MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Breast Reduction Surgery-MP-MM-1421 06/01/2025 KY inactive as of 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 6 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 7 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 I. References ………………………….. ………………………….. ………………………….. ……………………. 7 Breast Reduction Surgery-MP-MM-1421Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectBreast Reduction Surgery B. BackgroundWomen diagnosed with macromastia (excessively large breasts) seeking breast reduction typically present with complaints of a feeling of heaviness, chronic pain, and tension in the neck, shoulders, and upper back. Macromastia commonly causes permanent grooving an d ulceration of the shoulder following years of wearing support bras to try to minimize symptoms. The physical and psychological symptoms of macromastia can significantly and negatively impact an individuals life and should be taken into considerati on when evaluating surgical intervention. Reduction mamm aplasty is a surgical procedure that reduces the weight and volume ofthe breast. As much as 1 to 5 pounds of excess breast tissue is routinely removed during a reduction mamm aplasty depending on breast and body mass . Indications for surgery include chronic pain and skin symptoms , neuropathy, breast discomfort, physical impairment , and psychological symptoms that can be associated with poor self-esteem and loss of desire to engage in activities. Gynecomastia is a benign proliferation of glandular tissue of the breast in males . Thiscondition may be caused by androgen deficiency, congenital disorders, medications,chronic medical conditions, tumors, or endocrine disorders. Depending on the cause of the tissue proliferation, surgical removal may be considered cosmetic or medically necessary. C. Definitions Body Surface Area (BSA) A metric used for physiologic measurements, pharmacologic dosing, and therapeutic calculations, including the Schnur Sliding Scale for breast reduction surgery. Cosmetic Procedures Procedures performed for aesthetic purposes that do not improv e or restor e physiologic function. Functional/Physical or Physiological Impairment Impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired or delayed capacity to move and coordinate actions or perform physical activities and is exhibited by difficulties in physical and m otor tasks, independent movement, or performing basic life functions. Gynecomastia Enlargement of the male breast secondary to a proliferation of ductal, stromal, and/or fatty tissue. Gynecomastia Scale A qualitative classification system for gynecomastia developed by the American Society of Plastic Surgeons (ASPS). o Grade I Small breast enlargement with localized button of tissue that is concentrated around the areola. o Grade II Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Breast Reduction Surgery-MP-MM-1421Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Grade III Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present. o Grade IV Marked breast enlargement with skin redundancy and feminization of the breast. Intertriginous Rash Dermatitis occurring between juxtaposed folds of skin , caused by retention of moisture and warmth and providing an environment favoring overgrowth of normal skin micro-organisms. Kyphosis Over-curvature of the thoracic vertebrae (upper back) associated with degenerative diseases , such as arthritis, developmental problems, or with osteoporotic compression fractures of vertebral bodies. Macromastia (Breast Hypertrophy) An increase in the volume and weight of breast tissue relative to the general body habitus. Symptomatic Breast Hypertrophy A syndrome of persistent neck and shoulder pain, shoulder grooving from brassiere straps, chronic intertriginous rash of the infra – mammary fold and/or frequent episodes of headache, backache, and upper extremity neuropathies caused by an increase in the volu me and weight of breast tissue beyond normal proportions. Schnur Sliding Scale Use d in calculating the amount of breast tissue to be removed in reduction mammoplasty (Appendix A). D. PolicyI. CareSource considers breast reduction surgery for macromastia medically necessary when ALL the following criteria are met and have been documented : A. Member is 18 years or older or under 18 years with evidence that breasts have finished growing for a minimum of 1 year . P arental/guardian consent is required for members under age 18 . B. Breast size interferes with activities of daily living, as indicated by 1 or more of the following: 1. arm numbness consistent with brachial plexus compression syndrome 2. cervical pain 3. chronic breast pain 4. headaches 5. nipple position greater than 21 cm below suprasternal notch 6. persistent redness and erythema (intertrigo) below breasts 7. restriction of physical activity 8. severe bra strap grooving or ulceration of shoulder 9. shoulder pain 10. thoracic kyphosis 11. upper or lower back pain C. Preoperative evaluation by surgeon concludes that amount of breast tissue to be removed (by mass or volume) will provide a reasonable expectation of symptomatic relief. D. No evidence of breast cancer 1. physical exam completed by a physician within the last year if under 40 years of age Breast Reduction Surgery-MP-MM-1421Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 2. women 40 to 54 years of age or older with mammogram negative for cancer performed within the year prior to the date of the planned breast reduction surgery 3. women 55 years of age and older with negative mammograms for cancer every 2 years 4. women with family history of breast cancer with mammograms starting at least 7 years prior to when the youngest family member was diagnosed with breast cancer (as early as 30 years old) II. Breast reduction surgery following mastectomy to achieve symmetry is covered as part of the Womens Health and Cancer Rights Act (WHCRA). Please refer to the CareSource Medical policy , Breast Reconstruction Surgery , for additional information. III. CareSource considers breast reduction surgery for gynecomastia medically necessary when ALL the following clinical criteria are met and have been documented: A. Member is 18 years or older , or under 18 years with evidence that breasts have finished growing for a minimum of one year . Parental/guardian consent is required for members under age 18 . B. A physical exam has been conducted by an appropriately credentialed provider and confirms the presence of gynecomastia: 1. pubertal male (adolescent) a. gynecomastia present for more than 1 year after pathological causes ruled out b. Gynecomastia Grade II, III, or IV 2. postpubertal male a. gynecomastia present for more than 3 months after pathological causes ruled out b. Gynecomastia Grade III or IV C. The tissue being removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of drug treatment that can be discontinued. D. The gynecomastia is attributed to an underlying condition (not an all-inclusive list), including: 1. androgen deficiency 2. chronic liver disease that causes decreased androgen availability 3. Klinefelter syndrome 4. adrenal tumors that cause androgen deficiency or increased secretion of estrogen 5. brain tumors that cause androgen deficiency 6. testicular tumors that cause androgen deficiency or tumor secretion of estrogen 7. endocrine disorders (eg, hyperthyroidism) E. The gynecomastia causes functional impairment (eg , pain, chronic irritation) and breast reduction surgery is not for cosmetic reasons. F. Breast malignancy was ruled out. Breast Reduction Surgery-MP-MM-1421Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 IV. Schnur Sliding Scale The Schnur Sliding Scale is one of several evaluation tool s used to determine the appropriate volume of tissue to be removed relative to a members total body surface area ( BSA ). This estimation can be instrumental in determining whether breast reduction surgery is being planned for cosmetic reasons or as a medically necessary procedure. A. The weight of tissue to be removed from each breast is recommended to be above the 22 nd percentile on the Schnur Sliding Scale (Appendix A below) based on the members BSA. B. The BSA in meters squared (m 2) is calculated using the Mosteller formula (square root of the result of height (in ches ) multiplied by weight (lbs) and divided by 313 1). Appendix A: Schnur Sliding ScaleBody Su rface Ar ea an d M inim um Re quire ment for Breast Tissue R emoval Body Surface Area ( m2)Gr ams per Br east of Minimum Breast T issue to be Remo ved1.350-1.374 1991.375-1.399 208 1.400-1.424 218 1.425-1.449 227 1.450-1.474 238 1.475-1.499 249 1.500-1.524 260 1.525-1.549 272 1.550-1.574 284 1.575-1.599 297 1.600-1.624 310 1.625-1.649 324 1.650-1.674 338 1.675-1.699 354 1.700-1.724 370 1.725-1.749 386 1.750-1.774 404 1.775-1.799 422 1.800-1.824 441 1.825-1.849 461 Breast Reduction Surgery-MP-MM-1421Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 1.850-1.874 4821.875-1.899 504 1.900-1.924 527 1.925-1.949 550 1.950-1.974 575 1.975-1.999 601 2.000-2.024 628 2.025-2.049 657 2.050-2.074 687 2.075-2.099 717 2.100-2.124 750 2.125-2.149 784 2.150-2.174 819 2.175-2.199 856 2.200-2.224 895 2.225-2.249 935 2.250-2.274 978 2.275-2.299 10 22 2.300-2.324 10 68 2.325-2.349 11 17 2.350-2.374 11 67 2.375-2.399 12 19 2.400-2.424 12 75 2.425-2.449 13 33 2.450-2.474 13 93 2.475-2.499 14 55 2.500-2.524 15 22 2.525-2.549 15 90 2.550 or grea ter 16 62 E. State-Specific InformationN/A F. Conditions of CoverageN/A Breast Reduction Surgery-MP-MM-1421Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 G. Related Policies/Rules Breast Reconstruction Surgery Medical Necessity Determinations H. Review/Revision HistoryDATE ACTIONDate Issued 01/18/2023 New policyDate Revised 03/15/2023 06/21/202302/28/202404/24/202403/12 /2025Revised D.I, D.I.A., D.II. and D.II.A. Updated references. Approved at Committee . Removed II. C. Updated references. Approved at Committee. Revision: editorial changes, removed definitions, expanded policy to cover members under 18 years of age, and updated references. Approved at Committee. Revision: added BI-RADS to background, aligned gynecomastia surgery with EOC, added Section II I, added references. Approved at Committee. Annual review: updated background and definitions, added D.I.D.4., revised gynecomastia criteria, and updated references. Approved at Committee. Date Effective 06/01/2025 Date Archived I. References1. ASPS recommended insurance coverage criteria for third-party payers: gynecomastia. American Society of Plastic Surgeons. Accessed March 3, 2025. www.plasticsurgery.org 2. ASPS recommended insurance coverage criteria for third-party payers: reduction mammaplasty. American Society of Plastic Surgeons. Accessed March 3, 2025. www.plasticsurgery.org 3. Billa E, Kanakis GA, Goulis DG. Imaging in gynecomastia. Andrology . 