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
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Breast Reconstruction Surgery-OH MCD-MM-0001 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 ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 H. References ………………………….. ………………………….. ………………………….. …………………….. 4 Breast Reconstruction Surgery-OH MCD-MM-0001Effective Date: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.A. SubjectBreast Reconstruction Surgery B. BackgroundWith an estimated 27 9,000 new cases yearly, breast cancer continues to be the leading cause of new cancer among women in the United States and a leading cause of cancer death. Breast reconstruction is intended to reduce post-mastectomy complications , es tablish symmetry between the surgical breast and the contralateral breast , and improve quality of life following breast cancer surgery . Breast reconstruction procedures may include breast reduction, breast augmentation with FDA-approved breast implants, nipple reconstruction (inc luding surgery, tattooing, or both) , and breast contouring. Reconstruction may be performed immediately following a mastectomy or can be delayed for weeks or years until the member has undergone radiation, chemotherapy, or decides th at reconstruction is want ed . Breast augmentation with an FDA-approved implant can be performed in one stage ,during which the implant is inserted during the same surgical visit as the mastectomy , or in two stages using an implanted tissue expander in the first stage followed by removal of the expander and insertion of the permanent breast implant. Complications may occur from breast implants immediately postoperatively or years later and can include exposure, extrusion, infection, contracture, rupture, and /or pain. Clinically significant complications may require implant removal. Autologous tissue/muscle breast flap reconstruction is a safe and effective alternative to breast implants. Muscle, subcutaneous tissue, and skin can be transposed from the donor site either locally (eg, latissimus dorsi myocutaneous [LD ] flap, pedicledtransverse rectus abdominus myocutaneous [TRAM ] flap) or distally (eg, free TRAMflap, deep inferior epigastric perforator [DIEP ] flap, superficial inferior epigastric artery perforator [SIEP ] flap, inferior or superior gluteal flap, superior gluteal artery perforator flab, Reubens flap, transverse upper gracilis [TUG ] flap). The choice of procedure can be affected by the members age and health, contralateral breast size and shape, personal preference, and expertise of the surgeon. Individuals may also select non-invasive options , such as mastectomy bras and externalbreast prostheses.C. Definitions Breast Conserving Surgery (Lumpectomy, Partial Mastectomy) Surgical removal of tumor and small amount of surrounding breast tissue. Contralateral Breast Unaffected/nonsurgical breast. Cosmetic Procedures Procedures completed to improve appearance and self – esteem and to reshape normal structures of the body. Mastectomy Surgical remov al of one or both breasts. Breast Reconstruction Surgery-OH MCD-MM-0001Effective Date: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.D. PolicyI. Breast reconstruction is not gender specific. II. Surgical OptionsCareSource considers breast reconstruction medically necessary when ANY of the following clinical indications apply: A. following outlined criteria in MCG S-862 Mastectomy, Complete, with Insertion of Breast Prosthesis or Tissue Expander B. following outlined criteria in MCG S-864 Mastectomy, Complete, with Tissue Flap Reconstruction C. congenital deformities affect ing the members physical and psychological well-being D. severe fibrocystic breast disease that limits the members function E. unintentional trauma or injuries F. complications after breast surgery for non-malignant conditions (eg, pain, irritation, bleeding, discharge, complications causing difficulty with lactation) III. CareSource considers treatment of physical complications , including lymphedema ,following breast reconstruction medically necessary. Please see the Womens Health and Cancer Rights Act (WHCRA) at www.cms.gov for more information. IV. Surgical Exclusions:A. CareSource does not cover any breast reconstruction procedures