MEDICAL POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Non-Emergency Facility to Facility Transfers-IN MCD-MM-1446 05/01/2026 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-IN MCD-MM-1446 Effective Dat e: 05/01/2026 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 Inter-Facility Transfer The transfer of patients between two healthcare facilities. Intra-Facility Transfer The transfer of patients within the same facility. Non-Emergency A situation for which immediate response is not needed for the provision of medical treatment. Non-Participating (Out-of-Network) Facility Facility that is not contracted with CareSource. 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. Receiving Facility The facility to which a transfer is planned. D. PolicyI. The following non-emergency transfers require a medical necessity review: 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 medical necessity review, the receiving facility submits the medical necessity review request to CareSource. Non-Emergency Facility to Facility Transfers-IN MCD-MM-1446 Effective Dat e: 05/01/2026 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 medical necessity review require that the member be medically stable for transfer AND meet at least 1 of the following criteria:A. Member requires transfer to a level of care unavailable at the originating facility. B. Member requires transfer for a medically necessary diagnostic or therapeutic service un available at the originating facility. C. Member requires transfer for services of a specialist to evaluate, diagnose, or tre at a condition when that specialist is not available at the originating facility. D. Member requires transfer because care was received by the member 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. E. Member requires transfer to improve the health and welfare of the member (ie, parental bonding) . F. Transfer 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 birt h complications or other medically necessary conditions. III. The following non-emergency transfers do not require a medical necessity review:A. inter-facility transfers within the same healthcare system B. intra-facility transfers within the same facility IV. 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 provider, 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 01/15/2025 01/28/2026 Annual review. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Annual review. Replaced prior authorization with medical necessity review and physician with provider. Updated references. Approved at Committee. Date Effective 05/01/2026 Date Archived Non-Emergency Facility to Facility Transfers-IN MCD-MM-1446 Effective Dat e: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 H. References 1. Appropriate interhospital patient transfer. American College of Emergency Physicians. January 2022. Accessed January 07, 2026 . www.acep.org 2. Heaton J K. EMS Inter-Facility transport. StatPearls . StatPearls Publishing . Updated February 18, 2025. Accessed January 07, 2026. www.ncbi.nlm.nih.gov 3. Discharges and Transfers, 42 C.F.R. 412.4 (202 6). 4. Obstetric Care Consensus Number 9. Levels of Maternal Care. American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine; 2023. Accessed January 07 , 202 6. www.acep.org Independent med ical review 02/21/2023IN-MED-P-3566914 Issue Date 03/15/2023 OMPP Approved 03/17/2025
MEDICAL POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Microwave Ablation of Tumors-IN MCD-MM-1482 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Microwave Ablation of Tumors-IN MCD-MM-1482 Effective Date: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMicrowave Ablation of Tumors B. BackgroundMicrowave ablation (MWA), a type of thermo-ablation, uses microwave energy to cause thermal coagulation and tissue necrosis at a specific location. When a tumor is not amenable to resection or a patient is ineligible for surgery, MWA may be an appropriate alternative definitive treatment. This procedure can be done percutaneously, using minimally invasive surgical techniques, or during open surgery, and involves placement of one or more probes directly into the tumors location where microwave energy can be directly applied, causing destruction of the tumor and limited surrounding tissues. Microwave ablation does not spare vessels. Hepatocellular carcinoma is the most common type of primary liver cancer. Treatment options include surgical excision, hepatic artery infusion chemotherapy, trans-arterialbland or chemo embolization, selective interstitial radiotherapy (Yttrium 90microspheres), percutaneous ethanol injection, cryoablation, and thermo-ablation . Liver transplantation for curative intent may be appropriate for some patients. M icrowave ablation, a type of thermo-ablation, ha s demonstrated comparable results to other treatment options for small tumors. Liver metastases are a common manifestation of many primary cancers. The number, location, size, and patients general health influence the choice of treatment for liver metastases. While s urgical resection with curative intent is ideal, this may not bepossible in all patients . Non-surgical ablative techniques may be used for both curative and palliative intent, includ ing systemic chemotherapy , targeted therapy, immunotherapy , external beam radiotherapy, cryoablation, thermo-ablation, arterial embolization techniques, and selective internal radiation therapy. Lung cancer is one of the most common types of cancer as well as a common site ofmetastases. Since symptoms often do not appear until advanced disease, prognosis can be poor . Common treatments for primary or metastatic cancer in the lung include surgery, chemotherapy, radiotherapy, photodynamic therapy, thermal ablation, immunotherapy, and biological therapy. Treatment selection is based on type, size, position and stage of c ancer, and the patients overall health. Small renal masses (SRMs) less than 4cm in size suspicious for clinical stage T1a renal cell carcinoma are the most common type of kidney tumor encountered. SRMs are often found incidentally with imaging for unrelated indications. Thermo-ablative technique s likeMWA are gaining greater acceptance in clinical practice due to favorable outcomes observed in initial studies, low incidence of complications, lower cost, and ability to treat patients in the outpatient setting. Potential benefits of these technique s should be balanced against the lack of long-term follow-up data. For larger renal masses (T1b), several ablative procedures may be required to achieve the same results as other treatment techniques. Microwave Ablation of Tumors-IN MCD-MM-1482 Effective Date: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 C. Definitions Tumor Ablation Direct application of energy to eradicate or destroy focal tumors. The method of ablation is dependent on the characteristics of the lesion and risk mitigation. o Microwave Ablation (MWA) Delivery of high-frequency microwave energy to rapidly agitate water molecules in the target tissue; the energy is converted to heat, which causes tissue necrosis. D. PolicyI. Microwave ablation for tumor treatment using an FDA-approved device is considered medically necessary when ONE of the following indications are met: A. Member has primary or metastatic hepatic (liver) tumor and ALL the following: 1. The tumor is unresectable due to location of lesion(s) , OR the member has comorbid condition (s) that are contraindicative to surgery. 2. Tumor is 5cm in size , OR there are no more than 3 nodules, all of which are 3cm in size . 3. Microwave ablation may be used alone or in conjunction with open or minimally invasive resection of other liver tumors. Curative resection of all disease must be the stated goal of therapy . B. Member has primary or metastatic lung tumor, and ALL the following: 1. The tumor is unresectable due to location of lesion(s), OR the member has comorbid condition(s) that are contraindicative to surgery. 2. Single tumor is 3cm in size. C. Member has T1 renal cell carcinoma and ONE of the following: 1. Renal mass is 4cm in size and the member is not eligible for surgery or declines surgery. 2. Renal mass is > 4cm but 7cm and the member is not eligible for surgery. II. Microwave ablation is not covered for any other indication, including (but not limited to), the following:A. Microwave ablation for any other tumor type is considered experimental and investigational due to a lack of clinical evidence on its efficacy . B. Microwave ablation for tumors larger than the above indications is considered experimental and investigational due to a lack of clinical evidence on its efficacy compared to other treatment modalities. E. Conditions of CoverageNA F. Related Policies/RulesNA Microwave Ablation of Tumors-IN MCD-MM-1482 Effective Date: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 G. Review/Revision HistoryDATE ACTIONDate Issued 02/15/2023Date Revised 09/27/2023 08/28/2024 06/18/2025 02/11 /2026 Annual review: updated references. Approved at Committee. Review: updated references, approved at Committee. Review: updated references, approved at Committee. Review: expanded background, added renal carcinoma indications, approved at Committee. Date Effective 05/01/ 2026 Date Archived H. References1. Aarts BM, Gomez FM, Lopez-Yurda M, et al. Safety and efficacy of RFA versus MWA for T1a renal cell carcinoma: a propensity score analysis. Eur Radiol . 2023;33(2):1049-1049. doi: 10.1007/s00330-022-09110-w. 2. Abdalla M, Collings AT, Dirks R, et al. Surgical approach to microwave and radiofrequency liver ablation for hepatocellular carcinoma and colorectal liver metastases less than 5cm: a systematic review and meta-analysis. Surg Endosc. 2023;37(5):3340-3353. doi:10.1007/s00464-022-09815-5. 3. Cazzato RL, de Rubeis G, de Marini P, et al. Percutaneous microwave ablation of bone tumors: a systematic review. Eur Radiol . 2021;31(5):3530-3541. doi:10.1007/s00330-020-07382-8. 4. Cui R, Yu J, Kuang M, et al. Microwave ablation versus other interventions for hepatocellular carcinoma: a systematic review and meta-analysis. JCancer Res Ther . 2020;16(2):379-386. doi:10.4103/jcrt.JCRT_403_19 5. Curley SA, Stuart KE, Schwartz JM, et al. Localized hepatocellular carcinoma: liver – directed therapies for nonsurgical candidates who are eligible for local ablation. UpToDate. Updated April 17, 2025. Accessed January 23, 2026 . www.uptodate.com 6. Dupuy DE. Image-guided ablation of lung tumors. UpToDate. Updated November 6, 2023. Accessed January 23, 2026. www.uptodate.com 7. Genshaft SJ, Suh RD, Abtin F, et al. Society of Interventional Radiology quality improvement standards on percutaneous ablation of non-small cell lung cancer and metastatic disease to the lungs. JVasc Interv Radiol . 