Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service , medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new 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 mem ber or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy t o services provided in a particular case and may modify this Policy at any time. REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Implantable Pain Pump PY-1067 03/01/2020 08/ 31/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 H. References ………………………….. ………………………….. ………………………….. …………………….. 4 Archived Implantable Pain Pump INDIANA MARKETPLACE PLANS PY-1067 Effective Date: 03/01/2020 2 A. Subject Implantable Pain Pump B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be estab lished based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility . It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain o n a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definit ions Implantable Pain Pump: Implantable pain pumps are medical devices which are inserted subcutaneously to deliver drugs for infusion through intrathecal catheters. Implantable pain pumps allow drug delivery directly to specific sites and can be programmed for continuous or variable rates of infusion. D. Policy I. Implantable Pain Pump A. Prior authorization (PA) is required for all implantable pain pumps, including trial administration, permanent placement and single shot intrathecal injections for the treatment of severe chronic intractable pain of malignant or non-malignant origin. 1. Prior authorizations for implantable pain pump services are not required for the following: a. Implantable device is considered part of the procedure and does not require a separate PA. b. Analysis post implantation c. Refilling and maintenance of the implanted device d. Removal/Revision of implanted device B. Short term and permanent Implantable Pain Pumps are considered medically necessary according to the criteria found in the Implantable Pain Pump Medical policy MM-0721. Archived Implantable Pain Pump INDIANA MARKETPLACE PLANS PY-1067 Effective Date: 03/01/2020 3 E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Implantable Pain Pump Description 62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy 62355 Removal of previously implanted intrathecal or epidural catheter 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming 62365 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion 62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill 62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming 62369 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill 62370 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill (requiring skill of a physician or other qualifie d health care professional) 95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; 95991 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional F. Related Policies/Rules Implantable Pain Pump MM-0721 Archived Implantable Pain Pump INDIANA MARKETPLACE PLANS PY-1067 Effective Date: 03/01/2020 4 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 03/01/2020 Date Archived 08/31/2020 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy . H. References 1. CMS Physician’s Fee Schedule . (n.d.). Retrieved November 8, 2019, from https:// www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx . The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Archived
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Trigger Point Injections PY-1097 03/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………… 2 B. Background ………………………….. ………………………….. ………………………….. ……………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ……………………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. .. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. . 3 H. References ………………………….. ………………………….. ………………………….. ………………… 3 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medicalnecessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral,authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increase d 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 loc al area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medica l Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict be tween this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 A. Subject Trigger Point Injections Trigger Point InjectionsINDIANA MARKETPLACE PLANS PY-1097 Effective Date: 03/01/2020 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclus ion of a code inthis policy does not imply any right to reimbursement or guarantee claims payment.Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized aschronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensivepain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health se rvices. C. DefinitionsTrigger Point Injections: A trigger point is 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. The purpose of a trigger-point injection is to treat not only the sympt om but also the cause through the injection of a single substance (e.g., a local anesthetic) or a mixture of substances (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. D. Pol icyI. Trigger Point Injections A. A prior authorization (PA) is required for each trigger point injection for pain management. B. Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. C. Injections may be repeated only with documented positive results to prior trigger point injections of the same anatomic site. Documentation should include at least 50% improvement in pain, functioning and activity tolerance. D. Localization techniques to ima ge or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. 3 Trigger Point InjectionsINDIANA MARKETPLACE PLANSPY-1097 Effective Date: 03/01/2020 E. 