B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit R ecoveriesA. Lookback period is 12 months from the last date of service or discharge . B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timefr ame is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active Eligibility RecoveriesA. Lookback period is 12 months from date CareSource is no tified by Medicaid of the updated eligibility status. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely fil ing guidelines. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules National Agreement, Article V. CLAIMS AND PAYMENTS, 5.11 (d). G. Review/Revision History DATE ACTIONDate Issued 02/05/2020Date Revised Date Effective 09/01/2020 New policy Date Archived Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 09/01/2020 4 H. References1. Georgia General Assemb ly. (2018). O.C.G.A. 33-20A-62 Payment. Retrieved January 28, 2020 from www. ga.elaws.us The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved. GA-MED-P-131362 Date Iss ued 02/05/2020 DCH Approved 06/09/2020
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illne ss, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of C overage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to servic es provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Implantable Spinal Cord Stimulator PY-1075 09/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. …………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 5 H. References ………………………….. ………………………….. ………………………….. …………………….. 5 2 A. SubjectImplantable Spinal Cord Stimulator Implantable Spinal Cord StimulatorGEORGIA MEDICAID PY-1075 Effective Date: 09/01/2020 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusio n of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patien ts symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-mana gement and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualifi ed to deliver these health services. C. Definitions Implantable Spinal Cord Stimulator: Spinal cord (dorsal column) stimulation (SCS) is a pain relief technique that delivers a low-voltage electrical current to the spinal cord to block the sensation of pain . D. PolicyI. Implantable Spinal Cord Stimulator A. Prior authorization (PA) is required for all implantable spinal cord stimulators, including short-term trial placement and permanent placement. 1. Prior authorizations for implantable spinal cord stimulator services are not required for the following: a. Implantable device and device components are considered part of the procedure and does not require a separate PA. b. Removal/revision of implanted device. 3 c. Electronic analysis/studies post implantation Implantable Spinal Cord StimulatorGEORGIA MEDICAID PY-1075 Effective Date: 09/01/2020 B. Short term and permanent Implantable Spinal Cord Stimulators are considered medically necessary according to the criteria found in the Implantable Spinal Cord Stimulator Medical policy MM-0812. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a r eference. This list may not be all inclusive and is subject to updates. Implantable Spinal Cord Stimulator Codes Description 63650 Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) plac ed via laminotomy or laminectomy, including fluoroscopy, when performed 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs 95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs 95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs 95929 Central motor evoked potential study (transcranial motor stimulation); lower limbs 4 Implantable Spinal Cord StimulatorGEORGIA MEDICAID PY-1075 Effective Date: 09/01/2020 95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs 95939 Central motor evoked potential study (transcranial motor stimulation); in upper and lower 95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/of f cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial ner ve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming 95971 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimu lation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming b y physician or other qualified health care professional 95972 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimu lation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional F. Related Policies/RulesImplantable Spinal Cord Stimulator MM-0812 G. Review/Revision HistoryDATE ACTIONDate Issued 05/13/2020Date Revised Date Effective 09/01/2020 Date Archived 01 /01/2021 5 H. ReferencesImplantable Spinal Cord StimulatorGEORGIA MEDICAID PY-1075 Effective Date: 09/01/2020 1. Georgia Department of Community Health Fee Schedules. Retrieved on April 22, 2020 from www.mmis.georgia.com The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-MED-P-131362 Date Issued 05/13/2020 DCH Approved 06/09/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Facet Joint Interventions PY-116 2 09/01 /2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on th e date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are 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 morbidit y, 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 federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Poli cy 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. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5 Facet Joint Interventions GEORGIA MEDICAID PY-1162 Effective Date: 09/0 1 /2 02 02A. Subject Facet Joint Interventions B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qu alifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-servic e channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or s ervice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient's daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Zygapophyseal (aka facet) Joint Level refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophy seal joint. Diagnostic Medial Branch Nerve Block Injection refers to the diagnosis of facet-mediated pain requiring the establishment of pain relief following medial branch blocks (MBB ) or intra-articular injections (IA). Neither physical exam nor imaging has adequate diagnostic power to confidently distinguish the facet joint as the pain source. Radiofrequency Facet Ablation (RFA) is performed using percutaneous introduction of an elec trode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves . D. Policy I. Facet Joint Interventions A. A p rior authorization (PA) is required for each facet joint intervention for pain management.. II. Diagnostic Medial Branch Nerve Block Injections A. An initial medial branch nerve block injection in the lumbar and cervical/thoracic region is required for diagnosis. Diagnostic injections are necessary due to the high false positive rates of single injections. Facet Joint Interventions GEORGIA MEDICAID PY-1162 Effective Date: 09/0 1 /2 02 031. The member must meet the medically necessary criteria in the corresponding Facet Joint Interventions medical policy, MM-0967, before a diagnostic injection is performed. III. Medial Branch Nerve Block Injections A. Once a positive diagnostic medial branch nerve block injection has been established, a maximum of six (6) injections may be performed in the cervical/thoracic spine and six (6) in the lumbar spine per rolling twelve (12) month period. B. Per CPT guidelines, imaging guidance and any injection of contrast are inclusive components of all facet medial branch nerve blocks and are not reimbursed separately. IV. Radiofrequency Facet AblationA. Radiofrequency Facet Ablations are considered medically necessary when the member meets ALL of the medically necessary criteria in the corresponding Facet Joint Interventions medical policy, MM-0967. B. A maximum of two (2) radiofrequency facet ablations per rolling 12 months for each spinal region (cervical/thoracic or lumbar) involving no more than four (4) joints per session (e.g., two (2) bilateral levels or four (4) unilateral levels). 1. Repeat Radiofrequency Facet Ablation in the same spinal region and vertebral location is considered medically necessary when ALL of the criteria in the corresponding Facet Joint Interventions medical policy , MM-0967 has been met. V. Sedation A. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. 1. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. F. Related Policies/Rules Facet Joint Interventions MM-0974 Facet Joint Interventions GEORGIA MEDICAID PY-1162 Effective Date: 09/0 1 /2 02 04G. Review/Revision History DATE ACTIONDate Issued 05/13/2020 This policy replaces the Facet Medial Branch Nerve Block MM-1061 and Radiofrequency Facet Ablation MM-1082 policies.Date Revised Date Effective 09/01 /2020 Date Archived H. References 1. Georgia Department of Community Health Fee Schedul es. Retrieved on April 15, 2020 from www.mmis.georgia.gov The Reimbursement Po lic y Sta te m ent d etai le d a bo ve h as r ecei ved due c on sidera tio n a s d efi ned i n the ReimbursementPo lic y St ate m ent Polic y a nd i s a pp ro ved. GA-MED-P-131362 Date Issued 05/ 13/2020 DCH Approved 06/09/2020
Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and t he 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. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder w ill not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Three-Day Payment Window PY-1043 09/01/2020-07/31/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject …………………………………………………………………………………………………………………. 2 B. Background …………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………….. 2 D. Policy …………………………………………………………………………………………………………………… 2 E. Conditions of Coverage …………………………………………………………………………………………… 3 F. Related Policies/Rules ……………………………………………………………………………………………. 3 G. Review/Revision History ………………………………………………………………………………………….. 3 H. References ……………………………………………………………………………………………………………. 3 2 A. SubjectThree-Day Payment Window Three-Day Payment Window GEORGIA MEDICAID PY-1043 Effective Date: 09/01/2020B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting prov ider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Services provided within 3 days of an inpatient admission or discharge for the same or related diagnosis provided by the same facility are considered part of the admission.C. DefinitionsInpatient-A member who has been admitted to a participating hospital on recommendation of a licensed doctor and is receiving room, board, and professional services in the hospital on a continuous twenty-four hour a day basis. A length of stay less than twenty-four hours may be considered inpatient if the service can only be provided on an inpatient basis. Transfers between units within the hospital are not considered new admissions. Outpatient services-A member who is receiving professional services at a participating hospital. Same or related diagnosis-Primary diagnosis code based on the first three digits of the ICD-10 code. D. PolicyI. Three-Day Payment Rule A. Claims submitted for outpatient services (including laboratory and radiology services) that were provided within the three calendar days prior to the inpatient admission for the same member will be denied because the inpatient and outpatient services must be combined. 1. This only applies when: a. The same or related diagnosis are considered part of the inpatient admission; and b. Services are provided by the same facility. B. The outpatient services and inpatient services must be submitted on one inpatient claim. C. The dates of the claim should inclusive of the outpatient and inpatient services. 3 Three-Day Payment Window GEORGIA MEDICAID PY-1043 Effective Date: 09/01/2020 D.If an outpatient claim is paid before the inpatient claim is submitted, the inpatient claim will be denied with EOB 6516 Outpatient services performed three days prior to inpatient admission. To resolve this denial, providers should void the outpatient claim in history, incorporate the outpatient services into the inpatient claim, and resubmit the corrected inpatient claim. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. E.Related Policies/RulesF. Review/Revision History DATE ACTION Date Issued 04/29/2020 Date Revised Date Effective 09/01/2020 Date Archived 07/31/2022 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a form al documented Policy. G.References 1. Georgia Department of Community Health Division of Medicaid. (2019, October).PART II Policies and Procedures for Hospital Services. Retrieved November 1, 2019from www.mmis.georgia.govThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-MED-P-131362 Date Issued 04/29/2020 DCH Approved 06/09/2020