2021; 32:1242.e1-1242.e10. doi:10.1016/j.jvir.2021.04.027 8. Glassberg MB, Ghosh S, Clymer JW, et al. Microwave ablation compared with hepatic resection for the treatment of hepatocellular carcinoma and liver metastases: a systematic review and meta-analysis. World JSurg Oncol . 2019;17(1):98. doi:10.1186/s12957-019-1632-6 9. Golden ED, Mutlu A, Knavel-Koepsel EM, et al. Microwave ablation for renal cell carcinoma: a literature review and clinical insights. EMJ Radiol. 2025;6(1):71-85. doi:10.33590-emjradiol/MQUZ3849 10. Han Y, Yan X, Zhi W, et al. Long-term outcome following microwave ablation of lung metastases from colorectal cancer. Front Oncol . 2022 Jul;12:943715. doi:10/3389/fonc.2022.943715 Microwave Ablation of Tumors-IN MCD-MM-1482 Effective Date: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 11. Hines A, Goldberg SN. Radiofrequency ablation, cryoablation, and other ablative techniques for renal cell carcinoma. UpToDate. Updated September 3, 2024. Accessed January 23, 2026. www.uptodate.com12. Khandpur U, Haile B, Makary MS. Early-stage renal cell carcinoma locoregional therapies: current approaches and future directions. Clin Med Insights Oncol . 2024;18:18:11795549241285390. doi: 10.1177/11795549241285390 13. Matsui Y, Tomita K, Uka M, et al. Up-to-date evidence on image-guided thermal ablation for metastatic lung tumors: a review. Jpn JRadiol . 2022 ;40(10):1024-1034. doi:10/1007/s11603-022-01302-0 14. McClure T, Lansing A, Ferko N, et al. A comparison of microwave ablation and cryoablation for the treatment of renal cell carcinoma: a systematic literature review and meta-analysis. Urology . 2023;180:1-8. doi:10.1016/j.urology.2023.06.001. 15. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Hepa tocellular Carcinoma . Version 2.2025 . Issued October 22 , 2025. Accessed January 23, 2026 . www.nccn.org 16. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Kidney Cancer. Version 1.2026. Issued July 24, 2025. Accessed January 23, 2026. www.nccn.org 17. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology . Non-Small Cell Lung Cancer. Version 3.202 6. Issued December 2 4, 2025. Accessed January 23, 2026 . www.nccn.org 18. National Institute for Health and Care Excellence. Microwave ablation for treating liver metastases [IPG553]. Published April 27, 2016 . Accessed January 23, 2026 . www.nice.org 19. National Institute for Health and Care Excellence. Microwave ablation of hepatocellular carcinoma [IPG214]. Published March 28, 2007 . Accessed January 23, 2026 . www.nice.org 20. National Institute for Health and Care Excellence. Microwave ablation for primary or metastatic cancer in the lung [IPG716]. Published February 2, 2022 . Accessed January 23, 2026 . www.nice.org 21. Nelson DB, Tam AL, Mitchell KG, et al. Local recurrence after microwave ablation of lung malignancies: a systematic review. Ann Thorac Surg . 2019;107(6):1876-1883. doi:10.1016-j.athoracsur.2018.10.049 22. Pierorazio PM, Campbell SC. Clinical diagnosis and management of a small renal mass. UpToDate. Updated September 26, 2025. Accessed January 23, 2026. www.uptodate.com 23. Wang N, Xu J, Wang G, et al. Safety and efficacy of microwave ablation for lung cancer adjacent to the interlobar fissure. Thorac Cancer . 2022 ;13(18):2557-2565 . doi:10.1111/1759-7714.14589 24. Wu X, Uhlig J, Blasberg JD, et al. Microwave ablation versus stereotactic body radiotherapy for stage I non-small cell lung cancer: a cost-effectiveness analysis. J Vasc Interv Radiol . 2022;33(8):964-971.e2. doi:10.1016/j.jvir.2022.04.019 Independent med ical review September 2022Microwave Ablation of Tumors-IN MCD-MM-1482 Effective Date: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 IN-MED-P-4186019 Issue date 2/15/2023 Approved OMPP 08/21/2025
MEDICAL POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Infant Formula-IN MCD-MM-1357 11/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Infant Formula-IN MCD-MM-1357Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectInfant Formula B. BackgroundInfant formula may be provided through medical insurance when the member is unable to tolerate standard formula or breast milk due to a variety of conditions, including, but not limited to, gastrointestinal disorders, malabsorption, and inborn errors of me tabolism. These products must be F ood and Drug Administration (F DA ) approved and prescribed appropriately by a qualified physician. While the member is awaiting authorization, the Women, Infants and Children (WIC) program will provide a supplemental amount of exempt infant formula or medical food. Pursuant to Code of Federal Regulations 7 C .F.R. 246.10(d)(1)(iii) and 246.10(d)(1)(iv) to receive this WIC benefit, members must obtain documentation of a qualifying condition from a healthcare professional licensed to write medical prescriptions. Members should be referred to WIC only as a secondary provider. Medicaid becom es the primary provider after approval as a covered benefit is granted.C. Definitions Inborn Errors of