2021;9(5):1444-1456. doi:10.1111/andr.13051 4. Biro FM, Chan YM. Normal puberty. UpToDate. Updated September 24, 2024 . Accessed January 31, 2025 . www.uptodate.com 5. Braunstein G D, Anawalt BD. Clinical features, diagnosis, and evaluation of gynecomastia in adults. UpToDate. Updated April 26, 2023. Accessed January 31, 2025. www.uptodate.com 6. Braunstein G D, Anawalt BD . Management of gynecomastia. UpToDate. Updated September 27, 2024. Accessed January 31, 2025. www.uptodate.com 7. Briefing paper: plastic surgery for teenagers. American Society of Plastic Surgeons. Accessed January 31, 2025 . www.plasticsurgery.org 8. Guliyeva G, Cheung JY, Avila FR, et al. Effect of reduction mammoplasty on pulmonary function tests: a systematic review. Ann Plast Surg . 2021;87(6):694-698. doi:10.1097/SAP.0000000000002834 Breast Reduction Surgery-MP-MM-1421Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 9. Hansen J, Chang S. Overview of breast reduction. UpToDate. Updated April 19, 2023. Accessed January 31, 2025 . www.uptodate.com10. Holzmer SW, Lewis PG, Landau MJ, et al. Surgical management of gynecomastia: a comprehensive review of the literature. Plast Reconstr Surg Glob Open . 2020;8(10):e3161. doi:10.1097/GOX.0000000000003161 11. Kanakis GA, Norkap L, Bang AK, et al. EAA clinical practice guidelines gynecomastia evaluation and management. Andrology . 2019;7(6):778-793. doi:10.1111/andr.12636 12. Kimia R, Magee L, Caplan HS, et al. Trends in insurance coverage for adolescent reduction mamm aplasty. Am JSurg . 2022;224(4):1068-1073. doi:10.1016/j.amjsurg.2022.07.030 13. Klement KA, Hijjawi BJ, Neuner J, et al. Discussion of preoperative mammography in women undergoing reduction mamm aplasty. Breast J . 2019;25(3):439-44. doi:10.1111/tbj.13237 14. Knox JA, Nelson DA, Latham KP, et al. Objective effects of breast reduction surgery on physical fitness. Ann Plast Surg . 2018;80(1):14-17. doi:10.1097/SAP.0000000000001167 15. Lewin R, Liden M, Lundberg J, et al. Prospective evaluation of health after breast reduction surgery using the Breast-Q, Short-Form 36, Breast-Related Symptoms Questionnaire, and Modifed Breast Evaluation Form. Ann Plast Surg . 2019;83(2):143-151. doi:10.1097/SAP.0000000000001849 16. Magny SJ, Shikhman R, Keppke AL. Breast Imaging Reporting and Data System . StatPearls Publishing; 2024. Accessed January 31, 2025 . www.ncbi.nlm.nih.gov 17. Mastectomy for gynecomastia. MCG. 28 th ed draft. Updated March 14, 2024. Accessed March 3, 2025. www.careweb.careguidelines.com 18. Morrison KA, Vernon R, Choi M, et al. Quantifying surgical complications for reduction mammaplasty in adolescents. Plast Reconstr Surg . 2023;151(3):376e – 383e. doi:10.1097/PRS.0000000000009905 19. NCCN guidelines for patients 2022: breast cancer screening and diagnosis. NCCN. www.nccn.org 20. Nuzzi LC, Firriolo JM, Pike CM, et al. The effect of reduction mamm aplasty on quality of life in adolescents with macromastia. Pediatrics . 2017;140(5):e20171103. doi:10.1542/peds.2017-1103 21. Nuzzi LC, Pramanick T, Walsh LR, et al. Optimal timing for reduction mamm aplasty in adolescents. Plast Reconstr Surg . 2020;146(6):1213-1220. doi:10.1097/PRS.0000000000007325 22. Patel K, Corcoran J. Breast reduction surgery in adolescents. Pediatr Ann . 2023;52(1):e31-e35. doi:10.3928/19382359-20221114-06 23. Perdikis G, Dillingham C, Boukovalas S, et al. American Society of Plastic Surgeons evidence-based clinical practice guideline revision: reduction mammaplasty. Plast Reconstr Surg . 2022;149(3):392e-409e. doi:10.1097/PRS.0000000000008860 24. Perez-Panzano E, Gascon-Catalan A, Sousa-Dominguez R, et al. Reduction mamm aplasty improves levels of anxiety, depression and body image satisfaction in Breast Reduction Surgery-MP-MM-1421Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.9 patients with symptomatic macromastia in the short and long term. JPsychosomObstet Gynaecol . 2017;38(4):268-275. doi:10.1080/0167482X.2016.1270936 25. Reduction mamm aplasty: A-0274. MCG. 28th ed. Updated March 14, 2024 . Accessed January 31, 2025 . www.careweb.careguidelines.com 26. Reeves RA, Kaufman T. Mammography . StatPearls . StatPearls Publishing; 2023. Accessed January 31, 2025 . www.ncbi.nlm.nih.gov 27. Sears ED, Lu YT, Swiatek PR, et al. Use of preoperative mammography during evaluation for nononcologic breast reduction surgery. JAMA Surg . 2019;154(4):356 – 358. doi:10.1001/jamasurg.2018.4875 28. Womens Health and Cancer Rights Act (WHCRA). Centers for Medicare and Medicaid Services . Accessed January 31, 2025. www.cms.gov 29. Taylor SA. Gynecomastia in children and adolescents. UpToDate. Updated July 12, 2024. Accessed January 31, 2025. www.uptodate.com 30. Xia TY, Scomacao I, Duraes E, et al. Aesthetic, quality-of-life, and clinical outcomes after inferior pedicle oncoplastic reduction mammoplasty. Aesthetic Plast Surg . 2023;47(3):905-911. doi:10.1007/s00266-023-03257-7 31. Zeiderman MR, Kelishadi SS, Tutela JP, et al. Reduction mammoplasty: intraoperative weight versus pathology weight and its implications. Eplasty . 2017;17:e32. Accessed January 31, 2025 . www.pubmed.ncbi.nlm.nih.gov
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Insulin Infusion Pump-MP-MM-1316 06/01/2025 Kentucky inactive as of 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectInsulin Infusion Pump B. Background38.4 million people (11. 6% of the population) in the United States have diabetes mellitus (DM), not including the estimated 8.5 million adults who are undiagnosed. Approximately 5 to 10% of individuals with diabetes have type 1 (T1D) , while type 2 (T2D) accounts for the remaining 90 to 95% of cases. The incidence of both T1D and T2D in children and adolescents has significantly increased, according to the Centers for Disease Control (CDC) National Diabetes Statistic Report. Some of the unique challenges associated with caring for children and adolescents include the patients size, de velopmenta l concerns, and inability to communicate symptoms of hypoglycemia. Health care resources spent on diabetes are considered to be higher than all other health conditions. Immediate impacts on both physical and mental well-being are common with both severe hy poglycemia and extreme hyperglycemia. Patients with diabetes need to be closely monitored. When blood glucose levels are poorly controlled, patients are at risk of complications, including heart disease, stroke, peripheral vascular disease, retinal damage, kidney disease, nerve damage, and imp otence. Patients should also be monitored for comorbidities that may not be presentduring the early stages of the disease but develop as the disease progresses, including hearing impairment, fatty liver disease, sleep apnea, periodontal disease, depressio n, anxiety, cognitive impairment, and fractures. Reasonable glycated hemoglobin (A1C) goals for diabetic patients should be customized for the individual patient, balancing established benefits with prevention of complications and risk of hypoglycemia. Goals vary depending on age, comorbidities, and the benefitsof intensive therapy. Patients with T1D while pregnant may require stricter control.Insulin therapy is the mainstay of treatment for T1D and T2D . External insulin pumps arean option for intensive insulin therapy designed to provide continuous subcutaneous insulin infusion (CSII) to improve glycemic control, meet basal insulin requirements, and supplement bolus insulin delivery to assist in mealti me insulin needs. The AmericanAssociation of Clinical Endocrinologists (AACE), American College of Endocrinology (ACE), and American Diabetes Association (ADA) recommend CSII only in individuals with T1D and patients with T2D who are insulin dependent. Insulin absorption with CSII therapy appears to be less variable and may help members that have not been able to achieve optimum glycemic goals with multiple daily injections. The choice of insulin delivery via multiple daily injections or continuous subcutaneous delivery of a rapid – acting insulin preparation via a pump should be carefully considered and thoroughly explained to the member. Insulin pumps should only be used in patients who are motivat ed and knowledgeable in DM self-care and able to safely manage the device. Additionally, newer, sensor-augmented insulin pump systems are available with continuous glucose monitoring (CGM) integrated into the pump, which may reduce nocturnal hypoglycemia. Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 C. Definitions Dawn Phenomenon An observed increase in blood sugar levels that takes place in the early morning, often between 2am and 8am. Insulin Infusion Pump An external pump used to deliver insulin subcutaneously or through an intraperitoneal route in a controlled and programmed way in order to prevent acute metabolic complications of diabetes and obtain normal blood glucose levels. Moderately Increased Albuminuria Persistent urine albumin-to-creatinine ratio values between 30 and 300mg/gram creatinine. Previously called microalbuminuria, this is usually indicative of diabetic nephropathy (unless there is some other coexistent renal disease). Sensor-Augmented Insulin Pump System An insulin infusion pump equipped with a CGM sensor that uses the glucose readings taken by the CGM sensor to modify the amount of insulin infused . D. PolicyI. CareSource considers the use of external insulin infusion pumps medically necessary when ALL the following criteria are met: A. Documented diagnosis of one of the following: 1. T1D 2. T2D with insulin dependency B. Diabetic education, equipment, and supplies must be ordered in writing by a physician or other appropriately credentialed health care provider . C. The members provider and provider team have an expert level of experience in the management and support of members with insulin infusion pumps . D. Documentation that the patient has completed a comprehensive diabetes education program within the last 12 months by a certified, registered, or licensed provider with expertise in diabetes . E. The member or members caregiver must be knowledgeable in operating the device . F. The member has been on a maintenance program for at least 6 months involving at least 3 injections of insulin per day requiring frequent self-adjustments of insulin dosage . G. The member has performed glucose self-testing at least 4 times per day on average during the last month . H. The member is at high risk for preventable complications of diabetes, early signs of which include: 1. moderately increased albuminuria (eg, microalbuminuria) 2. persistent difficulty in controlling blood sugar levels despite compliance with an intensive multiple-injection regimen, as indicated in documented member log I. The member has at least one of the following symptoms or conditions: 1. A1 Cgreater than 7% 2. history of recurring hypoglycemia Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 3. wide fluctuations in blood glucose before mealtime4. dawn phenomenon frequently exceeding 200 mg/dl 5. history of severe glycemic excursions II. ExclusionsA. CareSource considers insulin pump therapy not medically necessary when any of the following apply: 1. Member has end-stage complications such as renal failure. 