MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Mechanical Stretching Devices-OH MCD-MM-1225 06/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents 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 ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Mechanical Stretching Devices-OH MCD-MM-1225Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMechanical Stretching Devices B. Background Mechanical stretching devices are intended to restore range of motion (ROM) for joint stiffness or contracture by stretching joints. These devices provide passive stretching to an adjustable degree for a selected duration for multiple sessions. A variety of mechanical stretching devices are available for extension or flexion of the shoulder, elbow, wrist, fingers, knee, ankle, and toes. These devices can provide stretching for longer periods than a physical therapist and are generally used as adjunct treatment to physical therapy and/or exercise. Mechanical Stretching Devices (also known as dynamic splinting systems) include: Low-load prolonged duration stretch devices (LLPS) Static progressive stretch (SPS) splint devices Patient actuated serial stretch (PASS) devices C. Definitions Low-Load Prolonged Duration Stretch Devices (LLPS) These devices permit resisted active and passive motion (elastic traction) within a limited range. LLPS devices maintain a set level of tension by means of incorporated rubber bands or springs. Patient Actuated Serial Stretch (PASS) Devices These devices hold the joint in a set position but allow for manual modification of the joint angle and may allow for active motion without resistance (inelastic traction). This type of device itself does not exert a stress on the tissue unless the joint angle is set at the maximum ROM. Static Progressive Stretch Devices (SPS) These devices hold the joint in a set position but allow for manual modification of the joint angle and may allow for active motion without resistance (inelastic traction). D. Policy I. CareSource considers dynamic splinting devices medically necessary durable medical equipment (DME) as an adjunct treatment to physical therapy, massage, and/or exercise for an existing joint contracture when the following clinical criteria is met: A. medically necessary only for the following joints: knee, elbow, wrist, finger, ankle and toe B. after 3 weeks of exercise, physical therapy and skilled therapy in the initial subacute injury or post-operative period in members with: 1. signs and symptoms of persistent joint stiffness or contracture 2. limited range of motion that poses a meaningful functional limitation as judged by a physician C. documentation showing compliance with wear and compliance with any additional activity and exercise recommended by medical professional Mechanical Stretching Devices-OH MCD-MM-1225Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 D. may be used for an initial period of 4 weeks, a subsequent 4-week period with reevaluation, and then up to 4 months based on continued improvement. E. documentation to show objective ROM and functional improvement II. In the acute post-operative period for members who have undergone additional surgery to improve the range of motion of a previously affected joint, CareSource considers use of an LLPS device medically necessary for: A. an initial 4-week period B. an additional 4-week period, if improvement was noted after the initial 4 weeks, for up to 4 months. III. Non-Covered ServicesA. CareSource considers the use of dynamic splinting experimental and investigational for the following indications, including but not limited to: 1. adhesive capsulitis 2. carpal tunnel syndrome 3. cerebral palsy 4. foot drop associated with neuromuscular diseases 5. hallux valgus 6. head and spinal cord injuries 7. improvement of outcomes following botulinum toxin injection for treatment of limb spasticity 8. injuries of the ankle and shoulder 9. multiple sclerosis 10. muscular dystrophy 11. plantar fasciitis 12. rheumatoid arthritis 13. stroke 14. trismus B. CareSource considers the following devices experimental and investigational due to insufficient scientific evidence of efficacy: 1. patient Actuated Serial Stretch (PASS) devices (for example, ERMI Knee Extensionater and ERMI Shoulder Extensionater) 2. static Progressive Stretch devices (SPS) (for example, Joint Active Systems (JAS) splints (for example, JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and JAS Pronation-Supination) E. Conditions of CoverageAll claims for LLPS are subject to post-payment review by CareSource. F. Related Policies/Rules NA Mechanical Stretching Devices-OH MCD-MM-1225Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 G. Review/Revision History DATE ACTIONDate Issued 11/09/2023 New PolicyDate Revised 02/15/2023 06/07/2023 05/22/2024 03/12/2025 03/11/2026 e-voted addition of ankle and toe to policy to match fee schedule and MCG. Annual review. Added examples of PASS and SPS devices. Annual review. Updated references. Approved at Committee. Updated references. Approved at Committee. Added compliance documentation requirements to Sec.I. C. and ROM and improvement documentation to I. E. Updated references. Approved at Committee. Date Effective 06/01/2026 Date Archived H. References1. Furia JP, Willis FB, Shanmugam R, et al. Systematic review of contracture reduction in the lower extremity with dynamic splinting. Adv Ther . 2013;30(8):763-770. doi:10.1007/s12325-013-0052-1 2. Dynamic Joint Extension and Flexion Devices: ACG A-0882. MCG. 29th ed. 2025. Accessed February 3, 2026. www.careweb.careguidelines.com 3. Glasgow C, Tooth LR, Fleming J, et al. Dynamic splinting for the stiff hand after trauma: predictors of contracture resolution predictors of contracture resolution. J Hand Ther . doi:10.1016/j.jht.2011.03.001 4. Harvey LA, Katalinic OM, Herbert RD, et al. Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews . 2017;1(1):CD007455. doi:10.1002/14651858.CD007455.pub3 5. Karjalainen TV, Lusa V, Page MJ, O'Connor D, Massy-Westropp N, Peters SE. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev. 2023;2(2):CD010003. doi:10.1002/14651858.CD010003.pub2 6. Medical Technology Directory. Mechanical Stretching Devices for the Treatment of Joint Contractures of the Extremities. Hayes; 2022. Accessed February 3, 2026. www.hayesinc.com 7. Zatarain LA, Smith DK, Deng J, et al. A randomized feasibility trial to evaluate use of the jaw dynasplint to prevent trismus in patients with head and neck cancer receiving primary or adjuvant radiation-based therapy. Integr Cancer Ther . 2018. 17(3):960- 967. doi:10.1177/1534735418784363. Independent medical review 12/21Approved by ODM 03/17/2026
MEDICAL POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Transcranial Magnetic Stimulation for Treatment of Depression-OH MCD-MM-0233 06/01/2026Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Transcranial Magnetic Stimulation for Treatment of Depression-OH MCD-MM-0233 Effective Dat e: 06/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectTranscranial Magnetic Stimulation for Treatment of Depression B. BackgroundTranscranial magnetic stimulation (TMS) was originally introduced in 1985 as a noninvasive treatment modality for treatment-resistant Major Depressive Disorder (MDD) . Brief , repetitive pulses of magnetic energy are sent to the scalp via a large electromagnetic coil , generating a low level of electrical stimulation. These magnetic fields pass through the sk ull and induce electric al currents that depolarize neurons in a focal area of the surface cortex. The magnetic field generated by this type of stimulation is very small and cannot be felt by the patient but is strong enough to flow into the brain without inducing seizures or creating a need for anesthesia. TMS is generally an outpatient procedure with conscious patients and sessions tha t varybetween 30 to 40 minutes. Treatment can be delivered as a single pulse or as a series of pulses. Despite variability in the number of pulses delivered per session and the number of sessions per patient, research indicates that typical courses of TMS consist of treatment up to 5 days a week for up to 6 weeks. A tapering schedule is used to end treatment. C. Definitions Acute (Index) Course of Treatment The initial series of treatment given to relieve acute symptoms of MDD . Adequate Trial Taking a drug at least 4 weeks at or near the maximum dose for the specific medication as approved by the F ood and Drug Administration (FDA) or documentation exists that higher doses were not tolerated when the dose is less than the FDA approved maximum. Continuation TMS Treatment beginning after the acute/index course lasting up to 6 months and designed to prevent the worsening of symptoms and continue d treatment for a depressive episode that has not yet remitted. Depression Rating Scale Standardized scales for national use that reliably assess the range of symptoms most commonly observed in adults with MDD, including type and magnitude. Listed below are examples of commonly used scales : OBeck Depression Inventory (BDI) o Geriatric Depression Scale (GDS) o Hamilton Depression Rating Scale (HAM-D) o Patient Health Questionnaire-9 (PHQ-9) o Quick Inventory of Depressive Symptomatology (QIDS) Maintenance TMS Regularly scheduled TMS sessions on a weekly, biweekly, or monthly basis used to prevent relapse of depressive symptoms. Medication Side Effects Unexpected effects that cause significant distress, inhibit daily function, have the potential to worsen health, or are life threatening. Remission The absence of significant signs or symptoms of a n MDD episode during the previous 2 months. Transcranial Magnetic Stimulation for Treatment of Depression-OH MCD-MM-0233 Effective Dat e: 06/01/2026 The MEDICAL Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the MEDICAL Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 3 D. PolicyI. A review of medical necessity is required for initial or continuation courses of TMS .II. Initial (acute/index) treatment is considered medically necessary when ALL the following criteria are met:A. Member is 18 years of age or older .B. Member has a confirmed diagnosis of major depressive disorder , single or recurrent , with a current severe episode as evidenced by a recent score on a standardized depression rating scale and at least 1 of the following :1. Need for treatment , as indicated by 1 of the following:a. r esistance to treatment with documented adherence as evidenced by a lack of a clinically significant response during a current or previous depressive episode and 2 or more classes of an tidepressant agents at or near maximum effective dose and duration approved by the FDAb. i nability to tolerate pharmacotherapy evidenced by 2 antidepressants with documented side effects2. Continuation of acute course of treatment, as indicated by a. c ontinuation of symptoms 30 days after index (acute) course of treatment b. p revious positive response to index (acute) course of treatment evidenced by a reduction of 50% in a depression severity rating scale as compared to baselineC . None of the following conditions or contraindications are present :1. epilepsy , history of seizure or other neurologic disease or disorder that may lower seizure threshold (eg, cerebrovascular accident, severe head trauma,increased intracranial pressure) or a family history of epilepsy (parent, sibling,child)2 . acute or chronic psychotic symptoms or disorders (eg, schizophrenia,schizophreniform, or schizoaffective disorder)3. bipolar disorder4. cochlear implant s or deep brain stimulator s5. current use of substances that may significantly lower seizure threshold (eg ,alcohol or stimulants ) or recent discontinuation of alcohol, benzodiazepines ,or anticonvulsants; sleep deprivation ; active illicit substance abuse6. metallic hardware or implanted magnetic-sensitive medical device s (eg,implanted cardioverter-defibrillator s , pacemaker s , metal aneurysm clips or coils , intracardiac lines, medication pumps ) or other metal fragments at a distance within the electromagnetic field of the discharging coil (eg, less than or equal to 30 cm to the discharging coil)7. unstable medical disorders (eg, recent heart attack, severe uncontrolled hypertension)8 . tattoos in the head or neck with ferromagnetic-containing inkI II . Maintenance treatment with TMS is not considered medically necessary . There is not sufficient evidence in peer reviewed literature to assess net benefit versus harm for patients. Transcranial Magnetic Stimulation for Treatment of Depression-OH MCD-MM-0233 Effective Dat e: 06/01/2026 The MEDICAL Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the MEDICAL Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 4 I V. Additional criteriaA. TMS must be administered by an FDA cleared device for the treatment of MDD in a safe and effective manner according to the manufacturers user manual and specified stimulation parameters.B. A treatment course should not exceed 5 days a week for 6 weeks (total of 30sessions), followed by a 3-week taper of 3 treatments in 1 week, 2 treatments the next week , and 1 treatment in the last week.C. TMS can be ordered by and performed under direction of a neurologist, licensed psychiatrist, or psychiatric nurse practitioner who has examined the member,reviewed the record when it is within the scope of practice, and has experience in administering TMS therapy within the scope of practice.E. Conditions of CoverageNAF. Related Policies/RulesMedical Necessity DeterminationsG. Review/Revision HistoryDATE ACTION Date Issued 07/12/2018 Date Revised 11/11/2020 10/28/2021 08/31/2022 01/19/2023 07/19/2023 06/19 /2024 06/04 /2025 03/11/2026 Removed a definition, added neurologist. Revised and expanded definitions. Added Section II and IV. Updated background , d efinitions , & criteria (MCG 26 th ed). Updated title for clarity. Annual review. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Annual review. Deleted III (repeat of D.II.B.2) and updated references. Approved at Committee. Annual review, updated Section II.C. Updated reference s . Approved at Committee. Date Effective 06/01/2026 Date Archived H. References1. American Psychiatric Association. Diagnostic and Statistical Manual of MentalDisorders, Fifth Edition, Text Revised. American Psychiatric Association; 2022.2. Holtzheimer PE. Unipolar major depression: administering transcranial magnetic stimulation (TMS). UptoDate. Updated July 21, 2025 . Accessed February 6, 2026 .www.uptodate.com3. Holtzheimer PE. Unipolar depression in adults: indications, efficacy, and safety of transcranial magnetic stimulation (TMS). UptoDate. Updated July 21, 2025 .Accessed February 6, 2026 . www.uptodate.com Transcranial Magnetic Stimulation for Treatment of Depression-OH MCD-MM-0233 Effective Dat e: 06/01/2026 The MEDICAL Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the MEDICAL Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 5 4. Jarrett R, Vittengl J. Major depressive disorder in adults : Continuation and maintenance treatment. UptoDate. Updated October 3, 2024 . Accessed February 6,2026 . www.uptodate.com5. National Institute of Mental Health. Brain Stimulation Therapies . National Institutes ofHealth; 2023. NIH publication 0925-0648. Accessed February 6, 2026 .www.nimh.nih.gov6. Perera T, George MS, Grammar G, et al. The Clinical TMS Society consensus review and treatment recommendations for TMS therapy for major depressive disorder. Brain Stimul . 2016;9(3):336-346. doi:10.1016/j.brs.2016.03.0107. Thase M, Connolly R. Treatment-resistant unipolar major depression (major depressive disorder) in adults. UpToDate. Updated November 17, 2025 . AccessedFebruary 6, 2026 . www.uptodate.com8. Transcranial magnetic stimulation: B-801-T. MCG Health, 2 9 th edit. Updated June13, 2025 . Accessed February 6, 2026 . www.careweb.careguidelines.comApproved by Ohio Department of Medicaid 03/17/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Genetic Testing and Counseling-OH MCD-MM-0003 06/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Polices/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Genetic Testing and Counseling-OH MCD-MM-0003Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectGenetic Testing and Counseling B. BackgroundAdvancements in technology have contributed to the rapid expansion of identified genetic variations . Some of these variations have been identified as disease-causing, while others are considered common variants with no clinical impact . With the ev er- expanding number of genetic tests available , it can be clinically difficult to determine the most appropriate tests for a particular patient. When clinically appropriate, genetic testing may provide diagnostic and/or actionable therapeutic results which can impact a patients outcome. Due to the complexity of genetic tests and th eir results , consultation with m edical genetics professionals and counselors may be required to assist members. According to the National Society of Genetic Counselors of the United States, genetic counseling is meant to integrate the following goals: 1) interpretation of family and medical histories to assess the chance of disease occurrence or recurrence; 2) education about the natural history of the condition, inheritance pattern, testing,management, prevention, support resources, and research; 3) counseling to promote informed choices in view of risk assessment, family goals, ethical and religious values; and 4) support to encourage the best possible adjustment to the disorder in an affected family member and/or to the risk of recurrence of that disorder. Genetic counselors are healthcare professionals trained to provide this care ; however , access issues may require other healthcare professionals to assume this role. Genetic counseling , whether provided by a certified genetic counselor or other qualified healthcare professional, is an integral component of genetic testing that is informative and supportive to memb ers, both before and after they undergo testing. C. Definitions Genetic Screening Th e process of testing a population for a genetic disease to identify a subgroup of people who either have the disease or the potential to pass it to offspring. Genetic Testing A medical test that identifies changes in genes, chromosomes, or proteins to confirm or rule out a suspected genetic condition , either hereditary or acquired. Human Leukocyte Antigen (HLA) Typing A test used to match patients and donors for bone marrow or cord blood transplants. Inherited Genetic Variant A type of DNA sequence change passed from parent to offspring (ie, germline). Precision Medicine A field of medicine that selects pharmacotherapies based on the patients genetics. Somatic Gene Variant A type of DNA sequence change that is not inherited from a parent but acquired during a persons life. Genetic Testing and Counseling-OH MCD-MM-0003Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 D. PolicyI. Prior authorization may be required for genetic testing . This includes both somatic and germline genetic testing. II. CareSource will review for medical neces sity using published MCG criteria whenavailable and the Medical Necessity Determinations administrative policy . This policy does not apply to requests that have MCG guidelines with clear genetic counseling requirements/recommendations. III. Proprietary panel testing requires evidence-based documentation per the MedicalNecessity Determinations administrative policy. Individual genetic tests may be requested separately based on the Medical Necessity Determinations administrati ve policy for panels not meeting medical necessity requirements. IV. Genetic counseling is required for all germline genetic testing , as indicated by ALLthe following: A. Counseling is provided by a healthcare professional with education and training in genetic issues relevant to the genetic tests under consideration . B. Counseling is provided to enable members informed decision making concerning proposed testing (eg, purpose of testing, management that may be informed by result, heritable nature informed by 3-generation family history, range of possible results, potentia l benefits and risks of testing (eg, psychological, social, economic). V. Somatic genetic testing (eg, cancer testing) does not require genetic counseling described above. VI. Human leukocyte antigen (H LA ) typing is not part of the genetic testing policy and do es not require pre-authorization. VII. W hile most inherited genetic testing is only necessary on ce in a lifetime, CareSource recognizes that a germline genetic test could be appropriately repeated in extraordinary circumstances due to changes in technology. This situation will be considered with the proper medical necessity documentation. E. Conditions of CoverageNAF. Related Polices/RulesMedical Necessity Determinations Cystic Fibrosis Testing Genetic Testing and Counseling-OH MCD-MM-0003Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 G. Review/Revision HistoryDATE ACTIONDate Issued 02/24/2015 New PolicyDate Revised 06/05/2019 09/03/2020 07/07/2021 05/25/2022 05/10 /202304/10/202407/03/2024 04/23 /202503/11 /2026Revised title, removed MCG table, condensed background Reviewed, updated referencesAnnual review: updated definitions, background, and references, re-organized criteria Annual review: updated background, definitions, and references , rephrased genetic counseling process. Approved at Committee. Review: updated references, approved at Committee Review: clarified genetic counseling requirements, added language regarding MCG. Approved at Committee Review: updated references, approved at Committee. Review: updated references, approved at Committee. Date Effective 06/01/2026 Date Archived H. References1. Ambulatory care : genetic medicine. MCG Health . 2 9th ed. Accessed January 30, 2026 . www.careweb.careguidelines.com 2. Cohen SA, Bradbury A, Henderson V, et al. Genetic counseling and testing in a community setting: quality, access, and efficiency. Am Soc Clin Oncol Educ Book . 2019;e34-e44. doi:10.1200/EDBK_238937 3. Crooke A, Jacobs C, Newton-John T, et al. Genetic counseling and testing practices for late-onset neurodegenerative disease: a systematic review. JNeurol. 2022;269(2):676-692. doi:10.1007/s00415-021-10461-5 4. Nowaczyk MJM. Genetic testing. UpToDate. Updated July 10, 2025 . Accessed January 30, 2026. www.uptodate.com 5. Mundy J, Davies HL, Radu M, et al. Research priorities in psychiatric genetic counselling: how to talk to children and adolescents about genetics and psychiatric disorders. Eur JHum Genet . 2023;31(3):262-264. doi:10.1038/s41431-022-01253-0 6. National Center for Biotechnology Information (NCBI). Genetic Testing Registry (GTR) National Library of Medicine. Accessed January 30, 2026 . www.ncbi.nlm.nih.gov 7. National Human Genome Research Institute. Coverage and Reimbursement of Genetic Tests. National Institutes of Health. Updated February 6, 2024 . Accessed January 30, 2026 . www.genome.gov 8. National Human Genome Research Institute. Regulation of Genetic Tests. National Institutes of Health. Updated February 19, 2024 . Accessed January 30, 2026 . www.genome.gov Genetic Testing and Counseling-OH MCD-MM-0003Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 9. Raby BA, Kohlmann W. Genetic counseling: family history interpretation and risk assessment. UpToDate. Updated April 9 , 2024. Accessed January 30, 2026 .www.uptodate.com 10. Sarata AK. Genetic Testing: Background and Policy Issues . Congressional Research Service Report ; 2015 . RL33832. Accessed January 30, 2026 . www.sgp.fas.org 11. Senter L, Austin JC, Carey M, et al. Advancing the genetic counseling profession through research: identification of priorities by the National Society of Genetic Counselors research task force. JGenet Couns. 2020;29(6):884-887. doi:10.1002/jgc4.1330 12. White S, Jacobs C, Phillips J. Mainstreaming genetics and genomics: a systematic review of the barriers and facilitators for nurses and physicians in secondary and tertiary care. Genet Med. 2020;22(7):1149-1155. doi:10.1038/s41436-020-0785-6 Approved by ODM 03/17/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Standing Frames-OH MCD-MM-1331 06/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Standing Frames-OH MCD-MM-1331Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectStanding Frames B. BackgroundSupported standing is a common, adjunctive therapeutic practice in which patients with neuromuscular conditions are enabled to assume an upright position. Homebased standing programs are commonly recommended for adults and children who cannot stand and/or walk independently and are usually part of a postural management program, which plays a role in preventing contracture, deformity, pain, and asymmetry. Standing frames (also known as standers) might include prone, supine, vertical, multi – positional , and sit-to-stand types. Standing frames are durable medical equipment (DME) that secure an individual in astanding position . These devices provide no mobility, but research has shown medical benefits supporting use, including an enhanced ability to perform tasks, maintained or improved joint range of motion, muscle spasticity and bone density , and an enhanced ability to perform activities of daily living. In recent studies, some adults and children report a decrease in pain, suppository use , decubitus ulcers, urinary tract infections (UTI), and clinical depression, while reporting an increase in improved bowel function , breathing, circulation , and muscle tone. Psychological benefits have also been documented and include improved socialization, patient satisfaction and quality of life due to improved interacti on with others. Additionalbenefits for some patients can include enhanced independence, improved vocational activities, and increased recreational activities with peers and others, which have been reported to instill a heightened sense of confidence and equality and improved self – esteem in children and adults. Acceptance by others and a sense of integration is perceived to be higher among standing frame users. No adverse events or effects have been frequently reported or documented in literature, but some contraindications have been widely discussed. Additionally, many patients do not report pain with use of standing frames. With the added benefit of the enhance mentof functional recovery with early physical rehabilitation, many providers are adding supported standing as a practice in postural management after consideration of contraindications is examined by a medical professional .C. Definitions Activities of Daily Living (ADLs) Fundamental skills required to independently care for oneself Durable Medical Equipment (DME or DMEPOS ) A collective term for a covered durable medical equipment item, prosthetic device, orthotic device, or medical supply item furnished by an eligible provider to an eligible recipient Home Medical Equipment Equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, is not useful to a person in the absence of illness or injury and is appropriate for use in the home. Postural Management A multi-disciplinary approach incorporating a comprehensive schedule of daily and night-time positions, equipment, and physical Standing Frames-OH MCD-MM-1331Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 activity to help maintain or improve body structures and function and increase activity and participation. Technologically Sophisticated Medical Equipment (TSME) Prescribed by an authorized health care professional and requir ing individualized adjustment or regular maintenance by a home medical equipment services provider to maintain a recipients health care condition or the effectiveness of the equipment. Standers are considered TSME. D. PolicyI. CareSource will review medical necessity requests for non-powered standing frames on a case-by-case basis once ALL the following information is submitted for review: A. New Equipment 1. stander information, including ALL the following details: a. manufacturer b. model number c. type of stander d. part number, if applicable and if available e. an itemized list of any additional and accessories with individual prices, if not included with the basic stander or if applicable 2. a face-to-face evaluation with a qualified professional, such as an occupational therapist or a physical therapist, that includes ALL the following: a. recommendation of a postural management program that includes supported standing b. type of stander recommended (eg, prone, supine, vertical, multi – positional, sit-to-stand) c. goals of the postural management program including the goals of the type of stander requested d. specific dosing of the requested stander for the goals to be met e. a documented trial with the type of stander requested demonstrating the recipient can tolerate the recommended dose 3. a prescription following a face-to-face encounter addressing the same medical condition for which the stander is prescribed with a medical professional who has a relationship with the member and documented in the medical record , valid for 1 year, unless a different length of time is specified, and must include ALL the following: a. dated signature of 1 of the following appropriately Ohio-licensed and/or certified medical professionals: 01. physician (MD or DO) 02. advanced practice registered nurse (APRN) with a relevant specialty 03. physician assistant (PA) b. specific recipient diagnosis ( -es) documenting a neuromuscular condition (eg, multiple sclerosis, cerebral palsy, spinal cord injury, stroke) or documented developmental delay impairing the recipients ability to stand independently 4. documentation showing that the member or parent/guardian received training in the use of the requested type of stander , which can be completed during a scheduled therapy session for the member, if applicable Standing Frames-OH MCD-MM-1331Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 5. documentation showing the member or parent/guardian demonstrated safe use of the requested type of stander in the home setting (eg, documentation from physical therapy or other therapy sessions documenting trials of use suffice) 6. documentation that device use can be reasonably expected to provide therapeutic benefits or enable the member to perform certain tasks unable to perform otherwise due to the diagnosis, such as but not limited to 1 or more of the following: a. aids in the prevention of atrophy in the trunk and leg muscles b. improves strength and/or circulation to the trunk and lower extremities c. prevents formation of decubitus ulcers with changeable positions d. helps maintain bone and/or skin integrity e. reduces swelling in the lower extremities f. improves range of motion and/or aids normal skeletal development g. improves function of kidneys, bladder, and/or bowels h. decreases muscle spasms i. strengthens cardiovascular system and builds endurance j. prevents or decreases muscle contractures and/or progressive scoliosis k. improves social interaction and psychological well-being l. increases performance of activities of daily living (ADLs) 7. no contraindications to supported standing, such as but not limited to a. healing fracture or severe osteoporosis precluding weight bearing of any kind b. significant hip or knee flexion or ankle plantarflexion contractures in which stretch or pressure prevents standing c. compromised cardiovascular or respiratory systems requiring frequent monitoring of circulation and function while in stander d. significant inflexible skeletal deformities e. lack of standing tolerance (ie, cannot maintain a standing position due to little or no residual strength in the hips, legs, and lower extremities) f. postural hypotension 8. CareSource reserves the right to request the following: a. proof of delivery b. documentation of routine maintenance, adjustments, readjustments, or repairs c. annual review of continued need by a qualified provider B. Replacement of a non-powered standing frame is considered medically necessary after 5 years when both of the following criteria have been met: 1. medical necessity criteria above are met 2. device is out of warranty or not functioning properly and cannot be refurbished or adequately repaired II. The following items or services are not covered or separately reimbursable:A. electric, motorized, or powered standing frames B. items or services covered under manufacturer or dealer warranty C. DME items that duplicate or conflict with another item currently in the recipients possession Standing Frames-OH MCD-MM-1331Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 D. replacement items or previously approved equipment that have been damaged because of perceived misuse, abuse, or negligenceE. Conditions of CoverageAdditional instructions regarding reimbursement of DME items may be located in OAC 5160-10-01. CareSource reserves the right to request additional information if medical necessity is not adequately documented.F. Related Policies/Rules Medical Necessity Determinations Durable Medical Equipment (DME) Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/31/2022 New policy.Date Revised 07/19/2023 07/17/202405/07/202502/11/2025Annual review. Updated formatting to AMA style. Updated references. Approved at Committee.Annual review. Updated prescription validity to 1 year. Added face to face encounter with provider. Updated references. Approved at Committee. Annual review: references updated. Approved at Committee. Periodic review. Added requirement for evaluation with qualified professional and added type of stander to trial, training, and demonstrated safe use in the home. Updated references. Approved at Committee. Date Effective 06/01/2026 Date Archived H. References1. Capati V, Covert SY, Paleg G. Stander use for an adolescent with cerebral palsy at GMFCS level with hip and knee contractures. Assist Technol . 2020;32(6):335-341. doi:10.1080/10400435.2019.1579268 2. Definitions , OHIO REV . CODE ANN . 4752.01 (20 18 ). 3. Durable Medical Equipment, Prosthesis, Orthoses, and Supplies (DMEPOS): General Provisions , OHIO ADMIN . CODE 5160-10-01 (202 4). 4. Edemekong PF, Bomgaars DL, Sukumaran S, et al . Activities of Daily Li ving. In: StatPearls. Updated May 4, 2025 . 5. Ferrarello F, Deluca G, Pizzi A, et al. Passive standing as an adjunct rehabilitation intervention after stroke: a randomized controlled trial. Arch Physiother . 2015;5(2). doi:10.1186/s40945-015-0002-05 6. Goodwin J, Lecouturier J, Basu A, et al . Standing frames for children with cerebral palsy: a mixed-methods feasibility study. Health Technol Assess . 2018;22(50):1-232. doi:10.3310/hta22500 7. Ibitoye MO, Hamzaid NA, Ahmed YK. Effectiveness of FES-supported leg exercise for promotion of paralysed lower limb muscle and bone health a systematic review. Biomed Tech (Berl) . 2023;68(4):329-350. doi:10.1515/bmt-2021-0195 Standing Frames-OH MCD-MM-1331Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 8. Macias-Merlo L, Bagur-Calafat C, Girabent-Farrs M, et al . Standing programs to promote hip flexibility in children with spastic diplegic cerebral pal sy. Pediatr Phys Ther . 2015;27(3):243-249. doi:10.1097/PEP.000000 00 00000150 9. Martinsson C, Himmelmann K. Abducted standing in children with cerebral palsy: effects on hip development after 7 years . Pediatr Phys Ther . 2021;33(2):101-107. doi:10.1097/PEP.0000000000000789 10. Masselink, CE, Detterbeck A, LaBerge NB, et al. RESNA and CTF position on the application of supported standing devices: Current state of the literature. Assist Technol . 2024;37(4):257-274. doi: 10.1080/10400435.2024.2411560 11. Newman M, Barker K. The effect of supported standing in adults with upper motor neurone disorders: a systematic review. Clin Rehabil . 2012;26(12):1059-1077. doi:10.1177/0269215512443373 12. ODA Provider Certification: Home Medical Equipment and Supplies , OHIO ADMIN . CODE 173-39-02.7 (2022). 13. Paleg G, Livingstone R. Evidence-informed clinical perspectives on postural management for hip health in children and adults with non-ambulant cerebral palsy. J Pediatr Rehabil Med . 2022;15(1):39-48. doi:10.3233/PRM-220002 14. Paleg G, Livingstone R. Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury and other neurological conditions. BMC Musculoskelet Disord . 2015;16:358. doi:10.1186/s12891-015-0813-x 15. Paleg GS, Smith BA, Glickman LB. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatr Phys Ther . 2013;25(3):232-247. doi:10.1097/PEP.0b013e318299d5e7 16. Pedlow K, McDonough S, Lennon S, et al. Assisted standing for Duchenne muscular dystrophy . Cochrane Database Syst Rev . 2019;10(10):CD011550. doi:10.1002/14651858. CS011550.pub2 17. Standing frame : A-0996. MCG . 29th ed ition. Accessed January 7, 2026 . www.careweb.careguidelines.com 18. Synnot A, Chau M, Pitt V, et al . Interventions for managing skeletal muscle spasticity following traumatic brain injury. Cochrane Database Syst Rev . 2017;11(11):CD008929. doi:10.1002/14651858.CD008929.pub2 Independent med ical review 08/2022Approved by ODM 03/06/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Adaptive Seating for Special Needs-OH MCD-MM-1718 06/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectAdaptive Seating for Special Needs B. BackgroundCerebral palsy, developmental delays, Down Syndrome , and other health conditions may compromise an individuals ability to maintain a sitting posture , muscle tone, and movement . Depending on the severity and type of health condition, individuals may require support for the head, trunk, pelvis, and legs limit ing the ability to interact with others, eat, dress, work, and play. In addition, stability and strength for mobility or transfers may be lacking . There are many types of adaptive seating with different support systems. There is not one device that will meet the needs of all users. Some are requested as alternate positioning outside of a wheelchair. Some are used more for lounging. Others provide toimprove participation in functional activity, peer and family interactions and play.Adaptive seating systems (AdSS) may be used by individuals to achieve and hold an upright sitting position, enabling individuals to engage with others and conduct activitiesof daily living. AdSS can be individualized to meet the unique needs of the person with accessories that allow the seats to tilt, adjust seat height, increase posture support, transfers, and grant limited mobility in the local environment.C. Definitions Adaptive Desks Generally considered furniture and used to support physical and educational needs in a school setting. Adaptive Seating Systems (AdSSs) Equipment designed to improve safety, efficiency of movement , and optimize positioning while promoting active participation in daily activities . There are 2 types o Activity Chairs Seats that o ptimiz e positioning (eg, adaptive chairs, special needs chairs, pediatric positioning chairs, sitters, and therapy chairs ). o High-Low Chairs Height adjustable seats that secure the individual at the midline with adjustable trunk support, shoulder straps, and hip belts. Adaptive Strollers Strollers with increased seating and positioning options than a basic stroller . D. PolicyI. Adaptive Seating Systems (AdSS) and Accessories A. Adaptive Seating Systems CareSource considers AdSS medically necessary when ALL the following medical and clinical criteria are met: 1. A prescription valid for 1 year is written by any of the following providers with an established relationship with the member and appropriate certifications or training after documenting a completed face-to-face encounter: a. physician Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 b. advanced practice registered nurse c. physician assistant 2. member cannot safely sit in conventional seating due to a medical condition, modifications to the members current seating equipment cannot meet their needs, and at least 1 of the following medical criteria must be met : a. significant head and/or trunk instability or weakness with decreased motor control b. requires external support to maintain an upright position and proper body alignment due to medical condition c. has no functional protective or righting reaction d. must be in an upright supported position for safe and effective feeding and would otherwise have to be held by the caregiver for feeding e. severe seizure activity f. orthopedic condition resulting in significant bony fragility or significant fracture 3. A physical therap ist (PT) or occupational therapist (OT) experienced in an appropriate specialty and independent from the equipment vendor completed an evaluation and documented that the member can benefit from and safely use the item requested. a. A trial of the equipment must be completed to ensure member can safely use the requested seat and the goals of the seat can be achieved. b. Caregiver education on the use of the equipment must be completed with demonstrated safe use. c. Improvement of function due to the equipment must be documented. d. Other equipment used by the member needs to be listed as part of the evaluation (ie, wheelchairs, standers, gait trainers, other seating ). 