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-1091 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, re gulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on th e date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidit y, 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 convenie nce of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Poli cy 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. CSMG Co. and its affiliates may use reasonable discretion in interpreting and app lying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Archived Sacroiliac Joint Procedures GEORGIA MEDICAID PY-1091 Effective Date: 06/01/2020 2 A. Subject Sacroiliac Joint Procedures B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the act ual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the su bmitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Stud y of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conserva tive treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures fo r the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Sacroiliac Joint Procedures: corticosteroid and local anesthetic therapeutic injections into the SIJ to treat pain that hasnt responded to conservative therapies. D. Policy I. Sacroiliac Joint Procedures A. A prior authorization (PA) is required for each sacroiliac joint injection for pain management. B. Sacroiliac joint injections 1. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic effect, repeating no more than once every seven (7) days and with at least a 75% or > reduction in pain after the first injection. 2. Once the diagnostic injections are performed and the diagnosis is established, two (2) therapeutic injections per joint may be performed over a 12 month period. 3. Injections should not be repeated more frequently than every two (2) months with no more than a total of four (4) injections (including both diagnostic and therapeutic) per joint in 12 months. C. Radiofrequency Facet Ablation for Sacroiliac Pain 1. Thermal or pulsed, cooled neurotomy by Radiofrequency Facet Ablation (RFA) or other techniques for sacroiliac pain are NOT covered. Archived Sacroiliac Joint Procedures GEORGIA MEDICAID PY-1091 Effective Date: 06/01/2020 3 E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes alo ng with appropriate modifiers. Please refer to the individual Georgia Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Sacroiliac Joint Procedures Description 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed F. Related Policies/Rules Sacroiliac Joint Procedures MM-0215 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 0 6/01/2020 Date Archived H. References 1. Georgia Department of Community Health Fee Schedules. Retrieved November 8, 2019 The Reimbursement 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 Reimbursement 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. GA-P – 0881 12/11/2019 DCH Approved 03/02/2020 Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Radiofrequency Facet Ablation PY-1082 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management 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, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical 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 federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Archived Radiofrequency Facet Ablation GEORGIA MEDICAID PY-1082 Effective Date: 06/01/2020 2 A. Subject Radiofrequency Facet Ablation B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the act ual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the su bmitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association f or the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporat es conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional pr ocedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Radiofrequency Facet Ablation: is performed using percutaneous introduction of an elect rode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. D. Policy I. Radiofrequency Facet Ablation A. A prior authorization (PA) is required for each radiofrequency facet joint degeneration /ablation for pain management . B. For each spinal region (cervical/thoracic or lumbar) two (2) radiofrequency facet ablations per rolling 12 months, involving no more than four (4) joints per session, e.g., two (2) bilateral level s or four (4) unilateral levels . C. A repeat RFA in the same spine region requires documented pain relief of at least 50% for a minimum of 6 months after the initial RFA . D. Repeat RFA cannot be performed for at least six (6) months following the initial RFA E. Radiofrequency facet ablation should be performed with imaging guidance . 1. Coverage for image guidance and any injection of contrast are inclusive components and are not reimbursed separately. Archived Radiofrequency Facet Ablation GEORGIA MEDICAID PY-1082 Effective Date: 06/01/2020 3 E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes alo ng with appropriate modifiers. Please refer to the individual Georgia Medicaid fee schedule for appropriate codes. The following list (s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Radiofrequency Facet Ablation Description 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 64636 Destruction by neurolytic agen t, paravertebr al facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) F. Related Policies/Rules Radiofrequency Facet Ablation MM-0216 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 06/01/2020 Date Archived H. References 1. Georgia Department of Community Health Fee Schedul es. Retrieved November 8, 2019 The Reimbursement 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 Reimbursement 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. GA-P – 0881 12/11/2019 DCH Approved 03/02/2020 Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Implantable Spinal Cord Stimulator PY-1075 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management 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, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical 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 federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Implantable Spinal Cord Stimulator GEORGIA MEDICAID PY-1075 Effective Date: 06/01/2020 2 A. Subject Implantab l e Spinal Cord Stimulator B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the act ual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the su bmitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Stud y of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conserva tive treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures fo r the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Implantable Spinal Cord Stimulator: Spinal cord (dorsal column) stimulation (SCS) is a pain relief technique that delivers a low-voltage electrical current to the spinal cord to block the sensation of pain. D. Policy I. Implantable Spinal Cord Stimulator A. Prior authorization (PA) is required for all implantable spinal cord stimulators, including short-term trial placement and permanent placement. 1. Prior authorization for implantable spinal cord services is not required for the following: a. Electronic anal ysis/studies post implantation B. Short term and permanent Implantable Spinal Cord Stimulators are considered medically necessary according to the criteria found in the Implantable Spinal Cord Stimulator Medical policy MM-0812 . Archived Implantable Spinal Cord Stimulator GEORGIA MEDICAID PY-1075 Effective Date: 06/01/2020 3 E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes alo ng with appropriate modifiers. Please refer to the Georgia Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Implantable Spinal Cord Stimulator Cod es Description 63650 Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performe d 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) plac ed via laminotomy or laminectomy, including fluoroscopy, when performed 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs 95926 Short-latency somatosensory evoked potential st udy, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs 95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs 95929 Central motor evoked potential study (transcranial motor stimulation); lower limbs 95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs 95939 Central motor evoked potential study (transcranial motor stimulation); in upper and low er 95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/tra nsmitter, without programming Archived Implantable Spinal Cord Stimulator GEORGIA MEDICAID PY-1075 Effective Date: 06/01/2020 4 95971 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg , contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional 95972 Electronic analys is of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or o ther qualified health care professional F. Related Policies/Rules Implantable Spinal Cord Stimulator MM-0812 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 0 6/01/2020 Date Archived H. References 1. Georgia Department of Community Health Fee Schedules. Retrieved November 8, 2019 The Reimbursement 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 Reimbursement 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. GA-P – 0881 12/11/2019 DCH Approved 03/02/2020 Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Implantable Pain Pump PY-1069 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requ irements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of ser vice, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the me mber or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedure s. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the pl an 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. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Po licy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Implantable Pain Pump GEORGIA MEDICAID PY-1069 Effective Date: 06/01/2020 2 A. Subject Implantable Pain Pump B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the act ual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the su bmitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Stud y of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. I nterventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Implantable Pain Pump : Implantable pain pumps are medical devices which are inserted subcutaneously to deliver drugs for infusion through intrathecal catheters. Implantable pain pumps allow drug delivery directly to specific sites and can be programmed for continuous or variable rates of infusion . D. Policy I . Implantable Pa in Pump A. Prior authorization (PA) is required for all implantable pain pumps, including trial administration, permanent placement and single shot intrathecal injections for the treatment of severe chronic intractable pain of malignant or non-malig nant origin. 1. Prior Authorizations for implantable pain pump services are not required for the following: a. Implantable device is considered part of the procedure and does not require a separate PA. b. Removal/revision of implanted device c. Electronic analysis post transplantation B. Short term and permanent Implantable Pain Pumps are considered medically necessary according to the criteria found in the Implantable Pain Pump Medical policy MM-0802 . Archived Implantable Pain Pump GEORGIA MEDICAID PY-1069 Effective Date: 06/01/2020 3 E.Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Georgia Medicaid fee schedule for appropriate codes.F. Related Policies/RulesImplantable Pain Pump MM-0 802G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 06/01/2020 Date Archived H.References1. Georgia Department of Community Health Fee Schedules. Retrieved November 8, 2019The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. GA-P-0881 12/11/2019 DCH Approved 03/02/2020 Archived
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