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. Payment may be made for one unit of service of the ap propriate procedure code reported on a claim for service rendered to a particular patient on a particular date. F. 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 sa me date of service unless there is an indication on the claim (e.g., in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. E. Conditions of CoverageReimburseme nt is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the CMS fee schedule for appropriate codes. The following lis t(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Trigger Point InjectionsDescription 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles F. Related Policies/RulesTrigger Point Injections MM-0145 G. Review/Revision HistoryDATE ACTIONDate Issued 12/11/2019Date Revised N/A Date Effective 03/01/2020 Date Archived 09/01/2020 H. References1. CMS Physician’s Fee Schedule . (n.d.). Retrieved November 8, 2019, from https:// www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx . The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of servic e, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new 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 mem ber or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy t o services provided in a particular case and may modify this Policy at any time. REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-1088 03/01/2020 07/ 31/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 3 H. References ………………………….. ………………………….. ………………………….. …………………….. 3 Archived 2 A. Subject Sacroiliac Joint Procedures Sacroiliac Joint Procedures INDIANA MARKETPLACE PLANS PY-1088 Effective Date: 03/01/2020 B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encourag ed to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant ee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments inclu de promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provi ded only by physicians qualified to deliver these health services. C. Definitions Sacroiliac Joint Procedures: corticosteroid and local anesthetic therapeutic injections into the sacroiliac joint to treat pain that hasnt responded to conservative therapies. D. Policy I. Sacroiliac Joint Procedures A. A prior authorization (PA) is required for each sacroiliac joint injection for pain management. Documentation, including dates of servic e, for conservative therapies are not required for PA, but must be available upon request. B. Sacroiliac joint injections 1. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic effect, repeating no more than once every seven (7) days and with at least a 75% or > reduction in pain after the first injection. 2. Once the diagnostic injections are performed and the diagnosis is established, two (2) therapeutic injections per joint may b e performed over a 12 month period. 3. Injections should not be repeated more frequently than every two (2) months with no more than a total of four (4) injections (including both diagnostic and therapeutic) per joint in 12 months. Archived 3 Sacroiliac Joint Procedures INDIANA MARKETPLACE PLANS PY-1088 Effective Date: 03/01/2020 C. Radiofrequency Facet Ablation for Sacroiliac Pain 1. Thermal or pulsed, cooled neurotomy by Radiofrequency Facet Ablation (RFA) or other techniques for sacroiliac pain are NOT covered. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Sacroiliac Joint Procedures Description 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed F. Related Policies/Rules Sacroiliac Joint Procedures MM-0149 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 03/01/2020 Date Archived 07/31/2020 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy . H. References 1. CMS Physician’s Fee Schedule . (n.d.). Retrieved November 8, 2019, from https:// www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx . The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Radiofrequency Facet Ablation PY-1080 03/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Archived Radiofrequency Facet Ablation INDIANA MARKETPLACE PLANS PY-1080 Effective Date: 03/01/2020 2 A. Subject Radiofrequency Facet Ablation B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and w ill be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most ac curate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during t heir lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyon d normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unrespons ive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Radiofrequency Facet Ablation: is performed using percutaneous introduction of an electrode under fluoroscopic guidance to thermocoa gulate medial branches of the dorsal spinal nerves. D. Policy I. Radiofrequency Facet Ablation A. A prior authorization (PA) is required for each radiofrequency facet joint denervation/ ablation for pain management . Documentation, including dates of service, for conservative th erapies are not required for PA but must be available upon request. B. For each spinal region (cervical/thoracic or lumbar) two (2) radiofrequency facet ablations per rolling 12 months, involving no more than four (4) joints per session, e.g., two (2) bilateral level s or four (4) unilateral levels . C. A repeat RFA in the same spine region requires documented pain relief of at least 50% for a minimum of 6 months after the initial RFA . D. Repeat RFA cannot be performed for at least six (6) months following the initial RFA . E. Radiofrequency facet ablation should be performed with imaging guidance. 