2. Neither the member nor anyone assisting the member is able to operate a pump or to perform frequent blood glucose monitoring. B. CareSource considers the following devices not medically necessary: 1. portable external insulin infusion pumps requested purely for convenience or member preference 2. surgically implanted infusion devices for systems 3. jet pressure devices 4. devices associated with chronic intermittent intravenous insulin therapy (CIIIT) 5. devices associated with pulsatile intravenous therapy (PIVIT) III. Device Replacement or RepairCareSource may cover the repair, adjustment, and/or replacement of purchased equipment, supplies, or appliances when approved. A. The repair, adjustment, or replacement of the purchased equipment, supply, or appliance is covered if: 1. The equipment, supply, or appliance is a covered service . 2. The continued use of the item is medically necessary . 3. There is reasonable justification for the repair, adjustment, or replacement. B. Replacement of a functioning device just because the warranty has expired is not considered medically necessary. C. Replacement of purchased equipment, supplies or appliances may be covered if: 1. The equipment, supply , or appliance is worn out or no longer functions. 2. Repair is not possible or would equal or exceed the cost of replacement. An assessment by a rehabilitation equipment specialist or vendor should be done to estimate the cost of repair. 3. Members needs have changed, and the current equipment is no longer usable due to weight gain, rapid growth, or deterioration of function, etc. 4. The equipment, supply, or allowance is damaged and cannot be repaired. 5. Benefits for repairs and replacement do not include: a. repair and replacement due to misuse, malicious breakage, or gross neglect b. replacement of lost or stolen items E. State-Specific InformationA. Georg ia marketplace. CareSource. Accessed February 13, 2025. www.caresource.com Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 B. Indiana marketplace. CareSource. Accessed February 13, 2025. www.caresource.comC. Kentucky marketplace. CareSource. Accessed February 13, 2025. www.caresource.com D. Ohio marketplace. CareSource. Accessed February 13, 2025. www.caresource.com E. West Virginia marketplace. CareSource. Accessed February 13, 2025. www.caresource.com F. Conditions of CoverageN/A G. Related Policies/RulesN/A H. Review/Revision HistoryDATE ACTIONDate Issued 04/13/2022 New policy, replacing individual state policiesDate Revised 03/29/2023 03/13/202402/26/2025Annual review: updated references. Approved at Committee. Annual review: editorial changes, updated background, and updated references. Approved at Committee. Annual review : added other provider to D.I.B . Approved at Committee. Date Effective 06/01/2025 Date Archived I. References1. American Diabetes Association Professional Practice Committee. Diabetes technology: standards of care in diabetes 2024. Diabetes Care . 2024;47(Suppl 1):S126-S126-S144. doi.org/10.2337/dc24-S007 2. Blonde L, Umpieerez GE, Reddy SS, et al. American Association of Clinical Endocrinology clinical practice guideline: developing a diabetes mellitus comprehensive care plan 2022 update. Endocr Pract . 2022;28(10):923-1049. doi:10.1016/j.eprac.2022.08.002 3. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States. Reviewed May 15, 2024. Accessed February 13, 2025 . www.cdc.gov 4. Glycemic targets: standards of medical care in diabetes 202 3. Diabetes Care . 202 3;46(Suppl 1):S 97-S110 . doi:10.2337/dc23-S006 5. Heinemann L, Fleming GA, Petrie JR, et al. Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care . 2015;38(4):716-722. doi:10.2337/dc15-0168 Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 6. Levitsky L L, Misra M . Overview of the management of type 1 diabetes mellitus in children and adolescents. UpToDate. Updated November 15, 2023. Accessed February 13, 2025 . www.uptodate.com 7. Levitsky L L, Misra M. Hypoglycemia in children and adolescents with type 1 diabetes mellitus. UpToDate. Updated December 30, 2022. Accessed February 13, 2025 . www.uptodate.com 8. Levitsky L L, Misra M. Insulin therapy for children and adolescents with type 1 diabetes mellitus. UpToDate. Updated October 23, 2023. Accessed February 13, 2025 . www.uptodate.com 9. Pharmacologic approaches to glycemic treatment: standards of care in diabetes – 202 3. Diabetes Care . 202 3;46(Suppl 1):S1 40-S157 . doi:10.2337/dc23-S009 10. Weinstock RS. Management of blood glucose in adults with type 1 diabetes mellitus. UpToDate. Updated January 2, 2024. Accessed February 13, 2025 . www.uptodate.com 11. Wexler DJ. Overview of general medical care in nonpregnant adults with diabetes mellitus. UpToDate. Updated August 30 , 2024. Accessed February 13, 2025 . uptodate.com Independent med ical review April 2020
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401 06/01/2025 Kentucky Inactive 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. …. 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 5 I. References ………………………….. ………………………….. ………………………….. …………………….. 5 Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPeripheral Nerve Blocks for Treatment of Pain B. BackgroundPeripheral nerve blocks are injections of medication into a specific area of the body where nerves cause pain to a specific organ or body region. Nerve blocks cause the temporary interruption of impulse conduction in peripheral nerves or nerve trunks and may or may not contain a steroid, which can be used to treat pain . Various areas of pain require different types of nerve blocks that can be administered in numerous parts of the body with some of the most common blocks being sympathetic, peripheral, and oc cipital. Sacroiliac and facet joint interventions, epidural steroid injections, and trigger point injections are addressed in other policies.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Ambulatory Surgery Surgery performed in a hospital-based or freestanding ambulatory surgery center (ASC) with patient discharge the same day. Chronic Pain Pain lasting more than 3 months, which is considered beyond normal healing time. Conservative Therapy A multimodality plan including both active and inactive conservative therapies . o Active Conservative Therapies Actions or activit ies that strengthen muscle groups and target key spinal structures, including physical therapy, occupational therapy, a physician-supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription , and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience and/ or noncompliance without explanation does not constitute inability to complete . o Inactive Conservative Therapies Passive activities by the member that aid in treating symptoms with pain , including rest, ice, heat, medical devices, acupuncture , TENS u se , and/or pharmacotherapy (prescription or over the counter [eg, NSAIDS, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator ( TENS ) A device that utilizes electrical current directed through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulat e the release of endorphins . Use, frequency, duration, and start dates must be documented in the medical record . Emergent Medically necessary care which is immediately needed to preserve life , prevent serious impairment to bodily functions, organs, or parts, or prevent placing the physical or mental health of a patient in serious jeopardy. Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Low-Risk Procedu re Procedures associated with minimal physiologic effect and exclude any intrathoracic, intra-abdominal, vascular, or orthopedic procedures. Sub-Acute Pain Pain lasting between 4 and 12 weeks. D. PolicyI. CareSource considers peripheral nerve blocks (PNB) , single injection, medically necessary when appropriate documentation for the treatment of acute pain or chronic pain are included, only as part of an active component of a comprehensive pain management program. CareSource uses MCG Health guidelines to ad dress criteria for specific nerve blocks. Documentation must include indications that ALL the following criteria are met: A. Ambulatory or outpatient procedure that is not emergent, low risk, and requires no inpatient care for a preoperative disease or condition (eg, altered mental status, hypotension, hypoxemia, tachycardia) B. Acute, sub-acute or chronic, neuropathic or radicular pain, as indicated by ONE or more of the following: 1. Cancer-related pain 2. Complex Regional Pain Syndrome (CRPS) 3. Peripheral neuropathy with pain that limits activities of daily living, excluding diabetic neuropathy 4. Peripheral vascular disease with rest pain 5. Acute herpes zoster of face or neck and prevention of postherpetic neuralgia 6. Pancreatic pain, pelvic pain, or abdominal pain related to malignancy 7. Chronic, relapsing pancreatitis C. Symptoms poorly controlled by maximum medical therapy or intolerable side effects to such therapy D. Failure of non-invasive treatment(s) (eg, non-steroidal anti-inflammatory drugs (NSAIDs), exercise, physical therapy, spinal manipulation therapy) E. No coagulopathy or thrombocytopenia F. No infection at or underlying the injection site II. Acute or Sub-Acute PainPNB may provide means of analgesia for acute pain in the following (not an all – inclusive list): A. Patients at risk of respiratory depression related to systemic or neuraxial opioids (eg, obstructive sleep apnea, severe obesity, underlying pulmonary disease, advanced age). B. Patients with another indication to minimize opioid use (eg, chronic opioid use, intolerance to opioids). C. Patients with acute, severe pain poorly managed with systemic medication. D. Patients who cannot tolerate chiropractic or other physical and/or manipulative therapies. Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 III. Chronic PainCareSource considers PNB , single injection, medically necessary when appropriate documentation for the treatment of chronic pain is included, only as part of an active component of a comprehensive pain management program when the following criteria are met: A. Failure of conservative therapy, as evidenced by ALL the following: 1. Documentation in the medical record of at least 6 weeks of active conservative therapy within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance . 2. Documentation in the medical record of at least 6 weeks inactive conservative therapy within the past 6 months . B. Insufficient evidence support s the use of PNB for chronic pain: 1. Genicular nerve or branches for chronic knee pain 2. Cluneal nerve injections or blocks for chronic low back pain or pelvic pain 3. Pudendal blocks for chronic pelvic pain conditions. IV. Peripheral Radiofrequency Ablation (RFA) or NeurotomyRadiofrequency ablation and/or neurotomy are considered experimental and investigational, or unproven for any indication, including but not limited to the treatment of acute or chronic pain due to insufficient evidence of efficacy in the peer reviewed literature. V. Limitations and ExclusionsA. A member can receive a maximum of 6 injections per area and anatomical side in a calendar year . B. Up to 2 anatomic sites (eg, specific nerve, plexus, or branch as defined by CPT code description) may be injected at any one session. C. Nerve blocks used as part of a surgical procedure or other medical procedure are not separately reimbursable but an inclusive component of that procedure. These injections will not be compensated separately or unbundled for coverage. D. Any procedure submitted for payment with an incorrect CPT code or description will be denied. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. If requesting a block to a specific part of the body, coding to the highest level of specificity should be used. E. Exclusion s 1. Treatment of peripheral neuropathy due to diabetes. 2. Use of nerve blocks with or without use of electrostimulation for treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases. Medical management using systemic medications is clinically indicated for the treatment of these conditions. E. State-Specific InformationN/A Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 F. Conditions of CoverageInterventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers within their scope of practice who are qualified to deliver these health services . G. Related Policies/RulesEpidural Steroid Injections Facet Joint Interventions Sacroiliac Joint Procedures Trigger Point Injections H. Review/Revision HistoryDATE ACTIONDate Issued 05/01/2023Date Revised 02/28/2024 07/03/2024 02/26/2025 Annual review-editorial changes ; Approved at Committee Revision – clarified limitations in D.V.A. Approved at Committee. Annual review, references updated. Approved at Committee. Date Effective 06/01/2025 Date Archived I. References1. Ailani J, Burch RC, Robbins MS; American Headache Society. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache . 2021;61(7):1021-1039. doi:10.1111/head.14153 2. Allen SM, Mookadam F, Cha SS, et al. Greater occipital nerve block for acute treatment of migraine headache: a large retrospective cohort study. JAm Board Fam Med . 2018;31(2):211-218. doi:10.3122/jabfm.2018.02.170188 3. American Headache Society. AHS consensus statement: The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache . 2019;59(1):1-18. doi:10.1111/head.13456 4. Antolak S, Antolak C, Lendway L. Measuring the quality of pudendal nerve perineural injections. Pain Physician . 2016;19:299-306. Accessed February 9, 202 5. www.pubmed.ncbi.nlm.nih.gov 5. Caponnetto V, Ornello R, Frattale I, et al. Efficacy and safety of greater occipital nerve block for the treatment of cervicogenic headache: a systematic review. Expert Rev Neurotherapeutics . 2021; 21(5):591-597. doi:10.1080/14737175.2021.1903320 6. Chang A, Dua A, Singh K, White BA. Peripheral nerve blocks. StatPearls . StatPearls Publishing; 2024. Accessed February 9, 2025 . www.ncbi.nlm.nih.gov 7. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated May 15, 2024. Accessed February 9, 2025. www.uptodate.com 8. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1 Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 9. Evidence Analysis Research Brief: Pudendal Nerve Decompression Surgery for Treatment of Pudendal Neuralgia. Hayes; 2022. Accessed February 9, 2025. www.evidence.hayesinc.com10. Evidence Analysis Research Brief: Radiofrequency Ablation of Cluneal Nerve for Treatment of Chronic Low Back Pain. Hayes; 2023. Accessed February 9, 2025. 11. Evolving Evidence Review: Middle Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2022. Reviewed April 4, 2023. Accessed February 9, 2025. www.evidence.hayesinc.com 12. Evolving Evidence Review: Superior Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2021. Reviewed December 18, 2024. Accessed February 9, 2025. www.evidence.hayesinc.com 13. Frank FT, Sawsan A. Chronic pelvic pain in adult females: treatment. UpToDate. Updated August 16, 2024. Accessed February 9, 2025. www.uptodate.com 14. Garza I. Occipital neuralgia. UpToDate. Updated December 17, 2024. Accessed February 9, 2025. www.uptodate.com 15. Garza I, Schwedt TJ. Chronic migraine. UpToDate. Updated October 3, 2024. Accessed February 9, 202 5. www.uptodate.com 16. Gautam S, Gupta N, Khuba S, et al. Evaluation of the efficacy of superior cluneal nerve block in low back pain: a prospective observational study. JBodyw Mov Ther . 2022;30:221-225. doi:10.1016/j.jbmt.2022.03.001 17. Headaches in Over 12s: Diagnosis and Management . National Institute for Excellence; 2012. CG150. Updated December 17, 2021. Accessed February 9, 2025. www.nice.org 18. Health Technology Assessment: Genicular Nerve Block for the Treatment of Knee Osteoarthritis. Hayes; 2023. Reviewed December 19, 2024. Accessed February 9, 2025 . www.evidence.hayesinc.com 19. Health Technology Assessment: Greater Occipital Nerve Blocks for Treatment of Migraine. Hayes; 2019. Reviewed October 10, 2022. Accessed February 9, 202 5. www.evidence.hayesinc.com 20. Health Technology Assessment: Local Injection Therapy for Cervicogenic Headache and Occipital Neuralgia. Hayes; 2017. Reviewed November 15, 2021. Accessed February 9, 2025. www.evidence.hayesinc.com 21. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain. Hayes; 2021. Reviewed April 17, 2024. Accessed February 9, 2025 . www.evidence.hayesinc.com 22. Hui J, Seko K, Shrikhande G, et al. A novel, nonopiod-based treatment approach to men with urologic chronic pelvic pain syndrome using ultrasound-guided nerve hydrodissection and pelvic floor musculature trigger point injections. Neurourol Urodyn . 2020;39(2):658-664. doi:10.1002/nau.24242 23. Inan L, Inan N, Unal-Artik H, et al. Greater occipital nerve block in migraine prophylaxis: narrative review. Cephalalgia . 2019;39:908-920. doi:10.1177/0333102418821669 24. Isu T, Kim K, Morimoto D, Iwamoto N. Superior and middle cluneal nerve entrapment as a cause of low back pain. Neurospine . 2018;15(1):25-32. doi:10.14245/ns.1836024.012 Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 25. Jeng C, Rosenblatt M. Overview of peripheral nerve blocks. UpToDate. UpdatedJanuary 10, 2024. Accessed February 9, 2025. www.uptodate.com 26. Matsumoto J, Isu T, Kim K, et al. Middle cluneal nerve entrapment mimics sacroiliac joint pain. Acta Neurochir (Wien) . 2019;161(4):657-661. doi:10.1007/s00701-019 – 03861-0 27. Mustafa A, Brooks B, Leishear K, et al. A novel treatment approach for women with chronic pelvic pain syndrome leading to increased pelvic functionality. JWomens Health Gyn . 2020;7:1-10. doi:10.17303/jwhg.2020.7.402 28. Nielsen TD, Moriggl B, Barckman J, et al. Randomized trial of ultrasound-guided superior cluneal nerve block. Reg Anesth Pain Med . 2019;44:772-780. doi:10.1136/rapm-2018-100174 29. Ornello R, Lambru G, Caponnetto V, et al. Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic review and meta – analysis. Expert Rev Neurotherapeutics . 2020;20(11):1157-1167. doi:10.1080/14737175.2020.1809379 30. Pilitsis JG, Khazen O. Occipital neuralgia. American Academy of Neurological Surgeons (AANS). Accessed February 9, 2025. www.aans.org 31. Plavnik K, Tenaglia A, Hill C, et al. A novel, non-opioid treatment for chronic pelvic pain in women with previously treated endometriosis utilizing pelvic-floor musculature trigger-point injections and peripheral nerve hydrodissection. PM R . 2020;12(7):655 – 662. doi:10.1002/pmrj.12258 32. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on chronic pain management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology . 2010;112(4):810-833. doi:10.1097/ALN.0b013e3181c43103 33. Shauly O, Gould DJ, Sahai-Srivastava S, et al. Greater occipital nerve block for the treatment of chronic migraine headaches: a systematic review and meta-analysis. Plast Reconstr Surg . 2019;144(4):943-952. doi:10.1097/PRS.0000006059 34. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: evaluation. UpToDate. Updated August 16, 2024. Accessed February 9, 2025. www.uptodate.com 35. Watson JC. Cervicogenic headache. UpToDate. Updated March 12, 2024. Accessed February 9, 2025. www.uptodate.com 36. Wray JK, Dixon B, Przkora R. Radiofrequency ablation. StatPearls . StatPearls Publishing; 2025. Accessed February 9, 2025. www.ncbi.nlm.nih.gov
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Sacroiliac Joint Procedures-MP-MM-1314 05/01/2025 Kentucky inactive as of 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectSacroiliac Joint Procedures B. BackgroundNearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent. Persistent pain is categorized as subacute when lasting between four and twelve weeks, and chronic when persisting for at least three months. Up to 10% to 25% of patients with persistent low back pain may have a component of pain related to sacroiliac joints (SIJ) . Comprehensive pain management care plans aremost effective in managing a patients chronic pain. These plans focus on a person-centered approach and incorporate conservative treatment with other modalities. These multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a pa tients daily life, even if the pain cannot be relieved com pletely. In addition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic treatments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be effective for diagnostic purposes but provide limited short-term relief from pain resulting from SI Jdysfunction. Long-term use has not be en adequately studied to establish standards of care. Radiofrequency ablation (RFA) is another treatment method, which uses heat to destroy nerves. RFA for the treatment of low back pain has inconsistent results in the peer-reviewed medical literature with l imited fol low – up. However, clinical experience suggests that some patients obtain more significant relief from these procedures, making it reasonable to offer SIJ injections and/or RFA when conservative management has failed. C. Definitions Conservative Therapy A multimodal plan of care including both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational therapy, physician supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Inactive Conservative Therapies Passive activit ies by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS use , and/or pharmacotherapy (prescription or over the counter [non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphin s. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. Sacroiliac Joint (SIJ) Injections Corticosteroid and local anesthetic therapeutic injections into the SIJ to treat pain that has not responded to conservative therapies. D. PolicyI. Sacroiliac Joint Injections A. Diagnostic injection s: CareSource considers up to 2 diagnostic sacroiliac joint injections for the treatment of chronic low back pain medically necessary when ALL the following criteria are met: 1. somatic or nonradicular low back and/or lower extremity pain experienced for at least 3 months 2. pain and tenderness located in the sacroiliac joint region 3. positive response to at least one SIJ pain provocation test (eg, distraction, compression, thigh thrust, Gaenslens, Patricks test/FABER test, sacral thrust) 4. failure of conservative therapy, as evidenced by ALL the following: a. documentation in the medical record of at least 6 weeks of active conservative therapy ( as defined above ) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increase d pain, or intolerance b. documentation in the medical record of at least 6 weeks of inactive conservative therapy (as defined above ) within the past 6 months 5. if a second diagnostic injection is requested, at least 1 week has passed since the initial injection B. Therapeutic injections: CareSource considers therapeutic sacroiliac joint injections medically necessary when ALL the following criteria are met: 1. most recent SIJ injection led to at least 75 % pain relief and functional improvement 2. member experiences return of pain or deterioration in function 3. injection is used in conjunction with conservative therapy (as defined above) 4. injection is repeated at a frequency no greater than every 2 months Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 5. no more than 4 injections total (diagnostic and therapeutic) have been administered at the same site in the last 12 monthsC. Exclusions/Limitations: 1. Codes 64451 and 27096 may not be billed together (on the same date for the same side of the body). Only one code will be reimbursed . 2. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately. 3. If neural blockade is applied for different regions or different sides, injections are performed at least one week apart. 4. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated injections of the SIJ to be effective as a long-term management modality. Long-term continuation may be subject to medical necessity review. 5. Monitored anesthesia and conscious sedation are not medically necessary. 6. The use of SI Jinjections for the treatment of pain as a result of Herpes Zoster is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. II. Radiofrequency Ablation of the S IJA. Initial radiofrequency ablation of the SIJ Radiofrequency ablation is considered medically necessary when ALL the following have been met in the last 6 months: 1. The clinical criteria above for failed conservative therapy (I.A. 4.a. and I.A.4. b.) has been met . 2. One diagnostic injection per joint to evaluate pain and attain therapeutic effect has been performed, with a reported 75% or greater reduction in pain after injection. B. Repeat radiofrequency ablation of the SIJ 1. Conservative therapy and diagnostic injections are not required if there has been a reduction in pain for at least 12 months or more from the initial RFA within the last 36 months. 2. When there has not been a repeat RFA in the last 36 months, a diagnostic injection is required. 3. A maximum of 1 radiofrequency ablation for SI Jpain per side per 12 months is considered medically necessary. C. Exclusions/Limitations 1. The use of cooled RFA for SI J-mediated low back pain is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. 2. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated the effectiveness of RFA as a long-term management modality. Long-term continuation may be subject to medical necessity review. Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 III. Implantable Spinal Cord StimulatorsMember s with indwelling implanted spinal cord stimulators or pain pumps should have a device interrogation report submitted with medical records for a prior authorization request for proposed interventional pain injections. If a device is not functioning properl y, an escalation in pain may warrant evaluation and management of the implanted device. E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 04/13/2022 New policyDate Revised 03/01/2023 01/31/202401/29/2025Annual review: restructured conservative management and clinical criteria , added provocation tests Annual review: updated references and formatting , moved state-specific information to section E, approved at Committee. Review: updated references, approved at Committee. Date Effective 05/01/2025 Date Archived I. References1. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):493-505. doi:10.7326/M16-2459 2. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated May 15, 2024 . Accessed January 5 , 2025 . www.uptodate.com 3. Cine HS, Uysal E, Demirkol M, Cetin E. Under what conditions is the intra-articular steroid injection superior to nonsteroidal anti-inflammatory drugs for treating sacroiliac joint pain? Eur Rev Med Pharmacol Sci . 2023;27(21):10539-10546. doi:10.26355/eurrev_202311_34331 4. Jamjoom AM, Saeedi RJ, Jamjoom AB. Placebo effect of sham spine procedures in chronic low back pain: a systematic review. JPain Res. 2021;14:3057-3065. doi:10.2147/JPR.S317697 5. Janapala RN, Knezevic E, Knezevic NN, et al. Systematic review and meta-analysis of effectiveness of therapeutic sacroilic joint injections. Pain Physician . 2023;26:E413-E435. Accessed January 5, 2025 . www.painphysicianjournal.com 6. Lee DW, Pritzlaff S, Jung MJ , et al. Latest evidence-based application for Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 radiofreqneucy neurotomy (LEARN): best practice guidelines from the American Society of Pain and Neuroscience (ASPN). JPain Res . 2021;14:2807-2831. doi:10.2147/JPR.S235665 7. Maas ET, Ostelo RWJG, Niemisto L, et al. Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev. 2015;2015(10):CD008572. doi:10.1002/14651858.CD008572.pub2 8. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint inerventions 2020 guidelines. Pain Phys ician . 2020;23(3S):S1-S127. Accessed January 5 , 2025 . www.painphysicianjournal.com 9. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 10. Szadek K, Cohen SP, de Andres Ares, J, et al. Sacroiliac joint pain. Pain Pract. 2023 ;00:1-20 . doi:10.1111/papr.13338 11. Wu L, Tafti D, Varacallo M. Sacroiliac joint injection. StatPearls . StatPearls Publishing; 2023. Updated August 4, 2023. Accessed January 5, 2025 . www.ncbi.nlm.nih.gov Independent Medical Review January 2025
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Trigger Point Injections-MP-MM-1317 05/01/2025 Kentucky inactive as of 01/01/2026 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 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………… 2 B. Background ………………………….. ………………………….. ………………………….. ……………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ……………………….. 2 E. State-Specific Information ………………………….. ………………………….. …………………………. 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. .. 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. . 4 I. References ………………………….. ………………………….. ………………………….. ………………… 5 Trigger Point Injections-MP-MM-1317Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectTrigger Point Injections B. BackgroundMyofascial trigger points are self-sustaining hyper-irritative foci in any skeletal muscle, often occurring in response to strain produce d by acute or chronic overload. There is no associated neurologic deficit, and the pain may be aggravated by hyperextension of the spine, standing , and walking. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS) which is responsive to appropriate treatme nt. To successfully treat ch ronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor. The purpose of a trigger point injection (TPI) is to treat not only the symptom but also the cause through the injection of a single substance (eg, a local anesthetic) or a mixture of substances (eg, a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Interventional procedures for management of pain should be part of a comprehensive pain management care plan that incorporates an initial trial of conservative treatment utilizing appropriate medications, physical therapy modalities and behavioral support , asneeded.Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers acting within their scope ofpractice who are qualified to deliver these health services.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Physician Supervised Home Exercise Program (HEP) A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to ph ysically perform exercises). Member inconvenience or noncompliance without explanation does not constitute an inability to complete. Subacute Pain Pain that has lasted between 4 weeks and 12 weeks. Trigger P oint A hyper excitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. D. PolicyI. Trigger Point Injections Initial Injections A. Trigger point injections of anesthetic and/or corticosteroid for back pain, neck pain, or myofascial pain syndrome are considered medically necessary when pain has persisted despite appropriate medical management and ALL the following criteria are met : Trigger Point Injections-MP-MM-1317Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 1. Member presents with new (acute or subacute) localized pain, occurring in the last 3 months . 2. Member has been refractory or intolerant of conservative therapies for at least 1 month, including at least 1 of the following : a. bed rest b. active exercise c. ultrasound d. range of motio n e. heating or cooling treatments f. massage 3. TPIs are being given as a part of an overall conservative manage ment (usually short term) plan, including at least 1 of the following: a. physical therapy b. occupational therapy c. physician supervised home exercise program (HEP) d. manipulative therapy 4. Pharmacotherapies are being administered, including at least 1 of the following : a. non-steroidal anti-inf lammatory drugs ( NSAIDS ) b. muscle relaxants c. non-narcotic analgesics d. anti-depressants 5. The member must have a diagnosis for which the trigger point injection is an appropriate treatment; ALL the following information must be documented in the medical record: a. proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point b. reason (s) for select ing this therapeutic option c. affected muscle or muscles d. muscle or muscles injecte d and the number of injections e. frequency of injections required f. name of the m edication used in the injection g. results of any prior treatment h. corroborating evidence that the injection is medically necessary B. Localization techniques to image or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. II. Trigger Point Injections Subsequent InjectionsA. Trigger point injections should be repeated only if doing so is reasonable and medically necessary. No more than 8 dates of service per calendar year per member may be reimbursed . B. Injections may be repeated only with documented positive results to the most recent trigger point injection of the same anatomic si te. Documentation should include at least 50% improvement in pain, functioning , and activity tolerance. Trigger Point Injections-MP-MM-1317Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 III. There is no laboratory or imaging test for establishing the diagnosis of trigger points .Diagnosis is dependent upon a detailed history and a thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis: A. history of onset and its cause (injury, sprain, etc.) B. distribution of pain C. restriction of movement D. mild muscle specific weakness E. focal tenderness of a trigger point F. palpable taut band of muscle in which trigger point is located G. local taut respo nse to snapping palpitation H. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point IV. Payment InformationA. Certain trigger point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. B. Payment may be made for 1 unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a pa rticular date. C. A trigger point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (eg, in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. D. Dry needling is not an acceptable alternative to trigger point injections by an appropriately licensed clinician. E. State-Specific InformationN/A F. Conditions of CoverageN/A G. Related Policies/RulesN/A H. Review/Revision HistoryDATE ACTIONDate Issued 04/27/2022 New policy , replacing individual state policiesDate Revised 03/29/2023 02/28 /2024Annual review: updated references, added definition and payment information. Approved at Committee Annual review: moved state-specific information to section E, updated references, approved at Committee. Trigger Point Injections-MP-MM-1317Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 02/12/2025 Review: updated references, approved at Committee.Date Effective 05/01/2025 Date Archived I. References1. Appasamy M, Lam C, Alm J, Chadwick AL. Trigger point injections. Phys Med Rehabil Clin NAm . 2022;33(2):307-333. doi:10.1016/j.pmr.2022.01.011 2. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated May 15, 2024. Accessed January 15, 2025. www.uptodate.com 3. Gerwin R. Myofascial trigger point pain syndromes. Semin Neurol . 2016;36(5):469 – 473. doi:10.1055/s-0036-1586262 4. Hammi C, Schroader JD, Yeung B. Trigger point injection. StatPearls . StatPearls Publishing; 2024. Updated July 24, 2023. Accessed January 15, 2025. www.ncbi.nlm.nih.gov 5. Hamzoian H, Zograbyan V. Trigger point injections versus medical management for acute myofascial pain: a systematic review and meta-analysis. Cureus. 2023;15(8):e43424. doi:10.7759/cureus.43424 6. Isaac Z. Management of non-radicular neck pain in adults. UpToDate . Updated November 14, 2024. Accessed January 15, 2025 . www.uptodate.com 7. Khoury AL, Keane H, Varghese F, et al. Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief. NPJ Breast Cancer . 2021;7:123. doi:10.1038/s41523-021-00321-w 8. Meyer GW. Anterior cutaneous nerve entrapment syndrome. UpToDate . Updated December 31, 2024. Accessed January 15, 2025 . www.uptodate.com 9. Moynihan LK, Elkadry E. Myofascial pelvic pain syndrome in females: treatment. UpToDate . Updated January 11, 2023 . Accessed January 15, 2025. www.uptodate.com 10. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate . Updated August 16, 2024. Accessed January 15, 2025. www.uptodate .com Independent Medical Review January 2025
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Saphenous Vein Ablation, Adhesive Injection-MP-MM-1395 05/01/2025 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 standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without 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 Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. State-Specific Information ……………………………………………………………………………………… 4 F. Conditions of Coverage ………………………………………………………………………………………… 4 G. Related Policies/Rules ………………………………………………………………………………………….. 4 H. Review/Revision History ……………………………………………………………………………………….. 4 I. References …………………………………………………………………………………………………………. 4 Saphenous Vein Ablation, Adhesive Injection-MP-MM-1395 Effective Date: 05/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d. 2A. SubjectSaphenous Vein Ablation, Adhesive Injection B. Background Varicose veins (varicosities) are dilated, thickened, elongated, and twisted blood vessels that may appear threadlike or as large grape-like clusters under the skin, most often on the legs. Varicose veins are considered a sign of chronic venous insufficiency, a condition characterized by dysfunction of the valves in veins leading to increased blood pressure, blood pooling, and venous reflux in affected areas. Varicose veins may be asymptomatic, or the associated venous insufficiency may cause symptoms such as heaviness, aching, numbness, swelling, and ulceration of the affected limb. In addition, risk is increased for thrombophlebitis, deep vein thrombosis (DVT), and pulmonary embolism. Approximately 25 million adults in the United States are affected by varicose veins. This condition can have a significant impact on patients quality of life (QoL) and increase the health care burden, with an estimated $1 billion incurred annually for treatment in the United States. Conservative therapy includes weight reduction, exercise and prescribed physical activity (walking, treadmill, cycling), periodic leg elevation and compressive therapy with use of surgical grade compression stockings. Non-surgi cal treatment for this condition includes radiofrequency ablation (RFA) and endovenous laser ablation (EVLA). A third, more recent treatment method is Cyanoacrylate adhesive closure (CAC), a catheter-directed procedure that seals the saphenous vein without the use of tumescent anesthesia. It involves the endovenous delivery of cyanoacrylate adhesive to the vein, i nducing a foreign body response resulting in fibrosis and closure. Closure rates for CAC are high without use of post procedure compression, which is unique to this nonthermal method of ablation. C. Definitions Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification The CEAP classification for chronic venous disorders serves as a basis to categorize the clinical presentation of the patient, the underlying etiology, what anatomic veins are affected, and the underlying pathology in those veins. The 7 clinical categories are: o C0 No visible or palpable signs of venous disease o C1 Telangiectasies or reticular veins o C2 Varicose veins; distinguished from reticular veins by a diameter of 3mm or more o C3 Edema o C4 Changes in skin and subcutaneous tissue secondary to CVD C4a Pigmentation or eczema C4b Lipodermatosclerosis or atrophie blanche o C5 Healed venous ulcer o C6 Active venous ulcer Saphenous Vein Ablation, Adhesive Injection-MP-MM-1395 Effective Date: 05/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d. 3 Cyanoacrylate adhesive closure (CAC) A nonthermal ablation technique uses a glue delivered into the saphenous vein using a catheter for access that induces a foreign body reaction leading to inflammation and fibrotic occlusion of the vessel. Saphenous veins Either of two main superficial veins of the leg, one larger than the other. These are : o Great saphenous vein (GSV) Originating in the foot and passing up the medial side of the leg and through the saphenous opening to join the femoral vein . o Small saphenous vein (SSV) Originating similarly and passing up the back of the leg to join the popliteal vein at the knee.D. Policy I. CareSource considers Saphenous Vein Ablation with cyanoacrylate adhesive medically necessary when ALL of the following are met: A. Failure of 3 months of conservative treatment, which may include: 1. weight reduction 2. exercise plan and prescribed physical activity (walking, treadmill, cycling) 3. periodic leg elevation 4. compression therapy B. If contraindicated (suspected or proven peripheral arterial disease, venous leg ulceration, superficial thrombophlebitis or severe peripheral neuropathy, etc.) conservative treatment may be waived. C. Documentation in the medical record of CEAP class C2-C6 disease. D. Reflux (> 500 msec), and/or vein diameter 3 mm , and ANY of the following: 1. ulceration secondary to venous stasis 2. significant pain or significant edema associated with saphenous reflux that interferes with activities of daily living (ADLs) 3. hemorrhage or recurrent bleeding associated with ruptured superficial varicosity 4. recurrent episodes of superficial phlebitis 5. refractory dependent edema II. Non-C overed/ Contraindications A. CEAP clinical classification C0-C1 is cosmetic and not medically necessary . B. previous administration of sclerotherapy agent
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Neonatal Discharge Criteria-MP-MM-1411 05/01/202 5 Kentucky inactive as of 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Neonatal Discharge Criteria-MP-MM-1411Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNeonatal Discharge Criteria B. BackgroundInfants who require neonatal admission remain at increased risk for morbidity and mortality following discharge. These infants require comprehensive discharge planning to ensure a smooth transition from the neonatal intensive care unit (NICU) and reduce mo rbidity and mortality after discharge. Despite the inability to predict the exact timing of a NICU discharge, discharge planning should begin at NICU admission in an effort to avoid overwhelming parents and hospital staff. This planning will aid in minimizing discharge delays and will promote s afe andhealthy discharges to home.Discharge may be appropriate when the establishment of physiologic competencies, including, but not limited to, thermoregulation, feeding, respiratory control, and stability regardless of weight or corrected gestational age, have been achieved.C. Definitions Acceptable Bilirubin Level Defined per American Academy of Pediatrics (AAP) guidelines. Bilirubin Blood test to measure liver function. Car Seat Test Eligibility An infant tolerance test for sitting usually occurring 36.4 Caxillary while clothed in an open bed/crib. D. PolicyI. CareSource considers neonatal discharge medically appropriate for non-technology dependent infants when ALL of the following clinical criteria are met: A. Thermoregulation Stability 1. Infant demonstrates the ability to maintain normal body temperature while clothed in an open crib. Up to 48 hours of stable body temperature is typically adequate for infants born