4. Any person-centered service plans for the member, when applicable, must list use of AdSS. 5. A complete description of the item requested, including a. manufacturer b. model of style c. size d. all bundled components e. any accessories or not-included components f. any itemization of all charges B. Accessories 1. Accessories are considered medically necessary when providing additional functional support than that offered by a chair alone and any of the following criteria are met : a. cannot maintain head control in an upright position b. unable to perform a functional weight shift requiring relief to prevent pressure injuries c. needs additional trunk support that is not provided by the chair alone d. changes in muscle tone affecting body tilt or needs additional support for proper digestion or avoidance of severe gastroesophageal reflux Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 e. needed for independent movement in and out of the chair or repositioning the chair to complete daily activitiesII. Exclusions and LimitationsA. AdSS does not include ANY of the following: 1. adaptive desks (except for members under 21 will be reviewed on a case by case basis for EPSDT ) 2. any items not meeting the medical necessity criteria in this policy B. Duplicative equipment is excluded. Equipment with the same function as an existing AdSS will not be reviewed for medical necessity. C. AdSS must be the lowest cost alternative that addresses the members health condition. D. AdSS is for the benefit of the member and not for any caregiver, family member, or provider convenience. E. Conditions of CoverageNA F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 12/04/2024 New policy. Approved at Committee.Date Revised 01 /28 /202 6 Annual review. Update d background, D.I.A.3. II, exclusions and references. Approved at Committee. Date Effective 06/01/2026 Date Archived H. References1. An gsupaisal M, Maathuis CGB, Hadders-Algra M. Adaptive seating systems in children with severe cerebral palsy across International Classification of Functioning, Disability, and Health for children and youth version domains: a systematic review. Dev Med Child Neurol . 2015;57(10):919-930. doi:10.1111/dmcn.12762 2. Barkoudah E, Whitaker A. Cerebral palsy: treatment of spasticity, dystonia, and associated orthopedic issues. UpToDate. Updated July 15, 2025 . Accessed January 14 , 202 6. www.uptodate.com 3. Hale LW, Martin C. Autism spectrum disorder in children and adolescents: behavioral and educational interventions. UpToDate. Updated June 19, 2025 . Accessed January 14 , 202 6. www.uptodate.com 4. Inthachom R, Prasertsukdee S, Ryan SE, et al. Evaluation of the multidimensional effects of adaptive seating interventions for young children with non-ambulatory cerebral palsy. Disabil Rehabil Assist Technol . 2021;16(7):780-788. doi:10.1080/17483107.2020.1731613 Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 5. Khan I, Leventhal BL. Developmental Delay . StatPearls Publishing; 2023. AccessedJanuary 14 , 202 6. www.ncbi.nlm.nih.gov 6. Lyman J. Complex rehabilitation fact sheet. Cerebral Palsy Foundation. Accessed January 14 , 202 6. cpresource.org 7. Paleg G, Livingstone R, Rodby-Bousquet E, et al. Care Pathways central hypotonia. American Academy of Cerebral Palsy and Developmental Medicine. Accessed January 14 , 202 6. www.aacpdm.org 8. Provider recommendations for FY 2024 budget medical care advisory committee meeting June 2022. National Council for Assistive & Rehab Technology. Accessed January 14 , 202 6. www.ncart.us 9. Ryan SE. Lessons learned from studying the functional impact of adaptive seating interventions for children with cerebral palsy. Dev Med Child Neurol . 2016;58 (Suppl 4):78-82. doi:10.1111/dmcn.13046 10. Saihinoglu D, Coskun G, Bek N. Effects of different seating equipment on postural control and upper extremity function in children with cerebral palsy. Prosthet Orthot Int . 2017;41(1):85-94. doi:10.1177/0309364616637490 Independent medical review December 2024ODM approved 03 /06 /202 6
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333 06/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Summary of Evidence ………………………….. ………………………….. ………………………….. ……… 2 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333Effective Dat e: 06/01/20262A. SubjectPeripheral Nerve Stimulators for Treatment of Pain B. BackgroundThe role of targeting and treating peripheral nerves as sources of pain when conservative therapy has failed is being more extensively explored than in previous years. Neuromodulation of peripheral nerves to treat refractory pain is one such area of interest. The neuromodulation of peripheral nerves to reduce pain is commonly known as peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS), and percutaneous-eletrical nerve field stimulation (PENFS). It has been developed as a minimally invasive pain management modality intended to manage acute and chronic pain. The proposed mechanism of action, referred to as the gate control theory, involves a method by which stimulation of large-diameter sensory neurons reduces transmission ofpainful stimuli from small nociceptive fibers to the brain. The stimulation system is placed adjacent to the nerve, a process commonly known as remote selective targeting. The lead is connected to a small, wearable stimulator. Depending on the device, the wearer may be able to adjust the level of stimulation using Bluetooth technology. C. DefinitionsAcute Pain Pain lasting 4 weeks or less. Chronic Pain A distressing feeling often caused by intense or damaging stimuli (pain) lasting more than 3 months, which is considered beyond normal healing time. Sub-Acute Pain Pain lasting between 4 and 12 weeks. D. PolicyI. Peripheral nerve stimulat ion for pain management is considered experimental and investigational due to limited evidence published in peer-reviewed medical literature to support its long-term safety and efficacy . Examples of PNS devices include, but are not limited to: A. IB-Stim (NeurAxis) B. Moventis PNS C. Nalu Neurostimulation System D. Nerivio E. SPRINT PNS System F. StimQ PNS System G. StimRouter Neuromodulation System E. Summary of EvidenceWest et al. (2024) published the findings of a 2-year multicenter ana lysis of 126 patients to aid in determining the long-term effectiveness of PNS and if there was an impact to opioid consumption with PNS treatment. The study found no changes in opioid consumption after 24 months and due to the substantial loss to follow-up, the long-term effectiveness of PNS could not be determined. Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333Effective Dat e: 06/01/20263Chogle et al. (2024) conducted a multicenter, prospective open-label study for children ages 8-18 who underwent PENFS. 371 participants were enrolled and 292 had sufficient data on at least one of the three outcome surveys. Outcomes were assessed at baseline , weekly until the last visit, and follow-up time points. After 3 weeks, there was significant loss of participation (76/290) , which inc reased through the 12-month follow-up period (12/290). The study concluded that the significant loss of participation in extended follow-up made it difficult to understand the long-term suitability of PENFS. Goree et al . (2024) conducted a multicenter, rando mized, double-blind, placebo-controlled trial for treating chronic, persistent postoperative pain after total knee arthroplasty for end-stage knee osteoarthritis with percutaneous peripheral nerve stimulation . PNS provides great pain relief and reduced opioid use within the first two weeks after surgery and this study aimed to determine if pain management could continue for persistent, chronic pain. 29 p atients underwent treatment with the device for 8 weeks and continued follow up at 3, 6, 9, and 12 months. 27 patients underwent placebo treatment with follow up at the same intervals. A greater propor tion of patients in the PNS group versus the placebo group had 50% reduction in pain relief through weeks 5-8. Pro spective follow-up is on going to determine long term results. F. Conditions of CoverageN/A G. Related Policies/RulesMedical Necessity Determinations Experimental and /or Investigational Item or Service H. Review/Revision HistoryDATE ACTIONDate Issued 10/01/2022Date Revised 07/29/2022 02/15/202301/17/202406/05/2024 05/07/2025 01/28/2025 Converted from administrative policy (AD-1201) to medical policy. Annual review. Updated definitions. Annual review : references updated ; approved at Committee. Revised Background, added D. III. A. Approved at Committee Annual review-references updated, approved at Committee. Annual review, added Nerivio to D. III. Section E., Summary of Evidence, added. Approved at Committee Date Effective 06/01/2026 Date Archived I. References1. Abd-Elsayed A, Keith MK, Cao NN, Fiala KJ, Martens JM. Temporary peripheral nerve stimulation as treatment for chronic pain. Pain Ther . 2023;12(6):1415-1426. doi:10.1007/s40122-023-00557-3 Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333Effective Dat e: 06/01/202642. Albright-Trainer B, Phan T, Trainer RJ, et al. Peripheral nerve stimulation for the management of acute and subacute post-amputation pain: a randomized, controlled feasibility trial. Pain Manage . 2022;12(3):357-369. doi:10.2217/pmt-2021-0087 3. Char S, Jin MY, Francio VT, et al. Implantable peripheral nerve stimulation for peripheral neuropathic pain: a systematic review of prospective studies. Biomed . 2022;10(10)2606. doi:10.3390/biomedicines10102606 4. Chogle A, El-Chammas K, Santucci N, et al. A multicenter registry study on percutaneous electrical nerve field stimulation for pediatric disorders of gut-brain. J Pediatr Gastroenterol Nutr . 2024;78(4):817-826. doi:10.1002/jpn3.12174 5. DSouza RS, Jin MY, Abd-Elsayed A. Peripheral nerve stimulation for low back pain: a systematic review. Curr Pain Headache Rep . 2023;27:117-128. doi:10.1007/s11916-023-01109-2 6. Dorfman L, El-Chammas K, Graham K, et al. Repeat round of auricular percutaneous electrical nerve field stimulation for pediatric disorders of gut brain interaction. JPediatr Gastroenterol Nutr . 2025;(81)(2):234-245. doi:10.1002/jpn3.70109 7. Evidence Analysis Research Brief: Peripheral Nerve Stimulation for the Treatment of Superior Cluneal Neuralgia. Hayes; 2024. Accessed January 21, 2026 . www.evidence.hayesinc.com 8. Evolving Evidence Review: IB-Stim (NeurAxis) for Treatment of Pain Associated with Irritable Bowel Syndrome in Adolescents. Hayes; 2022. Reviewed July 28, 2025 . Accessed January 21, 2026 . www.evidence.hayesinc.com 9. Evolving Evidence Review: Nerivio (Theranica Bio-Electronics LTD.) for Treatment of Acute Migraine Episodes in Adults. Hayes ; 2025. Accessed December 10, 2025. www.evidence.hayesinc.com 10. Evolving Evidence Review: SPRINT PNS System (SPR Therapeutics) for Chronic Pain. Hayes; 2021. Updated February 27, 2025 . Accessed January 21, 2026 . www.evidence.hayesinc.com 11. Goree JH, Grant SA, Dickerson DM, et al. Randomized placebo-controlled trial of 60 – day percutaneous peripheral nerve stimulation treatment indicates re lief of persistent postoperative pain and improved function after knee replacement. Neuromodulation . 2024; 27:847-861. doi:10.1016/j.neurom.2024.03.001 12. Hatheway J, Hersel A, Song J, et al. Clinical study of a micro-implantable pulse generator for the treatment of peripheral neuropathic pain: 3-month and 6-month results from the COMFORT-randomised controlled trial. Reg Anesth Pain Med . 2024;0:1-7. doi:10.1136/rapm-2023-105264 13. Health Technology Assessment: Percutaneous Peripheral Nerve Stimulation for Treatment of Chronic Pain. Hayes; 2022. Reviewed May 30 , 202 5. Accessed January 21, 2026 . www.evidence.hayesinc.com 14. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain. Hayes; 2021. Reviewed April 17, 2024. Accessed January 21, 2026 . www.evidence.hayesinc.com 15. Helm S, Shirsat N, Calodney A, et al. Peripheral nerve stimulation for chronic pain: a systematic review of effectiveness and safety. Pain Ther . 