1. Coverage for image guidance and any injection of contrast are inclusive components and are not reimbursed separately. Archived Radiofrequency Facet Ablation INDIANA MARKETPLACE PLANS PY-1080 Effective Date: 03/01/2020 3 E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to up dates. Radiofrequency Facet Ablation Description 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) F. Related Policies/Rules Radiofrequency Facet Ablation MM-0153 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 03/01/2020 Date Archived H. References 1. CMS Physicia n ‘s Fee Schedule . (n.d.). Retrieved November 8, 2019, from https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx . The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Positive Airway Pressure Devices for Pulmonary Disorders PY-0427 03/01/2020-04/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………… 3 F. Related Policies/Rules …………………………………………………………………………………………….. 4 G. Review/Revision History ………………………………………………………………………………………….. 4 H. References ……………………………………………………………………………………………………………. 4 Positive Airway Pressure Devices for Pulmonary Disorders INDIANA MARKETPLACE PLANS PY-0427 Effective Date: 03/01/20202A. Subject Positive Airway Pressure Devices for Pulmonary Disorders B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submit ting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Positive airway pressure (PAP) devices, involve using a machine that includes a mask or other device that fits over the nose and/or mouth to provide positive pressure to keep breathing airways open. Continuous positive airway pressure or CPAP is used to treat sleep-related breathing disorders including sleep apnea. It also may be used to treat preterm infants who have underdeveloped lungs. Bi-level or two level positive airway pressure or BiPAP is used to treat lung disorders such as chronic obstructive pulmonary disease (COPD). While CPAP delivers a single pressure, BiPAP delivers positive pressure both on inhalation and exhalation. PAP can provide better sleep quality, reduction or elimination of snoring, and less daytime sleepiness. The PAP machines should always be used according to the physicians order as well as every time during sleep at home, while traveling, and during naps in order to produce the most effective outcome. C. Definitions Adherence-is defined as the use of a PAP device for 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial usage. Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. D. Policy I. CareSource requires a prior authorization for PAP machines (CPAP/BiPAP). A. CPAP (E0601) and BiPAP (E0470, E0471 and E0472) machines are a 13 month rent to purchase. CareSource prior authorizations are for 3 months initial rental for PAP machines. B. After initial 3 months rental, providers must submit documentation for continued rental that shows the members adherence with the use of the PAP machine during the first 3 months of use. Prior authorization may be obtain for the remaining rental peri od (months 4-13). C. CareSource follows Centers for Medicare & Medicaid Services (CMS) guidelines for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea for medical necessity determination. II. Providers that dispense t he PAP machine must ensure and document the members adherence with its use. Positive Airway Pressure Devices for Pulmonary Disorders INDIANA MARKETPLACE PLANS PY-0427 Effective Date: 03/01/20203A. CareSource considers adherence with the use of PAP as the following: 1. In accordance with the Centers for Medicare & Medicaid Services (CMS) guidelines, adherence is defi ned as the use of a PAP device for 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial usage. 2. If there is a discontinuation of use at any time, the PAP supplier is expected to ascer tain adherence and stop billing for the equipment, related accessories and supplies. III. When lack of adherence of a PAP machine is confirmed, further rental and providers claims will be denied. A. Any reimbursement, for the PAP machine, that was dis pensed during the time of non-adherence will be recouped by CareSource. B. Any reimbursement, for the supplies, that were dispensed during the time of non-adherence will be recouped by CareSource. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description A4604 Tubing with integrated heating element for use with positive airway pressure device A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each A7028 Oral cushion for combination oral/nasal mask, replacement only, each A7029 Nasal pillows for combination oral/nasal mask, replacement only, pair A7030 Full face mask used with positive airway pressure device, each A7031 Face mask interface, replacement for full face mask, each A7032 Cushion for use on nasal mask interface, replacement only, each A7033 Pillow for use on nasal cannula type interface, replacement only, pair A7034 Headgear used with positive airway pressure device A7035 Headgear used with positive airway pressure device A7036 Chinstrap used with positive airway pressure device A7037 Tubing used with positive airway pressure device A7038 Filter, disposable, used with positive airway pressure device A7039 Filter, nondisposable, used with positive airway pressure device A7044 Oral interface used with positive airway pressure device, each A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only A7046 Water chamber for humidifier, used with positive airway pressure device, repl acement, each E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Positive Airway Pressure Devices for Pulmonary Disorders INDIANA MARKETPLACE PLANS PY-0427 Effective Date: 03/01/20204E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) E0472 Respiratory assist device, b i-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device) E0561 Humidifier, non-heated, used with positive airway pressure devi ce E0562 Humidifier, heated, used with positive airway pressure device E0601 Continuous positive airway pressure (CPAP) device Modifiers Description RR Rental (use the RR ‘ modifier when DME is to be rented) NU New equipment (use the NU modifier when DME is purchase d) F. Related Policies/Rules N/A G. Review/Revision History DATE ACTIONDate Issued 01/25/2018Date Revised 12/11/2019 Date Effective 03/01/2020 Updated modifiers Date Archived 04/30/2021 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Polic y. H. References 1. CPAP-NHLBI, NIH. (2019, July 29). Retrieved 7/ 29/19 from https://www.nhlbi.nih.gov/health-topics/cpap. 2. DME19-A. (2019, February 5). Retrieved 7/29/19 from https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME19-A.ht ml?