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Intraosseous Basivertebral Nerve Ablation – MP-MM-1376 05/01/2025 Kentucky inactive as of 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectIntraosseous Basivertebral Nerve Ablation B. BackgroundInterventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self – manag ement and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualifie d to deliver these health services. Chronic low back pain (CLBP) is a common disabling condition, estimated to afflict 80% of adults at some point. Degenerative disc disease (DDD) is an important cause of CLBP. While discs are avascular with limited nerve distribution, vertebral endplates ha vethe potential to trigger a cascade of degenerative events if there is a loss of integrity. Vertebral endplates are a thin interface between bone marrow and discs and contain neural elements. Breakdown of the endplate is believed to cause vertebrogenic c hronic low back pain, a type of chronic low back pain. Endplate degeneration can be observed on MRI through Modic changes (MC). Histologically, in MC type I (MC I) lesions, the endplate is disrupted as fibrous tissue replaces bone marrow, causing the disc-bone interface to be filled with vascularizedgranulation tissue. MC I represents bone marrow edema and inflammation. In MC type II(MC II) lesions, there is demonstration of fatty marrow replacement in addition to MC type I findings. MC II represents conversion of hematopoietic marrow into fatty, yellow bone marrow. MC type III (MC III) lesions are related to subchondral bone scle rosis. Analysis of Modic lesions shows that MC I is characterized by high bone turnover, MC II is characterized by decreased bone turnover, and MC III are stable. Radiofrequency ablation is a minimally invasive, percutaneous treatment which uses heat to ablate the nerve pathway that conducts the pain signal. The goal of RFA is to interrupt the pain pathway without causing excessive sensory loss, motor dysfunction, o r other complications. Intracept is an RFA system designed to ablate the basivertebral nerve of the vertebral endplate. C. Definitions Chronic Low Back Pain Persistent pain in the lumbar region lasting for more than 12 weeks. Conservative Therapy A multimodality plan of care including both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen muscle groups and target key spinal structures, including physical therapy, occupational therapy, physician supervised home exercise program (HEP), and/or chiropractic care. Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS use, and/or pharmacotherapy (prescription or over the counter [eg, non-steroidal anti-inflammatory drugs, acetaminophen]). Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphin s. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization reques t. Modic Changes Vertebral bone marrow signal intensity changes that are observable on MRI and are commonly associated with degenerative disc disease. o Modic Change Type I Characterized by hypo-and hyper-intense signal intensities on T1-and T2-weighted spin-echo (T1W1 and T2W1), respectively. o Modic Change Type II Characterized by hyper-intense signal intensities on both T1W1 and T2W1. o Modic Change Type III Characterized by hypo-intense signal intensities on both T1W1 and T2W1. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial or lateral branches of the dorsal spinal nerves. D. PolicyI. CareSource considers intraosseous basivertebral nerve ablation medically necessary when ALL the following clinical criteria are met: A. member has a diagnosis and documentation of chronic low back pain of at least 6 months duration B. failure of conservative therapy, as evidenced by ALL the following: 1. documentation in the medical record of at least 6 weeks of active conservative therapy (see definition above) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance 2. documentation in the medical record of at least 6 weeks of inactive conservative therapy (see definition above) within the past 6 months C. MRI has been performed and demonstrates Type I or Ty pe II modic changes at one or more vertebral endplates from level L3 to S1, as demonstrated by: 1. hypointense T1-weighted signal and hyperintense T2-weighted signal (ie, bone marrow edema and inflammation) , or Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 2. hyperintense T1-weighted signal and hyperintense T2-weighted signal (ie,bone marrow ischemia) D. device is FDA-approved (eg, Intracept System) E. member does not have any of the following contraindications: 1. severe cardiac or pulmonary compromise 2. member has a targeted ablation zone less than 10mm from a sensitive structure not intended to be ablated (including vertebral foramen) 3. active systemic infection or localized infection in the area to be treated 4. current pregnan cy 5. skeletal immaturity 6. implantable pulse generator (eg, pacemaker, defibrillator) or other electronic implant 7. scoliosis 8. spinal instability II. Repeat or additional intraosseous basivertebral nerve ablation is not considered medically necessary, as it has not been adequately studied in the peer-reviewed medical literature. III. Monitored anesthesia and conscious sedation during intraosseous basivertebral nerve ablation are considered not medically necessary and will therefore not be reimbursed.IV. Coverage is limited to the above criteria. Intraosseous basivertebral nerve ablation is considered not medically necessary for all other indications.E. State-Specific Information NA F. Conditions of Coverage NA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 01/04/2023 New policyDate Revised 06/07/2023 01/31/202401/29 /2025Annual review: reorganized conservative therapy, updated references. Approved at Committee. Annual review: updated references and formatting. Approved at Committee. Review: updated references, approved at Committee. Date Effective 05/01/2025 Date Archived Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 I. References1. Becker S, Hadjipavlou A, Heggeness MH. Ablation of the basivertebral nerve for treatment of back pain: a clinical study. Spine J . 2017;17(2):218-223. doi :10.1016/j.spinee.2016.08.032 2. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Low Back Pain . North American Spine Society ; 2020. Accessed January 2, 2025. www.spine.org 3. Evolving Evidence Review: Intracept Intraosseous Nerve Ablation System (Relievant Medsystems Inc.) for Treatment of Adults with Low Back Pain. Hayes ; 2023. Reviewed April 17, 2024. Accessed January 2, 2025. www.evidence.hayesinc.com 4. Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 2-year results from a prospective randomized double-blind sham-controlled multicenter study. Int JSpine Surg . 2019;13(2):110-119. doi :10.14444/6015 5. Lorio M, Clerk-Lamalice O, Beall DP, Julien T. ISASS guideline : intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain. Int JSpine Surg . 2020;14(1):18-25. doi:10.14444/7002 6. Lorio M, Clerk-Lamalice O, Rivera M, Lewandrowski K. ISASS policy statement 2022: literature review of intraosseous basivertebral nerve ablation. Int JSpine Surg. 2022;16(6):1084-1094. doi:10.14444/8362 7. McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain-related healthcare utilization following intrasosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. Pain Med . 2024;25:20-32. doi:10.1093/pm/pnad114 8. Nwosu M, Agyeman WY, Bisht A, et al. The effectiveness of intraosseous basivertebral nerve ablation in the treatment of nonradiating vertebrogenic pain: a systematic review. Cureus . 2023;15(4):e37114. doi:7759/cureus.37114 9. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 10. Sayed D, Naidu RK, Patel KV, et al. Best practice guidelines on the diagnosis and treatment of vertebrogenic pain and basivertebral nerve ablation from the American Society of Pain and Neuroscience. JPain Res . 2022;15:2801-2819. doi:10.2147/JPR.S378544 11. Smuck M, Khalil J, Barrette K, et al. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month result. Reg Anesth Pain Med. 2021;46:683-693. doi:10.1136/rapm-2020 – 102259 12. Smuck M, McCormick ZL, Gilligan C, et al. A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J . 2024;S1529-9430(24)01040-4. doi:10.1016/j.spinee.2024.09.016 13. U.S. Food and Drug Administration. 510(k) Premarket Notification: Intracept Intraosseous Nerve Ablation System , 510( k) approval K 222281; 2022. Accessed January 2, 2025. www.accessdata.fda.gov Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 14. U.S. Food and Drug Administration. 510(k) Premarket Notification: RelievantMedsystems RF Generator , 510( k) number: K171143; 201 7. Accessed January 2, 2025. www.accessdata.fda.gov 15. Viswanathan VK, Shetty AP, Rajasekaran S. Modic changes : an evidence-based, narrative review on its pathophysiology, clinical significance and role in chronic low back pain. JClin Orthop Trauma . 2020;11(5):761-769. doi:10.1016/j.jcot.2020.06.025 Independent med ical review 2022
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Special Needs Car Seats-MP-MM-1439 05/01/2025 Kentucky inactive as of 01/01/2026 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 standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without 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 Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. State-Specific Information ……………………………………………………………………………………… 4 F. Conditions of Coverage ………………………………………………………………………………………… 4 G. Related Policies/Rules ………………………………………………………………………………………….. 4 H. Review/Revision History ……………………………………………………………………………………….. 4 I. References …………………………………………………………………………………………………………. 4Special Needs Car Seats-MP-MM-1439 Effective Date: 05/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d. 2A. SubjectSpecial Needs Car Seats B. Background The American Academy of Pediatrics (AAP) states that all children should have access to proper resources for safe transportation, including children with specific functional needs. Safe transportation includes not only the proper restraints, but also the c orrect positioning to secure the child in the vehicle. The AAP notes that a standard car seat provides the best protection for most travel needs. However, additional research is needed for the biomechanics of test dummies representative of children with ce rtain functional needs in crash testing so that such test dummies can be utilized by the National Highway Traffic Safety Administration (NHTSF). Currently, the Federal Motor Vehicle Safety Standard (FMVSS) Number 213 regulates the design and performance of child restraint systems for children weighing up to 80 pounds. However, children greater than 80 pounds may require car seat restraint , and several manufacturers have tested car seats beyond an 80-pound maximum. Once a child has outgrown a standard 5-point harness car seat, options include car seats specially designed for full support of a childs head, neck, and back supporting up to 115 pounds. Conventional travel vests or specialized medical seating can be used for children who require additional trunk support but have stable neck control. Some older children with certain functional needs, including poor trunk control, can be transported in a special needs belt-positioning booster seat or a conventional belt-positioning booster with trunk support. Data has shown that rear-facing car seats offer greater protection for the head and neck than a front-facing car seat, by reducing neck loading in vehicular crashes with a frontal component. Therefore, the AAP encourages use of a rear facing car seat for as long as possible for all children, but especially for children diagnosed with a neurological condition(s), as a forward-facing car seat increases the risk of injury in a crash. Recommendations by the AAP specify that car seats should be placed in the rear seat of the vehicle. However, it is noted that a child with certain functional needs requiring frequent monitoring may need to be placed in the front seat when no adult is avail able to sit in the rear seat with the child. If the child is placed in the front seat, the automatic air bag should be disabled. C. Definitions Booster Seat A seat used for a child during transportation