2021;10(2):985-1002. doi:10.1007/s40122-021-00306-4 16. Huntoon MA, Slavin KV, Hagedorn JM, et al. A retrospective review of real-world outcomes following 60-day peripheral nerve stimulation for the treatment of chronic Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333Effective Dat e: 06/01/20265pain. Pain Physician . 2023;26(3):273-281. Accessed January 21, 2026 .www.painphysicianjournal.com 17. Kaye AD, Ridgell S, Alpaugh ES, et al. Peripheral nerve stimulation: a review of techniques and clinical efficacy. Pain Ther . 2021;10(2):961-972. doi:10.1007/s40122 – 021-00298-1 18. Li AH, Gulati A, Leong MS, et al. Considerations in permanent implantation of peripheral nerve stimulation (PNS) for chronic neuropathic pain. an international cross-sectional survey of implanters. Pain Pract . 2022;22(5):508-515. doi:10.1111/papr.13105 19. Luna D, Hettie G, Pirrotta L, et al. Real-world long-term outcomes of peripheral nerve stimulation: a prospective observational study. Pain Manag . 2025 ;15(1):37-44. doi:10.1080/17581869.2025.2451605 20. McCullough M, Kenney D, Curtin C, et al. Peripheral nerve stimulation for saphenous neuralgia. Reg Anesth Pain Med . 2024;49(6):455-460. doi:10.1136/rapm-2023 – 104538 21. Smith BJ, Twohey EE, Dean KP, DSouza RS. Peripheral nerve stimulation for the treatment of postamputation pain: a systematic review. Am JPhys Med Rehabil . 2023;102(9):846-854. doi:10.1097/PHM.0000000000002237 22. Strand N, DSouza RS, Hagedorn JM. Evidence-based clinical guidelines from the American Society of Pain and Neuroscience for the use of implantable peripheral nerve stimulation in the treatment of chronic pain. JPain Res . 2022;15:2483-2504. doi:10.2147/JPR.S362204 23. Vangeison CT, Bintrim DJ, Saha AK, et al. The role of peripheral nerve stimulation in refractory non-operative chronic knee osteoarthritis. Pain Manag . 2023;13(4):213 – 218. doi:10.2217/pmt-2023-0025 24. West T, Hussain N, Bhatia A, et al. Pain intensity and opioid consumption after temporary and permanent peripheral nerve stimulation: a 2-year multicenter analysis. Reg Anesth Pain Med . 2024. doi:10.1136/rapm-2024-105704 25. Xu J, Sun Z, Wu J, et al. Peripheral nerve stimulation in pain management: a systematic review. Pain Physician . 2021;24(2):E131-E152. Accessed January 21, 2026 . www.painphysicianjournal.com Approved by ODM on 02/25/2026
MEDICAL POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Metabolic, Bariatric and Revision Surgery-OH MCD-MM-1061 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents 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 Metabolic, Bariatric and Revision Surgery-OH MCD-MM-1061Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMetabolic, Bariatric and Revision Surgery B. Background Obesity continues to be a major health threat in the United States affecting an increasingly larger proportion of adults and children. The Centers for Disease Control and Prevention (CDC) estimates that over 40.3% of adults in the United States older than the age of 20 are obese (2021-2023). Obesity in adults aged 40 to 59 is higher (46.4%) than those under aged 40 (35.5%). The primary goals in achieving optimal health outcomes for CareSource members are to provide noninvasive approaches to reduce or prevent obesity by promoting healthy life-styles that will improve long-term outcomes. For individuals not able to manage serve obesity though non-surgical interventions, metabolic and bariatric surgery options may be an effective intervention. Revision procedures are typically done because of complications from or a failure of the initial surgical procedure. Complications may include surgical or anatomical complications, as well as nutritional or metabolic complications. A failure of the initial bariatric surgery may result in an inadequate weight loss or a weight regain. C. Definitions Revisional Bariatric Surgery (RBS) surgery to address those patients whose original operation was unsuccessful in achieving satisfactory weight loss goals, or in whom complications from the original operation have occurred. Inadequate Weight Loss Less than 50% expected weight loss and/or weight remains greater than 40% over ideal body weight (normal body weight BMI parameter = 18.5-24.9). D. Policy I. CareSource reviews medical necessity for the initial bariatric surgery using MCG criteria. II. CareSource considers surgical revision of a bariatric surgery procedure a covered service when medically necessary. III. Inadequate weight loss due only to non-compliance with dietary, behavior, or exercise recommendations is not a medically necessary indication for a revision procedure. III. A revision procedure is medically necessary when all of the following criteria are met and documented in the medical record: A. surgery/procedure selected is a proven procedure and not considered experimental/investigational and Metabolic, Bariatric and Revision Surgery-OH MCD-MM-1061Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 B. a technical failure or major complication has occurred from the initial procedure that cannot be managed medically. Technical failure and major complication examples include the following: 1. persistent pain and recurrent bleeding occur 2. chronic stenosis remains after multiple dilations 3. faulty component or malfunction that cannot be repaired 4. candy cane roux syndrome 5. complications that cannot be corrected with band manipulation, adjustments or replacement including band slippage and port leakage or a. obstruction confirmed by imaging studies. NOTE: Stretching of a stomach pouch formed by a previous bariatric surgery due to overeating is not considered a complication and therefore is not considered an indication for revision . IV. In the absence of a technical failure or major complication, individuals with weight loss failure 2 years following the initial bariatric surgery procedure must meet medical necessity requirements in the medical policy that applies to an initial bariatric surgery. V. CareSource does not consider endoscopic bariatric and metabolic therapies such as Intragastric balloon (IGB) , endoscopic sleeve gastroplasty (ESG), or aspiration therapy (AT) to be weight loss surgery. Individuals with weight loss failure from prior endoscopic therapies must meet medical necessity requirements in the medical policy that applies to an initial bariatric surgery. E. Conditions of CoverageN/A F. Related Policies/Rules Medical Necessity Determinations Experimental and Investigational Item or Service G. Review/Revision History DATE ACTIONDate Issued 07/22/2020 New policy Separated out from adolescent and adult policiesDate Revised 06/23/2021 06/22/202206/21/2023PA language replaced by medical necessity criteria. PA enforced by inclusion on the PA list. Updated references. Re-wording of section IV re: medical necessity for revision bariatric surgery. Sec. V. Added IGB, ESG and AT non-coverage. Updated references. Annual review; no changes, Updated references, Approved at committee. Metabolic, Bariatric and Revision Surgery-OH MCD-MM-1061Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 06/19/202402/26/202502/25/2026Added definition of Revisional bariatric surgery (RBS). Updated references. Approved at Committee. Updated references. Approved at Committee. Changed title. Added extra background and section I regarding initial procedure medical necessity criteria. Updated references. Approved at Committee. Date Effective 06/01/2026 Date Archived H. References1. Chen S, Chiang J, Ghanem O, et al. Decision-making Considerations in Revisional Bariatric Surgery. Surg Laparosc Endosc Percutan Tech. 2024;34(4):400-406. doi:10.1097/SLE.0000000000001296 2. Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federal for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis. 2022;18(12):1345-1356. Accessed January 14, 2026. www.soard.org 3. Ellsmere J. Bariatric operations: late complications with subacute presentations. Updated July 18, 2023. Accessed January 17, 2026. www.uptodate.com 4. Evolving Evidence Review. Apollo ESG System (Apollo Endosurgery Inc.) for Endoscopic Sleeve Gastroplasty. September 11, 2024. Accessed January16, 2026. www.hayesinc.com. 5. Federal Drug Administration. Updated Sept. 15, 2023. Weight-Loss and Weight- Management Devices. Accessed January 16, 2026. www.fda.gov 6. Gastric Restrictive Procedure with Gastric Bypass (S-512). MCG. 29th ed. 2025. Accessed January 14, 2026. www.careweb.careguidelines.com 7. Intragastric Balloons for Treatment of Obesity. Hayes Technology Review Mar 16, 2022. Accessed January 14, 2026. www.hayesinc.com 8. Mechanick J, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures 2019 update: cosponsored by American Association of Clinical Endocrinologist/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity. 2020;28(4):683-839. doi:10.1002/oby.22719 9. Mirkin K, Alli VV, Rogers AM. Revisional Bariatric Surgery. Surg Clin North Am. 2021;101(2):213-222. doi:10.1016/j.suc.2020.12.008 10. Salas-Parra RD, Smolkin C, Choksi S, Pryor AD. Bariatric Surgery: Current Trends and Newer Surgeries. Gastrointest Endosc Clin NAm. 2024;34(4):609-626. doi:10.1016/j.giec.2024.06.005 11. Yung-Chieh, Y, Huang, C, Tai, C. Psychiatric aspects of bariatric surgery. Current Opinion in Psychiatry. 2014;27(5):374-379. doi:10.1097/YCO.0000000000000085. Independent medical review 7/2020 Metabolic, Bariatric and Revision Surgery-OH MCD-MM-1061 Effective Date: 06/01/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 5 Approved by ODM 03/03/202 6
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Facet Joint Interventions-OH MCD-MM-0967 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 5 F. Related Polices /R ules ………………………….. ………………………….. ………………………….. ………. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 5 H. References ………………………….. ………………………….. ………………………….. …………………….. 6 Facet Joint Interventions-OH MCD-MM-0967Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectFacet Joint Interventions B. BackgroundAn estimated 84% of adults experience back pain during their lifetime . Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms persist . Persistent pain is categorized as subacute when it lasts between 4 and 12 weeks and chronic when it persists for at least 3 months. Facet joint pain comprises 27% -40% of patients with chronic low back pain . Comprehensive pain management care plans are most effective in managing a patients chronic pain. These plans focus on a person-centered approach and incorporateconservative treatment with other modalities. These multidisciplinary treatments promot e self-management and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved completely. In addition to conservative therapy, treatment options may include nonpharmacologic or pharmacologic treatments, and nonsurgical or surgical interventions. Only p roviders qualified in i nterventional procedures for pain unresponsive to conservative treatment should perform these health services. Low back pain (LBP) can originate from different areas of the spine, such asintervertebral discs, facet joints, sacroiliac joints, and nerve roots. While some sources of spinal pain can be diagnosed by imaging, discogenic pain without disc herniation and facet joint or sacroiliac joint pain are difficult to diagnose with imaging alone. M edial branch nerve blocks are a diagnostic tool to identify the cause of pain and can provi de short term pain relief with certain medications. Following a presumptive diagnosis of facet joint pain through a physical examination and plain radiography or axial imaging , the diagnosis may be confirmed by relief of pain through injection of local anesthetic to the medial branches of the posterior rami of the dorsal spinal nerves supplying the proposed facet joint(s). Medial branch nerve blocks may be performed at the targeted joint itself, one joint above and one joint below on the same side, or bilaterally per treatment session. Medial branch nerve block injections should be performed with fluoroscopy or computed tomography . A patient may receive a diagnostic injection of a short-acting local anesthetic agent to identify the pain generator. If pain is relieved by the injection, then a radiofrequency ablation (RFA), which uses energy to destroy the nerve , can be performed . A successful radiofrequency facet ablation of the affected nerve (same anatomic location of the positive diagnostic block) may relieve pain for a period of months up to a year or more until nerve regeneration occurs. C. Definitions Conservative Therapy A multimodality plan of care including both active and inactive conservative therapies. Facet Joint Interventions-OH MCD-MM-0967Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Active Conservative Therapies Actions or activities that strengthen muscle groups and target key spinal structures, i nclud ing physical therapy, occupational therapy, a physician supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete a HEP due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain including rest, ice, heat, medical devices, acupuncture, TENS use , and/or pharmacotherapy (prescription or over the counter [eg, NSAIDS, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current directed through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins . Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy . Medial Branch Nerve Block Injection A diagnostic procedure in which a short – acting anesthetic (eg, lidocaine) is injected near small medial nerves connected to a specific facet joint. It may also be performed to treat back pain caused by facet joint(s) with a longer acting anesthetic (eg, bupivacaine). o Successful Diagnostic Injection An injection that achieves greater than 80% reduction in pain within the duration of effectiveness for the anesthetic used. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. D. PolicyCareSource considers facet joint interventions for management of chronic back pain medically necessary when the clinical criteria in this policy are met. I. Medial Branch Nerve Block InjectionsA. Up to 2 diagnostic medial branch nerve block injections in the cervical , thoracic , or lumbar regions are considered medically necessary when ALL of the following criteria are met: 1. Initial d iagnostic block confirm s facet joint as source of spinal pain and provides 80% or greater primary pain relief and duration of relief is consistent with agent employed. 2. Second diagnostic block confirms validity of the initial injection and is injected at the same level where the initial produced a positive response. 3. Each diagnostic block may treat up to 3 spinal levels (unilateral or bilateral) for a maximum of 6 spinal levels per spinal region per session . Facet Joint Interventions-OH MCD-MM-0967Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 4. Radiofrequency ablation is being considered as a therapeutic intervention.5. Injections should be at least 2 weeks apart . 6. Imaging studies and physical exam ruled out other causes of spinal pain (eg, fracture, tumor, infection, herniated disk, spinal stenosis, significant deformity) . 7. Patient history with at least 3 months of moderate to severe pain with functional impairment that has not adequately responded to active and inactive conservative therapy . 8. Failure of conservative therapy as evidenced by ALL of the following: a. Documentation in the medical record of at least 6 weeks of active conservative therapy (as defined above) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance. b. Documentation in the medical record of at least 6 weeks of inactive conservative therapy (as defined above) within the past 6 months. 9. No coagulopathy . 10. No current infection at the injection site. B. Diagnostic medial branch nerve blocks are NOT considered medically necessary when RFA is not being considered as a treatment option. II. Radiofrequency Ablation (RFA) for Facet Joint PainA. Initial RFA for Facet Joint Pain is considered medically necessary when in the past 36 months 1. The clinical criteria above (I.A.1-10 ) have been met . 2. 2 successful medial branch nerve block injections were performed at the same spinal region and achiev ed 80% or more pain relief . B. Repeat RFA for facet joint pain is considered medically necessary when in the past 36 months 1. Prior successful single or multilevel facet RFA in the same spinal region (cervical, thoracic, or lumbar) and side provid ed at least 50% pain relief over a minimum of 6 months . 2. The m ost recent RFA was at least 6 months prior . 3. No more than 4 RFAs per rolling 12 months ( 2 left and 2 right per spinal region) are considered appropriate . III. SedationA. Neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. B. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. Facet Joint Interventions-OH MCD-MM-0967Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 IV. Inconclusive or Non-Supportive EvidenceA. Medial branch nerve block injections are unproven for the treatment of chronic spinal pain. Routine therapeutic injections will not be authorized for chronic pain management . B. Intra-articular facet joint injections for neck and back pain are not considered medically necessary as there is limited evidence and the efficacy has not been established. C. Intra-articular facet joint injections do not qualify as diagnostic information for a proposed neurotomy . V. Spinal Cord Stimulators/Pain PumpsPatients with indwelling implanted spinal cord stimulators or pain pumps should include a device interrogation report with the required medical records for medical necessity review requests. If a device is not functioning properly, an escalation in pain ma y warrant evaluation and management of the implanted device. E. Conditions of CoverageN/A F. Related Polices /R ules Epidural Steroid Injections Peripheral Nerve Block s for Treatment of Pain Sacroiliac Joint Procedures Trigger Point Injections G. Review/Revision HistoryDATE ACTIONDate Issued 05/13/20 20 This policy replaces the Facet Medial Branch Nerve Block and Radiofrequency Facet Ablation policies. Added c riteria re: exclusion of repea t diagnostic injections for RFA. Date Revised 07/22/2020 11/11/202007/21/202106/22/2022 06 /21 /202305/08/202404/09/2025 Revisions: Medial Branch Nerve Block injection clinical criteria; requirement of one successful RFA session. Revision: RFA language revised around benefit limit for clarity. (This revision does not require a network notification or a change of the Effective Date). Annual Update: Removed PA language. Annual Review: updated background, references, definitions, re-organized criteria, added coagulopathy and infection language Annual Review: revised language, added RFA requirement for diagnostic injections, updated references; Approved at Committee. Annual review: updated references, approved at Committee Review: updated references, approved at Committee. Facet Joint Interventions-OH MCD-MM-0967Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 02/11 /2026 Review: changed physician to provider, removed dates of service documentation language, added related policies. Approved at Committee. Date Effective 05/01/2026 Date Archived H. References1. Ashmore ZM , Bies MM, Meiling JB, et al. Ultrasound-guided lumbar medial branch blocks and intra-articular facet joint injections: a systematic review and meta – analysis. Pain Rep. 2022;7(3):e1008. doi:10.1097/ PR9. 0000000000001008 2. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate . Updated January 27, 2026 . Access ed February 3, 2026 . www.uptodate.com 3. Chou R. Subacute and chronic low back pain: surgical treatment. UpToDate . Updated October 3 , 2023 . Access ed February 3, 2026 . www.uptodate.com 4. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline . Ann Intern Med . 2017;166(7):493-505. doi:10.7326/M16-2459 5. Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med . 2020;45(6):424-467. doi:10.1136/rapm-2019-101243 6. Copenhaver DJ, Pritzlaff SG, Jung M, et al. Interventional therapies for chronic pain. UpToDate. Updated September 22 , 2025. Accessed February 3, 2026 . www.uptodate.com 7. Curtis L, Shah N, Padalia D. Facet joint disease. StatPearls . StatPearls Publishing; updated March 27, 2025 . Accessed February 3, 2026 . www.ncbi.nlm.nih.gov 8. Facet Joint Injection : A-0695 . MCG Health. 2 9th ed. MCG Health; 202 5. Updated June 13, 2025 . Accessed February 3, 2026 . www.careweb.careguidelines.com 9. Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med . 2022;47(1):3-59. doi:10.1136/rapm-2021 – 103031 10. Isaac Z, Kelly H. Evaluation of the adult patient with neck pain. UpToDate. Updated March 28, 2025 . Accessed February 3, 2026 . www.uptodate.com 11. Le DT, Alem N. Facet Joint Injection. StatPearls . StatPearls Publishing; updated June 20 , 2023 . Accessed February 3, 2026 . www.ncbi.nlm.nih.gov 12. Lee DW, Pritzlaff S, Jung MJ, et al. Latest Evidence-Based Application for Radiofrequency Neurotomy (LEARN): best practice guidelines from the American Society of Pain and Neuroscience (ASPN). JPain Res . 2021;14:2807-2831. doi:10.2147/JPR.S325665 13. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain : American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint interventions Facet Joint Interventions-OH MCD-MM-0967Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 2020 guidelines . Pain Physician . 2020;23(3S):S1-S127. Accessed February 3, 2026 .www.painphysicianjournal.com 14. Manchikanti L, Knezevic E, Knezevic NN, et al. Effectiveness of facet joint nerve blocks in managing chronic axial spinal pain of facet joint origin: a systematic review and meta-analysis. Pain Physician . 2024 Feb;27(2):E169-E206. 15. Perolat R, Kastler A, Nicot B, et al. Facet joint syndrome: from diagnosis to interventional management. Insights Imaging . 2018;9(5):773-789. doi:10.1007/s13244-018-0638x 16. Won HS, Yang M, Kim YD. Facet joint injections for management of low back pain: a clinically focused review. Anesth Pain Med (Seoul) . 2020;15(1):8-18. doi:10.17085/apm.2020.15.1.8 Approved by ODM 0 2/19/2026 .
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Radiofrequency and Microwave Ablation of Tumors-OH MCD-MM-1349 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 D. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 E. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 F. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 G. References ………………………….. ………………………….. ………………………….. ……………………. 6 Radiofrequency and Microwave Ablation of Tumors-OH MCD-MM-1349Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectRadiofrequency and Microwave Ablation of Tumors B. BackgroundRadiofrequency and microwave ablation, both types of thermo-ablation, may be appropriate mod alities to treat certain types of tumors. Radiofrequency ablation involves the delivery of high frequency alternating current to induce thermal injury of target ed tissue. Microwave ablation utilizes microwave ener gy to cause thermal coagulation and tissue necrosis at the targeted site. Evidence for the use of thes e ablati ve techniques is constantly evolving based on tumor type, size, and location. Hepatocellular carcinoma is the most common type of primary liver cancer. Treatmentoptions include surgical excision, hepatic artery infusion chemotherapy, trans-arterial bland or chemoembolization, selective interstitial radiotherapy (Yttrium 90 microspheres), percutaneous ethanol injection, cryoablation, and thermo-ablation. Radiofrequency ablation and microwave ablation have demonstrated comparable results to other treatment options for smaller tumors. Liver metastases are a common manifestation of many primary cancers. The number, location, size, and patients general health determine the choice of treatment for livermetastases. While surgical resection with curative intent is ideal, this may not be possible for all patients . Non-surgical ablative techniques may be used for both curative and palliative intent, includ ing systemic chemotherapy , targeted therapy, immunotherapy , external beam radiotherapy, cryoablation, thermo-ablation, arterial embolization techniques, and selective internal radiation therapy. Lung cancer is one of the most common types of cancer , as well as a common site ofmetastases. Since symptoms often do not appear until advanced disease, prognosis can be poor . Common treatments for primary or metastatic cancer in the lung include surgery, chemotherapy, radiotherapy, photodynamic therapy, thermal ablation, immunotherapy, and biological therapy. Treatment selection is based on type, size, position and stage of cancer, and the patients overall health. Small renal masses (SRM) , less than 4cm i n size is suspicious for clinical state T1arenal cell carcinoma , are the most common t ype of kidney tumor encountered. SRMs are often found incidentally with imaging for unrelated indications. Thermo-ablative techniques like RFA and MWA are gaining greater acceptance in cl inical practice due to favorable outcomes observed in initial studies, low incidence of complications, low cost and ability to treat patients in the outpatient setting . Definitions Tumor Ablation Direct application of energy to eradicate or destroy focal tumors.The method of ablation is dependent on the characteristics of the lesion and risk mitigation. Radiofrequency and Microwave Ablation of Tumors-OH MCD-MM-1349Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Microwave Ablation (MWA) Delivery of high-frequency microwave energy to rapidly agitate water molecules in the target tissue; the energy is converted to heat, which causes tissue necrosis. o Radiofrequency Ablation (RFA) Delivery of radio waves to generate heat and induce tissue destruction in the targeted area. C. PolicyI. Microwave ablation for tumor treatment using an FDA-approved device is considered medically necessary when ONE of the following indications are met: A. Member has primary or metastatic hepatic (liver) tumor and ALL the following: 1. The tumor is unresectable due to location of lesion(s) OR the member has comorbid condition (s) that are contraindicative to surgery . 2. The t umor is 5cm in size or there are no more than 3 nodules, all of which are 3cm in size . 3. Microwave ablation may be used alone or in conjunction with open or minimally invasive resection of other liver tumors. Curative resection of all disease must be the stated goal of therapy . B. Member has primary or metastatic lung tumor and ALL the following: 1. The tumor is unresectable due to location of lesion(s) or the member has comorbid condition(s) that are contraindicative to surgery . 