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending 3 . Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) Devices for the Treatment of Obstru ctive Sleep Apnea (L33718) (2019, January 1). Retrieved 7/ 29/19 from https://www.cms.gov/med icare-coverage-database/details/lcd-details.aspx?LCDId=33718&ver=16&SearchType=Advanced&CoverageSelection=Local&Artic leType=SAD%7cEd&PolicyType=Both&s=42&KeyWord=Positive+Airway+Pressure+(PAP)+Devices+for+the+Treatment+of+Obstructive+Sleep+Apnea&KeyWordLoo kUp=Title&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAA& 4 . Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/ . The Reimbursement Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Reimbursement Polic y Sta te m ent Polic y a nd i s a pp ro ved.
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of servic e, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy t o services provided in a particular case and may modify this Policy at any time. REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Implantable Spinal Cord Stimulator PY-1135 03/01/2020 07/ 31/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 H. References ………………………….. ………………………….. ………………………….. …………………….. 4 Archived Implantable Spinal Cord Stimulator INDIANA MARKETPLACE PLANS PY-1135 Effective Date: 03/01/2020 2 A. Subject Implantable Spinal Cord Stimula tor B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain o n a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definit ions Implantable Spinal Cord Stimulator: Spinal cord (dorsal column) stimulation (SCS) is a pain relief technique that delivers a low-voltage electrical current to the spinal cord to block the sensation of pain. D. Policy I. Implantable Spinal Cord Stimulator A. Prior authorization (PA) is required for all implantable spinal cord stimulators, including s hort-term trial placement and permanent placement. 1. Prior authorizations for implantable spinal cord stimulator services are not required for the following: a. Implantable device is considered part of the procedure and does not require a separate PA. b. Analysis/study post implantation c. Removal/Revision of implanted device B. Short term and permanent Implantable Spinal Cord Stimulators are considered medically necessary according to the criteria found in the Implantable Spinal Cord Stimulator Medical policy MM-0715. Archived Implantable Spinal Cord Stimulator INDIANA MARKETPLACE PLANS PY-1135 Effective Date: 03/01/2020 3 E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Indiana Marketplace Plans approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS Physicians Fee Schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Implantable Spinal Cord Stimulator Codes Description 63650 Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performe 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs 95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs 95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs 95929 Central motor evoked potential study (transcranial motor stimulation); lower limbs 95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs 95939 Central motor evoked potential study (transcranial motor stimulation); in upper and lower 95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, a nd passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming Archived Implantable Spinal Cord Stimulator INDIANA MARKETPLACE PLANS PY-1135 Effective Date: 03/01/2020 4 95971 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimu lation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming b y physician or other qualified health care professional 95972 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimu lation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional F. Related Policies/Rules Implantable Spinal Cord Stimulator MM-0715 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 03/01/2020 Date Archived 07/31/2020 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy . H. References 1. CMS Physician’s Fee Schedule . (n.d.). Retrieved November 8, 2019, from https:// www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx . The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Facet Medial Branch Nerve Blocks PY-1062 03/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Facet Medial Branch Nerve Blocks INDIANA MARKETPLACE PLANS PY-1062 Effective Date: 03/01/2020 2 A. Subject Facet Medial Branch Nerve Blocks B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined whe n the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriat e CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long t erm outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue heali ng time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to cons ervative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Facet Medial Branch Nerve Blocks: Injection of a local anesthetic with or without a corticosteroid into the vicinity of the medial branch nerve s of the dorsal rami. D. Policy I. Facet Medial Branch Nerve Blocks A. A prior authorization (PA) is required for each facet medial branch nerve block injection for pain management. Documentat ion, including dates of service, for conservative therapies are not required for PA but must be available upon request. 1. Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB injections. a. A second confirmatory MBB is allowed if documentat ion indicates the first MBB produced significant relief of primary (index) pain 50%. 2. A maximum of six (6) facet injection sessions inclusive of medial branch blocks, intraarticular injections, and facet cyst rupture and facet medial branch neurtomies may be performed per rolling 12 months in the cervical/thoracic spine and six (6) in the lumbar spine. 3. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necess ary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. Archived Facet Medial Branch Nerve Blocks INDIANA MARKETPLACE PLANS PY-1062 Effective Date: 03/01/2020 3 4. Per CPT guidelines, imaging guidance and any injection of cont rast are inclusive components of all facet medial branch nerve blocks and are not reimbursed separately. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of cod es is provided as a reference. This list may not be all inclusive and is subject to updates. Facet Medial Branch Nerve Blocks Description 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary p rocedure) 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 64494 Inje ction(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure 64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to c ode for primary procedure) F. Related Policies/Rules Facet Me dial Branch Nerve Blocks MM-0158 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 03/01/2020 Date Archived Archived Facet Medial Branch Nerve Blocks INDIANA MARKETPLACE PLANS PY-1062 Effective Date: 03/01/2020 4 H. References 1. CMS Physicia n ‘s Fee Schedule . (n.d.). Retrieved November 8, 2019, from https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx . The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increa sed 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 l ocal area, are the lowest cost alternative, and are not provided mainl y for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/o r other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in i nterpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Epidural Steroid Injections PY-1052 03/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. . 2 B. Background ………………………….. ………………………….. ………………………….. …………………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …….. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ………. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ……. 4 H. References ………………………….. ………………………….. ………………………….. ……………………… 5 Epidural Steroid Injections 2A. Subject Epidural Steroid Injections INDIANA MARKETPLACE PLANS PY-1052 Effective Date: 03/01/2020 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclus ion of a code inthis policy does not imply any right to reimbursement or guarantee claims payment.Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized aschronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-mana gement and aim toreduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualifi ed to deliver these health services.C. DefinitionsEpidural Steroid Injections: for persistent or chronic radicular pain involve injection of corticosteroid, local anesthetic, opioid, or combination medication into the epidural space, requiring fluoroscop ic imaging and injection of an appropriate agent to achieve a selective reproducible blockage of a specific nerve root. Anatomic locations for epidural injections may involve the interlaminar space at the midline between vertebral bodies, caudal epidural injections, or transforaminal epidural injections. Epidural injections may be diagnostic for localizing and determining the cause of radiating pain and providing short term pain relief D. PolicyI. Epidural Steroid Injections A. A prior authorization (PA) is re quired for each epidural injection for pain management, excluding labor and delivery in childbirth and for post-surgical pain. Documentation, including dates of service for conservative therapies, are not required for PA, but must be available upon request . B. Interlaminar or Caudal Epidural Injections 1. More than 1 epidural injection per treatment date will not be authorized. 2. Bilateral injections and modifiers will not be recognized and coverage will be denied. 3. Prior authorization will be required for each epidural injection by the same or any physician. 4. Repeat injections sooner than 3 weeks may not reach pharmacodynamic effect of the corticosteroid and will not be covered. Epidural Steroid Injections 3INDIANA MARKETPLACE PLANS PY-1052 Effective Date: 03/01/2020 5. Requests for repeat injections beyond 3 weeks without documentation of suitable pain score reduction and functional improvements, or other documented rationale as described in Policy secti on will not be covered. C. For Transforaminal Epidurals or Selective Nerve Root Blocks (SNRBs) 1. Transforaminal Epidurals provided to more than 2 vertebral levels per treatment date, whether unilateral or bilateral, will not be authorized and will not be covered. 2. Bilateral injections require the appropriate modifier. 3. Prior authorization is required for treatment sessions per each spine region. 4. Repeat injections sooner than 3 weeks may not reach pharmacodynamic effect of the corticosteroid and will not be covered. 