that lifts the child by several inches, designed for use with an adult seat belt. Car Safety Seat (CSS) A portable seat for a person weighing under 80 pounds that attaches to an automobile seat and holds the person safely. Federal Motor Vehicle Safety Standard 213 (FMVSS No. 213) Requires child restraint systems (CRSs) to be equipped with attachments that enable the CRS to attach to the vehicle's child restraint anchorage system. The agency added a height Special Needs Car Seats-MP-MM-1439 Effective Date: 05/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d. 3provision to make the new standard's applicability clear to booster seat manufacturers who choose not to label their restraints with a weight. National Highway Traffic Safety Administration (NHTSA) A division of the U.S. Department of Transportation dedicated to achieving the highest standards of excellence in motor vehicle and highway safety. Neck Loading The dynamic loading of the neck that occurs when the torso is suddenly stopped by the seat belt while the head continues pulling from the neck. Travel Vest Optimizes the existing vehicle seat belt system to protect the child by keeping a low center of gravity and allowing the vehicle seat belt and seat cushion to manage the crash forces.D. Policy I. CareSource considers a special needs car seat medically necessary when ALL the following clinical criteria are met: A. The car seat is a child restraint system that meets National Highway Traffic Safety Administration Federal Motor Vehicle Safety Standard (FMVSS No. 213). B. The car restraint system is not modified or used in a manner other than that specified by the manufacturer unless the modified restraint system has been crash tested and has met all applicable FMVSSs approved by the NHTSA. C. The special needs car seat is the most cost-effective option while still addressing the medical/functional needs of the member. D. The safety and effectiveness of the special needs car seat has been substantiated by current evidence-based national, state, and peer-reviewed medical guidelines. E. The length or weight limits of a conventional CRS with an internal 5-point harness has been outgrown and at least one of the following criteria is met. 1. The member has respiratory issues or conditions that require enhanced positioning for safety, including any of the following (not an all-inclusive list): a. hypotonia b. craniofacial abnormalities c. primary airway problems d. cerebral palsy 2. The member has a physical condition (eg, seizure or hypertonicity/spasms) that prevents the independent maintenance of a seated position or requires support to allow a functional position or prevent further disability. 3. The member has gastrointestinal issues, including but not limited to: a. emesis b. gastroesophageal reflux (GERD) c. gastrostomy feeding tube 4. The member uses a spica cast. II. Persons with a tracheostomy tube should not use a CRS with a harness or seat belts that could dislodge the tube. It is strongly recommended that an occupational therapist or passenger safety technician with training and experience in the safe Special Needs Car Seats-MP-MM-1439 Effective Date: 05/01/2025 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d. 4transportation of persons with special needs provide guidance for appropriate equipment selection and use. III. A special needs car seat will not be considered medical necessary for any of the following: A. The special needs car seat is a more recent advancement in technology when the members current special needs car seat can meet the members basic medical/functional needs. B. The special needs car seat is considered investigational, experimental, or has unproven medical indications for use.E. State-Specific Information N/A F. Conditions of Coverage N/A G. Related Policies/Rules N/A H. Review/Revision History DATE ACTIONDate Issued 03/01/2023 New policyDate Revised 02/28/2024 2/12/2025Annual review: updated car seat definition, added D.I.C-D.,D.I.E.2, and D.II-III., updated references. Approved at Committee. Annual review: updated criteria in D.I.E. and references. Approved at Committee. Date Effective 05/01/2025 Date Archived I. References1. Adams AJ, Johnson MA, Ryan KA, et al. Safe transportation in-spica following surgical treatment of infantile DDH: solutions and threats. JPediatr Orop. 2019;39(7):e488-e493. doi:10.1097/BPO.0000000000001317 2. Angsupaisal M, Maathuis CGB, Hadders-Algra M. Adaptive seating systems in children with severe palsy across International Classification of Functioning, Disability and Health for Children and Young version domains: a systematic review. Dev Med Child Neurol. 2015;57(10):919-930. doi:10.1111/dmcn.12762 3. Car seats and booster seats. National Highway Traffic Safety Administration. Accessed January 28, 2025. www.nhtsa.gov 4. Car seat safety. National Child Passenger Safety Board. Accessed January 28, 2025. www.cpsboard.org 5. Huang PP, Durbin DR. Promoting safety in children with disabilities. UpToDate. Updated January 4, 2024. Accessed January 28, 2025. www.uptodate.com Special Needs Car Seats-MP-MM-1439 Effective Date: 05/01/2025 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d. 56. Inthachom R, Prasertsukdee S, Ryan SE, et al. Evaluation of the multidimensional effects of adaptive seating interventions for young children with non-ambulatory cerebral palsy. Disabil Rehabil Assist Technol . 2021;16(7):780-788. doi:10.1080/17483107.2020.1731613 7. Legare JM, Adam MP, Feldman J, et al. Achondroplasia. GeneReviews; 2023. Revised May 11, 2023. Accessed January 28, 2025. www.ncbi.nlm.nih.gov 8. ONeil J, Hoffman B, American Academy of Pediatrics Council on Injury, Violence, and Poison. Transporting Children with Special Health Needs. Pediatrics .2019;143(5):e20190724. doi:10.1542/peds.2019-0724 9. Rig by P, Ryan S, Campbell K. Effect of adaptive seating devices on the activity performance of children with cerebral palsy. Arch Phy Med Rehabil . 2009;90(8):1389-1395. doi:10.1016/j.apmr.2009.02.013 10. R yan SE. Lessons learned from studying the functional impact of adaptive seating interventions for children with cerebral palsy. Dev Med Child Neurol. 2016;58(4):78 – 82. doi:10.1111/dmcn.13046 11. Smith VC, Stewart J. Discharge planning for high-risk newborns. UpToDate. Updated April 10, 2023. Accessed January 28, 2025 . www.uptodate.com 12. Vives-Torres CM, Valdamo M, Jimenez-Octavio JR, et al. Comparison of upper neck loading in young adult and elderly volunteers during low speed frontal impacts . Frontiers Bioeng Biotechnol. 2021;9:682974. doi:10.3389/fbioe.2021.682974 I nde pendent med ica l rev iew 02/15/2023
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Durable Medical Equipment Repairs-MP-MM-1582 04/01/202 5 Kentucky inactive as of 01/01/2026 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.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia 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 Durable Medical Equipment Repairs-MP-MM-1582Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectDurable Medical Equipment Repairs B. BackgroundDurable medical equipment (DME) is equipment that serves a medical purpose, helps complete activities of daily living (ADLS), can withstand repeated use and is primarily used in the home . DME includes items, such as wheelchairs, hospital beds, continuous positive airway pressure (CPAP), walkers, oxygen tanks, etc. DME is dispensed when medical necessity is established to meet the needs of the member s medical condition. DME is likely to last 3 years or more but may require maintenance, service, or repairperiodically. When service is required, the DME provider may request authorization to perform the required maintenance, service, or repair to restore the DME item to working order. C. Definitions Durable Medical Equipment (DME) Equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, is not useful to a person in the absence of illness or injury, is appropriate for use in the home . Healthcare Common Procedure Coding System (HCPCS) A numeric and alphanumeric code set maintained and distributed by The Centers for Medicare and Medicaid Services (CMS) for the uniform designation of certain medical procedures and related services. Repair The repairs, including replacement of essential accessories (eg, hoses, tubes, mouth pieces ) are covered when necessary to make th e item/device serviceable. Replacement Equipment beyond its reasonable or useful life span , irreparable , and includes the same or similar type of equipment . D. PolicyI. A review of medical necessity is required for all DME repairs. If the DME item was not originally approved by CareSource, medical necessity must be established before any repair is authorized. II. Providers must include the following:A. specification of the item, including manufacturer, model, and serial number , if applicable B. date on which the item was originally purchased or dispensed or, if the date is not known, the approximate age of the item C. any warranty period and the type of warranty (manufacturer or dealer) D. a full description of the wear, damage, or malfunction E. a full description of the repair F. a description, with dates, of previous repairs (both major and minor) G. a complete itemization of parts Durable Medical Equipment Repairs-MP-MM-1582Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 H. an estimate of labor time needed (Labor should be billed with K0739 for 15-minute increments, 4 units = 60 minutes of labor .) III. During the medical necessity review A. Providers should advise CareSource when, in the professional opinion, replacement of an item would be more cost-effective than repair. B. CareSource may consider whether the purchase of a new piece of equipment may be more cost-effective than continued repair. C. Multiple repairs requested within a short time span may suggest deliberate or malicious damage or destruction. In these cases, repair may be denied. IV. No separate payment will be made for the following items or services:A. temporary replacement (“loaner”) equipment provided while an individual’s own equipment is being repaired B. repair of an item if within the preceding 12 months Medicaid payment has been made for the repair of a duplicate or conflicting item currently in the individual’s possession C. repair of an item that is no longer deemed to be medically necessary V. CareSource considers a replacement part as a new equipment purchase , and modifier NU should be used instead of modifier RB. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/14/2024 New policy. Approved at Committee.Date Revised 01/15/2025 Annual review. Updated references and medical necessity language . Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. Definitions, 42 U.S.C. 1395x (2024). 2. Repairs, maintenance, replacement, and delivery. Medicare Benefit Policy Manual, XV: Covered Medical and Other Health Services . Centers for Medicare and Medicaid Services; 2023:110.2. Accessed December 16, 2024. www. cms.gov
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