2. Single tumor is 3cm in size. C. Member has T1 renal cell carcinoma and ONE of the following: 1. Renal mass is 4cm in size and the memb er is not eligible for surgery or declines surgery. 2. Renal mass in > 4 cm but 7cm and the member is not elig ible for surgery. II. Microwave ablation is not covered for any other indication, including (but not limited to), the following:A. Microwave ablation for any other tumor type is considered experimental and investigational due to a lack of clinical evidence on its efficacy . B. Microwave ablation for tumors larger than the above indications is considered experimental and investigational due to a lack of clinical evidence on its efficacy compared to other treatment modalities. III. Radiofrequency ablation for tumor treatment is considered medically necessary forANY of the following indications (NOTE: updates to MCG take precedence over the below criter ia) : A. Barrett esophagus with dysplasia B. bone metastases C. hepatocellular carcinoma with ALL the following: 1. Child-Pugh class A or Bliver function (score of 9 or less) 2. surgical evaluation indicates at least 1 of the following: a. patient is a candidate for surgical resection following radiofrequency ablation Radiofrequency and Microwave Ablation of Tumors-OH MCD-MM-1349Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 b. patient is a candidate for transplant following bridge therapy by radiofrequency ablation c. patient is not a surgical candidate (or elects against surgery) d. patient is not a transplant candidate 3. tumor has ALL the following: a. location amenable to percutaneous, minimally invasive or open surgical ablation b. margins accessible to ablation c. not in close proximity to critical structures (eg, major vessels, major bile ducts, diaphragm, other intra-abdominal organs) d. single tumor 5cm or smaller in diameter OR no more than 3 tumors, each of which is 3cm or smaller in diameter 4. no portal hypertension D. kidney tumor with ALL the following: 1. clinical stage T1 renal lesion 2. patient is not candidate for or elects against active surveillance 3. patient is not a surgical candidate (or elects against surgery) 4. tumor is not a renal angiomyolipoma E. liver metastases from colorectal carcinoma with ALL the following: 1. patient is not an ideal surgical candidate (or elects against surgery) 2. tumor has ALL the following: a. location amenable to percutaneous or surgical ablation b. margins accessible to ablation c. no t in close proximity to critical structures (eg, major vessels, major bile ducts, diaphragm, other int ra-abdominal organs) d. single tumor 5cm or smaller in diameter OR no more than 3 tumors, each of which is 3cm or smaller in diameter 3. no extrahepatic disease F. lung cancer (non-small cell [NSCLC ]) with ALL the following: 1. patient is not a surgical candidate (or elects against surgery) 2. tumor with ALL the following: a. less than 3cm in diameter b. node negative (stage I) c. not in close proximity to major pulmonary vessels or esophagus G. osteoid osteoma H. soft tissue sarcoma with at least ONE of the following: 1. gastrointestinal stromal tumor with limited progressive disease (ie, appearance of new lesion, increase in tumor size) 2. soft tissue sarcoma of extremity, superficial trunk, or head/neck, as indicated by both a. synchronous stage IV disease b. need for treatment of tumor bulk limited to single organ that is amenable to local therapy, or palliation of disseminated metastases I. thyroid cancer with at least ONE of the following: Radiofrequency and Microwave Ablation of Tumors-OH MCD-MM-1349Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 1. differentiated thyroid carcinoma (eg, follicular, papillary) with at least ONE of the following: a. distant metastasis or persistent disease not amenable to treatment with radioactive iodine b. recurrent disease following treatment of locoregional disease 2. medullary carcinoma with at least ONE of the following: a. palliative treatment of symptomatic metastases or progressive disease needed b. Patient asymptomatic, with at least ONE of the following: 01. disease metastasis 02. persistent disease following treatment of locoregional disease 03. recurrent disease following treatment of locoregional disease J. thyroid nodules, with ALL the following: 1. compressive symptoms from nodules (eg, cough, dysphagia, foreign body sensation, pain, voice changes) 2. patient not a surgical candidate (or elects against surgery) K. uterine leiomyomas with ALL the following: 1. laparoscopic ultrasound-guided procedure planned 2. leiomyomas documented by imaging study (e g, ultrasound) or hysteroscopy) 3. patient desires uterine conservation or is not a surgical candidate 4. patient is premenopausal 5. persistent symptoms (3 months or greater in duration) directly attributed to presence of leiomyomas, as indicated by at least ONE of the following: a. abnormal uterine bleeding unresponsive to conservative management (eg, hormonal therapy) b. bowel dysfunction c. dyspareunia d. infertility e. iron deficiency anemia f. pelvic pain or pressure g. urinary dysfunction 6. testing has ruled out other potential ca uses of symptoms D. Conditions of CoverageNA E. Related Policies/RulesNA F. Review/Revision HistoryDATE ACTIONDate Issued 10/12/2022Date Revised 09/27 /2023 08/28/2024 Annual review: updated references. Approved at Committee. Rev iew: updated references, approved at Committee Radiofrequency and Microwave Ablation of Tumors-OH MCD-MM-1349Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 06/18/202502/11 /2026Review: added Barrett and thyroid nodule indications, updated references, approved at Committee.Review: expanded background, added renal MWA indications, approved at Committee. Date Effective 05/01/2026 Date Archived G. References1. Aarts BM, Gomez FM, Lopez-Yurda M, et al. Safety and efficacy of RFA versus MWA for T1a renal cell carcinoma: a propensity score analysis. Eur Radiol . 2023;33(2):1049-1049. doi: 10.1007/s00330-022-09110-w. 2. Abdalla M, Collings AT, Dirks R, et al. Surgical approach to microwave and radiofrequency liver ablation for hepatocellular carcinoma and colorectal liver metastases less than 5cm: a systematic review and meta-analysis. Surg Endosc. 2023;37(5):3340-3353. doi:10.1007/s00464-022-09815-5 3. Cazzato RL, de Rubeis G, de Marini P, et al. Percutaneous microwave ablation of bone tumors: a systematic review. Eur Radiol . 2021;31(5):3530-3541. doi:10.1007/s00330-020-07382-8. 4. Chung SR, Suh CH, Baek JH, et al. Safety of radiofrequency ablation of benign thyroid nodules and recurrent thyroid cancers: a systematic review and meta – analysis. Int JHyperthermia . 2017;33:920-930. doi:10.1080/02656736.2017.1337936 5. Cui R, Yu J, Kuang M, et al. Microwave ablation versus other interventions for hepatocellular carcinoma: a systematic review and meta-analysis. JCancer Res Ther . 2020;16(2):379-386. doi:10.4103/jcrt.JCRT_403_19 6. Curley SA, Stuart KE, Schwartz JM, et al. Localized hepatocellular carcinoma: liver – directed therapies for nonsurgical candidates who are eligible for local ablation. UpToDate. Updated April 17 , 2025 . Accessed January 23, 2026. www.uptodate.com 7. Dupuy DE. Image-guided ablation of lung tumors. UpToDate. Updated July 16, 2025 . Accessed January 23, 2026 . www.uptodate.com 8. Genshaft SJ, Suh RD, Abtin F, et al. Society of Interventional Radiology quality improvement standards on percutaneous ablation of non-small cell lung cancer and metastatic disease to the lungs. JVasc Interv Radiol . 2021;32:1242.e1-1242.e10. doi:10.1016/j.jvir.2021.04.027 9. Glassberg MB, Ghosh S, Clymer JW, et al. Microwave ablation compared with hepatic resection for the treatment of hepatocellular carcinoma and liver metastases: a systematic review and meta-analysis. World JSurg Oncol . 2019;17(1):98. doi:10.1186/s12957-019-1632-6 10. Golden ED, Mutlu A, Knavel-Koepsel EM, et al. Microwave ablation for renal cell carcinoma: a literature review and clinical insights. EMJ Radiol. 2025;6(1):71-85. doi:10.33590-emjradiol/MQUZ3849 11. Han Y, Yan X, Zhi W, et al. Long-term outcome following microwave ablation of lung metastases from colorectal cancer. Front Oncol . 2022;12:943715. doi:10/3389/fonc.2022.943715 Radiofrequency and Microwave Ablation of Tumors-OH MCD-MM-1349Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 12. Hines A, Goldberg SN. Radiofrequency ablation, cryoablation, and other ablative techniques for renal cell carcinoma. UpToDate. Updated September 3, 2024. Accessed January 23, 2026. www.uptodate.com13. Khandpur U, Haile B, Makary MS. Early-stage renal cell carcinoma locoregional therapies: current approaches and future directions. Clin Med Insights Oncol . 2024;18:18:11795549241285390. doi: 10.1177/11795549241285390 14. Matsui Y, Tomita K, Uka M, et al. Up-to-date evidence on image-guided thermal ablation for metastatic lung tumors: a review. Jpn JRadiol . 2022. ;40(10):1024-1034. doi:10/1007/s11603-022-01302-0. 15. McClure T, Lansing A, Ferko N, et al. A comparison of microwave ablation and cryoablation for the treatment of renal cell carcinoma: a systematic literature review and meta-analysis. Urology . 2023;180:1-8. doi:10.1016/j.urology.2023.06.001. 16. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Hepato cellular Carcinoma . Version 2.2025 . Issued October 22 , 2025 . Accessed January 23, 2026 . www.nccn.org 17. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Kidney Cancer. Version 1.2026. Issued July 24, 2025. Accessed January 23, 2026. www.nccn.org 18. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer . Version 3.202 6. Issued December 24 , 2025. Accessed January 23, 2026 . www.nccn.org 19. National Institute for Health and Care Excellence. Microwave ablation for treating liver metastases [IPG553]. April 27, 2016 . Accessed January 23, 2026 . www.nice.org 20. National Institute for Health and Care Excellence. Microwave ablation of hepatocellular carcinoma [IPG214]. March 28, 2007 . Accessed January 23, 2026 . www.nice.org 21. National Institute for Health and Care Excellence. Microwave ablation for primary or metastatic cancer in the lung [IPG 716 ]. February 2, 20 22 . Accessed January 23, 2026 . www.nice.org 22. Nelson DB, Tam AL, Mitchell KG, et al. Local recurrence after microwave ablation of lung malignancies: a systematic review. Ann Thorac Surg . 2019;107(6):1876-1883. doi:10.1016-j.athoracsur.2018.10.049 23. Palussiere J, Chomy F, Savina M, et al. Radiofrequency ablation of stage IA non – small cell lung cancer in patients ineligible for surgery: results of a prospective multicenter phase II trial. JCardiothorac Surg . 2018;13(1):91. doi:10/1186/s13019 – 018-0773-y 24. Pierorazio PM, Campbell SC. Clinical diagnosis and management of a small renal mass. UpToDate. Updated September 26, 2025. Accessed January 23, 2026. www.uptodate.com 25. Radiofrequency Ablation of Tumor : ACG : A-0718 (AC). 29th ed. MCG H ealth ; 2025. Updated January 25, 2025 . Accessed January 23, 2026 . www.careweb.guidelines.com Radiofrequency and Microwave Ablation of Tumors-OH MCD-MM-1349Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 26. Wang N, Xu J, Wang G, et al. Safety and efficacy of micro wave ablation for lung cancer adjacent to the interlobar fissure. Thorac Cancer . 2022 ;13(18):2557-2565 . doi:10.1111/1759-7714.14589 27. Wu X, Uhlig J, Blasberg JD, et al. Microwave ablation versus stereotactic body radiotherapy for stage I non-small cell lung cancer: a cost-effectiveness analysis. J Vasc Interv Radiol . 2022;33(8):964-971.e2. doi:10.1016/j.jvir.2022.04.019 Independent med ical review September 2022Approved ODM 02/19/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Breast Reduction Surgery-OH MCD-MM-0020 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 7 F. Related Polic ies /R ules ………………………….. ………………………….. ………………………….. ……… 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 7 H. References ………………………….. ………………………….. ………………………….. …………………….. 