5. Requests for repeat injections beyond 3 weeks without documentation of suitable pain score reduction and functional improvements, or other documented rationale as described in Policy section will not be covered. D. The maximum epidurals of all types of epidural injections a member can receive in a rolling 12 months is a total of 6, regardless of the number of levels involved. E. Real-time image guidance and any injection of contrast are inclusive components of epidural injections and are not com pensated for separately, or unbundled, for coverage. F. Ultrasound guidance for epidural injections is inappropriate. G. Conscious sedation, if required for co-morbidities or patient/physician preference, may be provided without prior authorization but servic es will be considered part of the procedure and are not eligible for additional reimbursement if administered by a second provider. 1. Coverage for monitored anesthesia will not be provided as not medically necessary. 2. When anesthesia services are provided they must be delivered by CareSource credentialed providers, including anesthesiologists and/or CRNAs. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Indiana Marketplace Plans approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS Physicians Fee Schedule for appropriate codes. The following list(s) of codes i s provided as a reference. This list may not be all inclusive and is subject to updates. Epidural Description62320 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thorac ic; without imaging guidance 62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thorac ic; with imaging guidance (ie, fluoroscopy or CT) 62322 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62323 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar 4 Epidural Steroid InjectionsINDIANA MARKETPLACE PLANS PY-1052 Effective Date: 03/01/2020 epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 62325 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opi oid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) 62326 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62327 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic , opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 64480 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (flu oroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 64484 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoros copy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) F. Related Policies/RulesEpidural Steroid Injections MM-0162 G. Review/Revision HistoryDATE ACTIONDate Issued 12/11/2019Date Revised N/A Date Effective 03/01/2020 Date Archived 09/01/2020 5 H. ReferencesEpidural Steroid InjectionsINDIANA MARKETPLACE PLANS PY-1052 Effective Date: 03/01/2020 1. CMS Physician’s Fee Schedule . (n.d.). Retrieved November 8, 2019, from https:// www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKET PLACE PLANS Policy Name Policy Number Effective Da te Glycosylated Hemoglobin A1C PY-0335 02/01/2020-0 9/ 30 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy Statement ……………………………………………………………………………….. 1 A. Subject …………………………………………………………………………………………………………….. 2 B. Background………………………………………………………………………………………………………. 2 C. Def initions ………………………………………………………………………………………………………… 2 D. Policy ………………………………………………………………………………………………………………. 2 E. Conditions of Co v er ag e ………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………… 5 G. Review/Revision History ……………………………………………………………………………………… 5 H. Ref erences ………………………………………………………………………………………………………. 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does n ot ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy 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. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tGlycosylated Hemoglobin A1C Gl y c o s y l ated Hemoglobin A1C INDIANA MARKET PLACE PLANS PY-0335 Effec ti v e Date: 02/01/2020B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p roc essing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. Gly c ated hemoglobin/protein testing is widely ac cepted as medically necess ary for the manag ement and control of diabetes. Glyc osylated hemoglobin A1C/protein levels are us ed to d etermine lo ng-term glucose c ontrol in d iabetes. Gly c osylated hemoglobin lev els reflect the av erag e lev el of g luc ose in the blood ov er a three-month period.C. Def initions Glycosylated Hem oglobin (A1C) a b lood test that measures your av erage blood s ugar lev els o v er the p ast 3 months. It is one of the c ommonly us ed tes ts to diagnose prediabetes and d iab etes . Glycated protein-a b lood t est that is used to ass ess g ly ce mi c c ontrol over a p eriod of 1-2 week s and lo ng-term c ontrol in d iabetic patients with abnormalities of ery throcytes. D. Polic yI. Prio r autho rization is no t required for partic ipating p roviders for glycos ylated hemoglobin (A1C)/p ro tein b lood tes ting. Note: Altho ugh CareSourc e does not r equire a p rior authorization for g lycosylated hemo g lobin (A1C)/protein blood tes ting, CareSource may req uest d ocumentation to s up p ort medic al nec essity. Appropriate and complete doc umentation must be p res ented at the time of rev iew to v alidate medical nec essity .II. CareSo urc e c ons iders sc reening for the d iagnos is of d iabetes as medic ally nec essary p rev entiv e care for t he following member g roups acc ording to the United Sta t es Prev entive Serv ic es Tas k Fo rce (US PS TF): A. As y mptomatic members age 40 to 70 y ea r s who are ov erweight or o b es eB. As y mptomatic me mbers of any ag e or weight who are in the f ollowing high-risk g roups : 1. Immed iate family his tory of diabetes 2. His t o ry of gestational diabetes or polycy stic ov arian s y ndrome 3. A f ric an Americans 4. Nat iv e Americans 5. Alas k an Natives 6. As ian Americans 3 7. His p anic s and Latinos8. Nat iv e Hawaiians 9. Nat iv e Pa c if i c Is landers Gl y c o s y l ated Hemoglobin A1C INDIANA MARKET PLACE PLANS PY-0335 Effec ti v e Date: 02/01/2020C. As