Metabolism (IEM) (eg, Inherited Metabolic Disease) A disease caused by inborn errors of amino acid, organic acid, or urea cycle metabolism and treatable by the dietary restriction of one or more amino acids. Medical Food A formula intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and formulated to be consumed or administered under the direction of a physician. Standard Food Regular grocery products including typical, not specially formulated infant formulas available without a prescription. D. PolicyI. Prior authorization is required. II. CareSource considers infant nutritional formula medically necessary when ALL the following criteria are met: A. Formula is being dispensed to treat an illness, including (but not limited to): 1. inborn errors of metabolism /metabolic disorders 2. severe food allergies that require an elemental formula 3. gastrointestinal disorders/malabsorption syndrome B. The member is unable to maintain body weight and nutritional status (initial and ongoing treatment) with standard food/formula. C. There is n o other means of nutrition that are feasible or reasonable . D. Convenience of the member or the members caretaker is not the primary reason for the request for the service. Infant Formula-IN MCD-MM-1357Effective Dat e: 11/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/12/2022Date Revised 10/11/2023 09/25/2024 07/16 /2025Annual review: updated references, approved at Committee.Review: removed D.II.E, updated references, approved at Committee. Review: updated references, approved at Committee. Date Effective 11/01/2025 Date Archived H. References1. Bakshi S, Paswan VK, Yadav SP, et al. A comprehensive review on infant formula: nutritional and functional constituents, recent trends in processing and its impact on infants’ gut microbiota. Front Nutr . 2023;10:1194679. doi:10.3389/fnut.2023.1194679 2. Burris A, Burris J, Jarvinen KM. Cows milk protein allergy in term and preterm infants: clinical manifestations, immunologic pathophysiology, and management strategies. NeoReviews . 2020;21(12):e795-e808. doi: 10.1542/neo.21-12-e795 3. Cederholm T, Barazzoni R, Austin P, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr . 2017; 36(1):49-64. doi:10.1016/j.clnu.2016.09.004 4. Food Supplements, Nutritional Supplements, and Infant Formulas, 405 IND . ADMIN . CODE 5-24-9 (202 5). 5. Guidance for Industry: Frequently Asked Questions about Medical Foods . 3 rd ed. US Dept of Health and Human Services; 2023. Accessed June 24 , 202 5. www.fda.gov 6. Inherited Metabolic Disease Coverage, IND . CODE 27-13-7-18 (2024). 7. Provider Reference Module: Durable and Home Medical Equipment and Supplies . Indiana Health Coverage Programs; 2024. Accessed June 24 , 2025 . www.in.gov 8. Supplemental Foods, 7 C .F.R. 246.10 (20 24). IN-MED-P-4186320 Issue Date 10/12/2022 Approved OMPP 08/12/2025
MEDICAL POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Inhaled Nitric Oxide-IN MCD-MM-1186 07/01/2025 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-IN MCD-MM-1186Effective Dat e: 07/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 D. PolicyI. CareSource considers the initiation of iNO therapy medically necessary for treating near-0057 hypoxic respiratory failure or evidence of persistent pulmonary hypertension when ALL of the following conditions are present: A. Conventional therapies (such as mechanical ventilation, administration of high concentrations of oxygen (80-100%), high frequency oscillatory ventilation (HFOV), induction of respiratory alkalosis, neuromuscular blockade, and sedation) have failed or are expected to fail. B. Absence of ductal dependent congenital heart disease. C. Evidence of PPHN, such as echocardiographic findings, results of a right heart catheterization or abnormal oxygen index/arterial blood gases that are NOT related to another medical condition. II. CareSource considers the use of iNO therapy medically appropriate for ANY of the following clinical conditions: A. Post-00520053 after repair of congenital heart disease with evidence of pulmonary hypertension. B. Post-operative management following pediatric heart or lung surgery with evidence of pulmonary hypertension. C. Management of pulmonary hypertension during a heart catheterization to determine pulmonary vasoreactivity. D. Management of BPD related pulmonary hypertension during acute crisis (patients with chronic pulmonary hypertension related to BPD should be transitioned to enteral therapy when acute crisis improves). III. INO therapy for more than 3 days is subject to medical necessity review with medical record documentation to support continued use. (If there is a lack of a positive response to therapy with inability to wean O2 and/or INO after 3 days, then discontinuation of INO therapy should be considere d.) IV. CareSource considers the use of iNO not medically necessary for the following indications: A. congenital diaphragmatic hernia B. acute bronchiolitis C. bronchopulmonary dysplasia D. acute pulmonary embolism E. acute respiratory distress syndrome F. acute lung injury G. lung transplantation H. liver transplantation I. pulmonary fibrosis J. hemorrhagic shock K. pneumonectomy post trauma L. cystic fibrosis M. malaria
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