8 Breast Reduction Surgery-OH MCD-MM-0020Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectBreast Reduction Surgery B. BackgroundReduction mamm aplasty is a surgical procedure that reduces the weight and volume of the breast. As much as 1 to 5 pounds of excess breast tissue is routinely removed during a reduction mamm aplasty depending on breast and body mass . Indications for surgery include chronic pain and skin symptoms, neuropathy, breast discomfort, physical impairment, and psychological symptoms that can be associated with poor self-esteem and loss of desire to engage in activities. Women diagnosed wit h macromastia (excessively large breasts) seeking breastreduction mammaplasty typically present with complaints of a feeling of heaviness,chronic pain , and tension in the neck, shoulders , and upper back. Macromastia commonly causes permanent grooving and ulceration of the shoulder following years of wearing support bras to try to minimize symptoms. The physical and psychological symptoms of macromastia can significantly and negatively impact an individuals life and should be taken into consideration when evaluating surgical intervention. Gynecomastia is the benign proliferation of glandular tissue of the breast in males. This condition may be caused by androgen deficiency, congenital disorders, medications,chronic medical conditions, tumors, or endocrine disorders. Depending on the cause of the tissue proliferation, surgical removal may be considered cosmetic or medically necessary.C. Definitions Body Surface Area (BSA) A metric used for physiologic measurements, pharmacologic dosing, and therapeutic calculations, including the Schnur Sliding Scale for breast reduction surgery. Cosmetic Procedures Procedures performed for aesthetic purposes that do not improv e or restor e physiologic function. Functional/Physical or Physiological Impairment Impairment caus es deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired , or delayed capacity to move and coordinate actions, or perform physical activities and is exhibited by difficulties in physical and motor tasks , independent movement , and performing basic life functions. Gynecomastia Enlargement of the male breast secondary to a proliferation of ductal, stromal, and/or fatty tissue. Gynecomastia Scale A qualitative classification system for gynecomastia developed by the American Society of Plastic Surgeons (ASPS). o Grade I Small breast enlargement with localized button of tissue that is concentrated around the areola. o Grade II Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Breast Reduction Surgery-OH MCD-MM-0020Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Grade III Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present. o Grade IV Marked breast enlargement with skin redundancy and feminization of the breast. Intertriginous Rash Dermatitis occurring between juxtaposed folds of skin, caused by retention of moisture and warmth and providing an environment favoring overgrowth of normal skin micro-organisms. Kyphosis Over-curvature of the thoracic vertebrae (upper back) associated with degenerative diseases , such as arthritis, developmental problems, or with osteoporotic compression fractures of vertebral bodies. Macromastia (Breast Hypertrophy) An increase in the volume and weight of breast tissue relative to the general body habitus. Mammography An imaging technique that uses low-energy X-rays to examine breast tissue for diagnosis and screening Schnur Sliding Scale Used in calculating the amount of breast tissue to be removed in reduction mammoplasty (Appendix A ) Symptomatic Breast Hypertrophy A syndrome of persistent neck and shoulder pain, shoulder grooving from brassiere straps, chronic intertriginous rash of the infra – mammary fold , and/or frequent episodes of headache, backache, and upper extremity neuropathies caused by an increase in the volume and weight of breast tissue beyond normal proportions. D. PolicyI. CareSource considers breast reduction surgery for macromastia medically necessary when ALL the following criteria are met and have been documented : A. Member is 18 years or older , or under 18 years with evidence that breasts have finished growing for a minimum of one year . Parental/guardian consent is required for members under age 18 . B. Breast size interferes with activities of daily living, as indicated by 1 or more of the following: 1. arm numbness consistent with brachial plexus compression syndrome 2. cervical pain 3. chronic breast pain 4. headaches 5. nipple position greater than 21 cm below suprasternal notch 6. persistent redness and erythema (intertrigo) below breasts , nonresponsive to conventional/medical management 7. restriction of physical activity 8. severe bra strap grooving or ulceration of shoulder 9. shoulder pain 10. thoracic kyphosi s 11. upper or lower back pain Breast Reduction Surgery-OH MCD-MM-0020Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 C. Preoperative evaluation by surgeon concludes that the amount of breast tissue to be removed (by mass or volume) will provide a reasonable expectation of symptomatic relief. D. No evidence of breast cancer 1. physical exam completed by a physician within the last year if under 40 years of age 2. women 40 to 54 years of age or older with mammogram negative for cancer performed within the year prior to the date of the planned breast reduction surgery 3. women 55 years of age and older with negative mammograms negative for cancer every 2 years 4. women with family history of breast cancer with mammogram s starting at least 7 years prior to when the youngest family member was diagnosed with breast cancer (as early as 30 years old) II. Breast reduction surgery following mastectomy to achieve symmetry is covered as part of the Womens Health and Cancer Rights Act (WHCRA). Please refer to theCareSource Medical policy titled Breast Reconstruction Surgery for additional information. III. CareSource considers breast reduction surgery for gynecomastia medically necessary when ALL the following clinical criteria are met and have been documented: A. Member is 18 years or older , or under 18 years with evidence that breasts have finished growing for a minimum of one year . Parental/guardian consent is required for members under age 18 . B. A physical exam has been conducted by an appropriately credentialed provider and confirms the presence of gynecomastia: 1. pubertal male (adolescent) a. gynecomastia present for more than 1 year after pathological causes ruled out b. gynecomastia grade II, III, or IV 2. postpubertal male a. gynecomastia present for more than 3 months after pathological causes ruled out b. gynecomastia grade III or IV C. The tissue being removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of drug treatment that can be discontinued. D. The gynecomastia is attributed to an underlying condition (not an all-inclusive list), including: 1. androgen deficiency 2. chronic liver disease that causes decreased androgen availability 3. Klinefelter syndrome 4. adrenal tumors that cause androgen deficiency or increased secretion of estrogen Breast Reduction Surgery-OH MCD-MM-0020Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 5. brain tumors that cause androgen deficiency6. testicular tumors that cause androgen deficiency or tumor secretion of estrogen 7. endocrine disorders (eg, hyperthyroidism) E. The gynecomastia causes functional impairment (eg, pain, chronic irritation ) F. Breast malignancy was ruled out. IV. Surgical Exclusions:A. Liposuction to perform breast reduction is considered not medically necessary.B. CareSource does not cover: 1. any procedures that are considered experimental, investigational, or unproven. 2. breast reduction surgery performed solely for cosmetic reasons (eg , poor posture, pendulousness, breast asymmetry, fit of clothing, changes in nipple – areola appearance). V. Schnur Sliding ScaleThe S chnur Sliding Scale is one of several evalu ation tools used to de termine the appr opriate volume of tissue to be r emoved relati ve to a members total body surface area ( BSA ). This esti mation can be instr umental in determining whet her br east reducti on sur gery is being planned for cos metic reas ons or as a medical ly neces sary procedure. A. The weight of tiss ue to be r emoved from each brea st is recommended to be above t he 22nd percentile on the Sc hn ur Sliding Scale ( App endix A belo w) based on t he members BSA. B. The BSA in met ers s quar ed ( m2) is c alcula ted using the Mos teller f ormu la (square root of the result of height (inches) multiplied by weight (lbs) and divided by 3131 ). App endix A: Schnur Sliding Sca leBody Su rface Ar ea an d M inim um Re quirement for Breast Tissue R emoval Body Surface Area (m2)Grams per Breast of Minimum Breast Tissue to be Removed 22 nd Percentile 1.350-1.374 199 1.375-1.399 208 1.400-1.424 218 1.425-1.449 227 1.450-1.474 238 1.475-1.499 249 1.500-1.524 260 1.525-1.549 272 Breast Reduction Surgery-OH MCD-MM-0020Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 1.550-1.574 2841.575-1.599 297 1.600-1.624 310 1.625-1.649 324 1.650-1.674 338 1.675-1.699 354 1.700-1.724 370 1.725-1.749 386 1.750-1.774 404 1.775-1.799 422 1.800-1.824 441 1.825-1.849 461 1.850-1.874 482 1.875-1.899 504 1.900-1.924 527 1.925-1.949 550 1.950-1.974 575 1.975-1.999 601 2.000-2.024 628 2.025-2.049 657 2.050-2.074 687 2.075-2.099 717 2.100-2.124 750 2.125-2.149 784 2.150-2.174 819 2.175-2.199 856 2.200-2.224 895 2.225-2.249 935 2.250-2.274 978 2.275-2.299 10 22 2.300-2.324 10 68 2.325-2.349 11 17 2.350-2.374 11 67 Breast Reduction Surgery-OH MCD-MM-0020Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 2.375-2.399 12 192.400-2.424 12 75 2.425-2.449 13 33 2.450-2.474 13 93 2.475-2.499 14 55 2.500-2.524 15 22 2.525-2.549 15 90 2.550 or grea ter 16 62 E. Conditions of CoverageN/A F. Related Polic ies /R ulesBreast Reconstruction Surgery G. Review/Revision HistoryDATE ACTIONDate Issued 07/20/2004Date Revised 05/25/2005 07/05/2006 09/18/2007 07/01/2009 02/01/2012 12/31/2014 12/01/2015 07/26/2017 03/16/202203/15/202302/28/202403/12/202502/11 /2026Annual update, minor editorial revisions, minor changes to policy, removed redundant mastectomy criteria from policyAdded male breast reduction surgery criteria. Updated references. Approved at PGC. Revised D.I, D.I.A., D.II. and D.II.A. Updated references. Approved at Committee. Revision: expanded policy to cover members under 18 years of age, removed definitions, and updated references. Approved at Committee. Annual review: updated background and definitions, added D.I.D.4., revised gynecomastia criteria, and updated references. Approved at Committee. Review: added definitions, and clarity around exclusions for cosmetic indications and liposuction, and updated references. Approved at Committee. Breast Reduction Surgery-OH MCD-MM-0020Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 Date Effective 05/01/2026Date Archived H. References1. ASPS recommended insurance coverage criteria for third-party payers: gynecomastia. American Society of Plastic Surgeons. Accessed January 7, 2026 . www.plasticsurgery.org 2. ASPS recommended insurance coverage criteria for third-party payers: reduction mammaplasty. American Society of Plastic Surgeons. Accessed January 7, 2026 . www.plasticsurgery.org 3. Billa E, Kanakis GA, Goulis DG. Imaging in gynecomastia. Andrology . 2021;9(5):1444-1456. doi:10.1111/andr.13051 4. Biro F M, Chan Y M. Normal puberty. UpToDate. Updated September 24, 2024 . Accessed January 7, 2026 . www.uptodate.com 5. Braunstein G D, Anawalt BD. Clinical features, diagnosis, and evaluation of gynecomastia in adults. UpToDate. Updated June 12, 2025 . Accessed January 7, 2026 . www.uptodate.com 6. Braunstein G D, Anawalt BD . Management of gynecomastia. UpToDate. Updated September 27, 2024 . Accessed January 7, 2026 . www.uptodate.com 7. Briefing paper: plastic surgery for teenagers. American Society of Plastic Surgeons. Accessed January 7, 2026 . www.plasticsurgery.org 8. Hansen J, Chang S. Overview of breast reduction. UpToDate. Updated May 2, 2025 . Accessed January 7, 2026 . www.uptodate.com 9. Holzmer SW, Lewis PG, Landau MJ, et al. Surgical management of gynecomastia: a comprehensive review of the literature. Plast Reconstr Surg Glob Open . 2020;8(10):e3161. doi:10.1097/GOX.0000000000003161 10. Kanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines – gynecomastia evaluation and management. Andrology . 2019;7(6):778-793. doi:10.1111/andr.12636 11. Kimia R, Magee L, Caplan HS, et al. Trends in insurance coverage for adolescent reduction mamm aplasty. Am JSurg . 2022;224(4):1068-1073. doi:10.1016/j.amjsurg.2022.07.030 12. Magny SJ, Shikhman R, Keppke AL. Breast Imaging Reporting and Data System. StatPearls . StatPearls Publishing; 2024. Accessed January 7, 2026 . www.ncbi.nlm.nih.gov 13. Mastectomy for gynecomastia. MCG. 2 9th ed . Updated June 13, 2025 . Accessed January 7, 2026 . www.careweb.careguidelines.com 14. NCCN guidelines for patients 202 5: breast cancer screening and diagnosis. NCCN. www.nccn.org 15. Patel K, Corcoran J. Breast reduction surgery in adolescents. Pediatr Ann . 2023;52(1):e31-e35. doi:10.3928/19382359-20221114-06 16. Perdikis G, Dillingham C, Boukovalas S, et al. American Society of Plastic Surgeons evidence-based clinical practice guideline revision : reduction mammaplasty. Plast Reconstr Surg . 2022;149(3):392e-409e. doi:10.1097/PRS.0000000000008860 Breast Reduction Surgery-OH MCD-MM-0020Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.9 17. Reduction mamm aplasty. MCG . 29th ed . Updated June 13, 2025 . Accessed January7, 2026 . www.careweb.careguidelines.com 18. Reeves RA, Kaufman T. Mammography. StatPearls . StatPearls Publishing; 2023.. Accessed January 7, 2026 . www.ncbi.nlm.nih.gov 19. Schnur PL, Hoehn JG, Ilstrup DM, Cahoy MJ, Chu CP. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. 1991 Sep;27(3):232-7. 20. Sears ED, Lu YT, Swiatek PR, et al. Use of preoperative mammography during evaluation for nononcologic breast reduction surgery. JAMA Surg . 2019;154(4):356 – 358. doi:10.1001/jamasurg.2018.4875 21. Taylor SA. Gynecomastia in children and adolescents. UpToDate. Updated July 12, 2024 . Accessed January 7, 2026 . www.uptodate.com 22. Womens Health and Cancer Rights Act (WHCRA). Centers for Medicare and Medicaid Services . Accessed January 7, 2026 . www.cms.gov 23. Zeiderman MR, Kelishadi SS, Tutela JP, et al. Reduction mammoplasty: intraoperative weight versus pathology weight and its implications . Eplasty . 2017;17:e32. Accessed January 7, 2026 . www.pubmed.ncbi.nlm.nih.gov Approved ODM 02/19/2026
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