y mptomatic preg nant women who have reac hed 24 week s of gestation. III. CareSo urc e c onsiders d iagnos tic testing for the management of diabetes as medically nec es s ary for the following member g roups, with the s pecified frequencies: A. Memb ers whose diabetes is controlled, o nc e ev ery 3 monthsB. Memb ers whose diabetes is not c ontrolled may req uire testing more than four t i mes a y ea r C. Preg nant wo men, onc e per mo nt h Note: CareSo urc e may req ues t doc umentation to s upport medic al nec essity , if tes ti ng is in ex c es s of the above g uidelines.IV. Alternativ e testing, inc luding glycated protein, for ex ample, fructosamine, may be indicated f or mo nito ring the d egree of glycemic control. A. It is theref ore c onceivable that a patient wi ll hav e both a g ly cated hemoglobin and g ly c ated protein o rdered on the s ame day . B. Th i s s ho uld be limited to the initial as say of glycat ed hemoglobin, wi th s ubsequent ex c lus ive us e of glyc ated pro tein. C. Thes e tests are no t considered to be medically nec essary for the diagnosis of diabetes . V. Reimb urs ement is b ased on submitting a claim with the appropriate ICD-10 d iagnosis c ode to matc h the CPT c o de listed within this policy. If the ap propriate ICD-10 d iagnos is code is not s ub mitted with the CPT c ode, the c laim will be denied. E. Conditions of Cov erage Reimb urs ement is dependent o n, b ut not limited to, s ubmitting Centers for Medicare and Med ic aid Ser v i c e s (CM S) ap proved HCP CS and CP Tc odes and the appropriate modifiers, if ap p lic able. Pleas e refer to the CMS fee s chedule for ap propriate c odes. The follo wing l i st(s) of codes is provided as a reference. This list may n ot be all inclusive and is subject to updates. CPT Code Description82985 Gly c ated p rotein 83036 Hemo g lobin; g lycosy lated (A 1C) ICD-10 Description D13.7 Benig n neo p las m of end ocrine p ancreas E08. Diab etes mellitus due to underlying c ondition wi th (A ny ICD-10 s tarting wi th E08.) E09. Drug or c hemic al induced diabetes mellitus wit h (Any ICD-10 s tarting wi th E 09 . ) E10. Ty p e 1 d iab etes mellitus wi th (A ny ICD-10 s tarting wi th E 10 . ) E11. Ty p e 2 d iab etes mellitus wi th (A ny ICD-10 s tarting wi th E 11 . ) E13. Other s p ec ified d iabetes mellitus wit h (Any ICD-10 s tarting wi th E 1 3. ) E15 No nd iabetic hy poglycemic c oma E16.0 Drug-ind uced hy pogly c emi a without c oma E16.1 Other h y p o g lyc em ia E16.2 Hypoglycemia, uns p ec ified E16.3 Inc reas ed s ec retion of g lucagon E16.8 Other sp ecified d isorders of p ancreatic internal s ecretion 4 Gl y c o s y l ated Hemoglobin A 1C INDIANA MARKET PLACE PLANS PY-0335 Effec ti v e Date: 02/01/2020E16.9 Dis o rder of panc reatic internal s ecretion, unspecified E31.0 Auto immune polyglandular f ailure E31.1 Po ly glandular hy perfunction E31.20 Multip le end ocrine neo plas ia [ MEN] s yndrome, unspecified E31.21 Multip le end ocrine neo plas ia [ ME N] ty pe I E31.22 Multip le end ocrine neo plas ia [ ME N] ty pe IIA E31.23 Multip le end ocrine neo plas ia [ ME N] ty pe IIB E31.8 Other p o ly glandular d ysf unct ion E31.9 Po ly glandular d ysf unct ion, uns pecified E74.8 Other sp ecified d isorders of c arbohydrate metabolism E79.0 Hy p eruric emia without s igns of inflammatory art hritis and tophaceous d i s e as e E83.10 Dis o rder of iro n metabolism, unspecified E83.110 Hered itary hemochromatosis E83.111 Hemo c hro matos is due to repeated red b lood c ell transfusions E83.118 Other hemo c hromatosis E83.119 Hemo c hro mato s i s , uns p ec ified E83.19 Other d is orders of iron metabolism E88.02 Plas minogen d ef iciency E89.1 Postprocedural h y p o i ns ul i n em ia H44.2E1 Deg enerative my opia wit h o ther mac ulopathy, rig ht eye H44.2E2 Deg enerative my opia wit h o ther mac ulopathy, lef t eye H44.2E3 Deg enerative my opia wit h o ther maculopathy, b ilateral eye I21.9 Ac ute my oc ardial infarc tion, uns pec ified I21.A1 My o c ardial infarc tion t ype 2 I21.A9 Other my o c ardial infarc tion t ype K86.0 A l c o ho l-induced c hronic p ancreatitis K86.1 Other c hro nic p ancreatitis K91.2 Po s tsurgical malabsorption, not elsewhere c lassif ied L97. No n-p res s ure chronic ulcer of other part of (A ny ICD-10 starting wi th L97.) L98.415 No n-p res s ure chronic ulcer of buttock wit h mus cl e inv olv ement without evidence o f nec rosis L98.416 No n-p res s ure chronic ulcer of buttock wit h bone involvement without evidenc e of nec ro s is L98.418 No n-p res s ure c hronic ulc er of buttock wi th o t he r s p ecified s everity L98.425 No n-p res s ure chronic ulcer of bac k wi th m uscle involvement without evidence of nec ro s is L98.426 No n-p res s ure chronic ulcer of back wi th bone involvement without evidence of nec ro s is L98.428 No n-p res s ure c hronic ulc er of bac k wi th other s pecified s everity L98.495 No n-p res s ure chronic ulcer of sk in of other s i tes wit h m uscle involvement without ev id enc e of nec rosis L98.496 No n-p res s ure chronic ulcer of sk in of other s i tes wit h bone involvement without ev id enc e of nec rosis O24. Pre-ex is ting ty pe 1 diabetes mellitus, in pregnancy (A ny ICD-10 s tarting wit h O24.) O30. Trip let p reg nanc y(Any ICD-10 starting wit h O30.) O99.810 Ab no rmal g lucose c omplicating p regnancy O99.815 Ab no rmal g lucose c omplicating the p uerperium R73.01 Imp aired f asting g lucose R73.02 Imp aired g lucose to leranc e (oral) R73.03 Pred iabetes R73.09 Other ab no rmal g lucose R73.9 Hy p erg l y c emi a, uns p ec ified R78.71 Ab no rmal lead leve l in blood 5 Gl y c o s y l ated Hemoglobin A 1C INDIANA MARKET PLACE PLANS PY-0335 Effec ti v e Date: 02/01/2020R78.79 Find ing of ab normal lev el of heavy metals in blood R78.89 Find ing of other specified s ubs tances , not normally found in b lood R79.0 Ab no rmal lev el of blood mineral R79.89 Other specifi ed abnormal findings of blood c hemis try R79.9 Ab no rmal f inding of blood chemistry, unspecified T38.3X1A Po is oning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentio nal), initial encounter T38.3X2A Po is oning by insulin and oral hypoglycemic [antidiabetic] drugs , intentional s e lf – harm, initial e nc ounter T38.3X3A Po is oning by insulin and oral hypoglycemic [antidiabetic] drugs, assault, i n it i a l enc o unter T38.3X4A Po is oning by insulin and oral hypoglycemic [antidiabetic] drugs, undetermined, initial enc o unter Z00.00 Enc o unter for g eneral ad ult medic al ex amination without ab normal findings Z00.01 Enc o unter for g eneral ad ult medical ex amination wit h ab normal findings Z01.812 Enc o unter for p reprocedural lab oratory ex amination Z13.1 Enc o unter for s c reening for d iabetes mellitus Z13.9 Enc o unter for s c reening, unspecified Z79.3 Lo ng t erm (c urrent) us e of hormonal c ontraceptives Z79.4 Lo ng t erm (c urrent) us e of insulin Z79.84 Lo ng t erm (c urrent ) us e of oral hy poglycemic drugs Z79.891 Lo ng t erm (c urrent) us e of opiate analgesic Z79.899 Other lo ng t erm (c urrent ) drug therapy Z86.2 Pers o nal history of diseases of the blood and blood-forming org ans and certain d is o rders inv olving the immune mechanism Z86.31 Pers o nal his tory of diabetic foot ul c e r Z86.32 Per s o nal his tory of ges tational diabetes Z86.39 Pers o nal his tory of other endoc rine, nutritional and metabolic d isease F. Related Polic ies/Rules N/ A G. Re v iew/Rev ision History DATE ACTIONDate Issued 02/01/2020Date Revised Date Effecti ve 02/01/2020 New p o licy Date Archived 09/30/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uid elines without a f ormal doc umented Policy. H. Ref erenc es1. Ab no rmal Blood Gluc ose and Ty p e 2 Diabetes Mellitus: Sc reening. (2015, October). Retrieved 8/29/2019 f ro m https :/ /www. uspreventiv eservicestaskforce.org /Page/Document/U pdate Summary Final/s creening-for-abnormal-blood-glucose-and-type-2 -diabetes?ds=1&s=diabetes . 2. Centers f or Medicare and Medic aid Services . (2019). NCD 190.21-Glycated Hemo g lobin/Glycated Protein (190.21). 3. Ges tatio nal Diabetes Mellitus, Screening. (2014, January). Retrieved 8/29/2019 from https://www.uspreventiveservicestaskforc e.org/Page/Document/UpdateSummaryFinal/gestatio nal-d iabetes-mellitus-screeni ng?ds=1&s=diabetes.
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Robotic-Assisted Surgery PY-0956 2/1/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased, or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Robotic-Assisted Surgery INDIANA MARKETPLACE PLANS PY-0956 Effective Date: 2/2/2020 2 A. Subject Robotic-Assisted Surgery B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. 4Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Robot-assisted surgery involves the use of a robot and computer technology under the direction and guidance of a surgeon. These surgeries are minimally invasive procedures using robotic devices designed to access surgical locations through smaller incisions or ports. There surgeries are generally performed using a workstation console containing remote controls for the surgical instruments as well as a computer equipped with a three-dimensional magnified video monitor of the surgical site through use of miniature cameras. The primary difference between robotic and conventional laparoscopic procedures is that the surgical instruments are manipulated indirectly through computer controls rather than manually by the surgeon. The robotic controls allow the surgical tools to emulate the movement of the surgeon performing cuts, clamps and suturing in a similar fashion as would be done in an open procedure. Examples of robotic surgical systems include the da Vinci Surgical System (Intuitive Surgical, Inc.) and the ZEUS Robotic Surgical System (Computer Motion, Inc.) C. Definitions Robotic Assisted Surgery-is defined as the performance of operative procedures with the assistance of robotic technology. D. Policy I. Robotic-Assisted Surgery, HCPCS S2900, is included in the primary surgical procedure and not separately reimbursable. II. Modifier 22 (increased procedural services): 1. Should be used only to report complications or complexities during the surgical procedure that are unrelated to the use of the robotic system, such as increased intensity, increased time, increased difficulty of procedures, or severity of patients condition. Robotic-Assisted Surgery INDIANA MARKETPLACE PLANS PY-0956 Effective Date: 2/2/2020 3 Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the (CMS) fee schedule for appropriate codes. E. Related Policies/Rules F. Review/Revision History DATE ACTION Date Issued 2/1/2020 New Policy Date Revised Date Effective 2/1/2020 Date Archived G. References 1. Robotic surgery. MedLine Plus Web site. http://www.nlm.nih.gov/medlineplus/ency/article/007339.htm . Published May 2013. Accessed October 9, 2019 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services; http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage 3. Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage 4. Daniel M. Herron, MD. A consensus Document on Robotic Surgery. Prepared by the SAGES-MIRA Robotic Surgery Consensus group. Position Papers/ Statement published on: 11/2007. Accessed October 9, 2019. Available at URL address: http://www.sages.org/publications/guidelines/consensus-document-robotic-surgery/ The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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