that are considered experimental, investigational, or unproven. B. CareSource does not cover: 1. procedures that are considered cosmetic in nature, including natural changes due to aging and weight loss/gain 2. lipectomy for donor site symmetry 3. suction lipectomy or ultrasonically assisted suction lipectomy (liposuction) for correction of surgically induced donor site asymmetry (eg, trunk or extremity) that results from one or more flap breast reconstruction procedures V. Non-Surgical AlternativesCareSource covers external breast prostheses and mastectomy bras following mastectomy or breast conserving surgery. All other indications are considered not medically necessary. VI. Breast reconstruction with free flap procedures, regardless of technique, applies to CPT code 19364 .E. Conditions of CoverageNA F. Related Policies/RulesNA Breast Reconstruction Surgery-OH MCD-MM-0001Effective Date: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.G. Review/Revision HistoryDATE ACTIONDate Issued 08/23/2004Date Revised 07/01/2009 07/01/2014 04/17/2015 04/18/2019 04/01/2020 02/17/2021 07/01/2021 03/16/2022 11/09/2022 09/27/2023 10/23/202404/09/202502/11 /2026Updated with more specific criteria . Reviewed criteria .No changes to content. Updated reference dates. Approved at PGC. Added section V, updated background and references. Annual review. Approved at committee. Annual review: updated risk reduction mastectomy and reorganized policy section for clarity. Review : elevated post-lumpectomy criteria, updated risk – reducing mastectomy and references . Approved at Committee. Review: revised section D.II to reference MCG for clarity of all indications. Updated references. Approved at Committee. Date Effective 05/01/2026 Date Archived H. References1. Alder L, Zaidi M, Zeidan B, et al. Advanced breast conservation and partial breast reconstruction a review of current available options for oncoplastic breast surgery. Ann RColl Surg Engl . 2022;104(5):319-323. doi:10.1308/rcsann.2021.0169 2. Breast reconstruction surgery. American Cancer Society . Updated September 19 , 2022 . Accessed January 15, 2026 . www.cancer.org 3. Breast cancer statistics. Centers for Disease Control and Prevention. Accessed January 15, 2026 . www.cdc.gov 4. Centers for Medicare and Medicaid Services. Womens Health and Cancer Rights Act (WHCRA) . Accessed January 15, 2026 . www.cms.gov 5. Colwell AS, Taylor EM. Recent advances in implant-based breast reconstruction. Plast Reconstr Surg . 2020;145(2):421e-432e. doi:10.1097/PRS.0000000000006510 6. Costanzo D, Klinger M, Lisa A, et al . The evolution of autologous breast reconstruction. Breast J . 2020;26(11):2223-2225. doi:10.1111/tbj.14025 7. Friedrich M, Kramer S, Friedrich D, et al. Difficulties of breast reconstruction problems that no one likes to face. Anticancer Res . 2021;41(11):5365-5375. doi:10.21873/anticanres.15349 8. Gradishar WJ, Moran MS, Abraham J, et al . NCCN guidelines insights: breast cancer, version 3.2024 . JNatl Compr Canc Netw . 202 4;22(5):332-357 . doi: 10.6004/jnccn.2024.0035 9. Griffin C, Fairhurst K, Stables I, et al. Outcomes of women undergoing mastectomy for unilateral breast cancer who elect to undergo contralateral mastectomy for Breast Reconstruction Surgery-OH MCD-MM-0001Effective Date: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.symmetry: a systematic review. Ann Surg Oncol . 2024;31(1):303-315. doi:10.1245/s10434-023-14294-6 10. Guliyeva G, Torres RA, Avila FR, et al. The impact of implant-based reconstruction on persistent pain after breast cancer surgery: a systematic review. JPlast Reconstr Aesthet Surg . 2022;75(2):519-527. doi:10.1016/j.bjps.2021.09.079 11. Health technology assessment : c omparative effectiveness review of human acellular dermal matrix for breast reconstruction. Hayes; 2019. Reviewed February 28, 2022. Accessed January 15, 2026 . evidence.hayesinc.com 12. Health technology assessment : a utologous fat grafting for breast reconstruction after breast cancer surgery. Hayes ; 2015 . Review ed November 1 3, 202 3. Accessed January 15, 2026 . evidence.hayesinc.com 13. Mastectomy, Complete, with insertion of breast prosthesis or tissue expander : S-862. MCG Health, 29 th ed. Updated June 13, 2025. Accessed January 14, 2026. careweb.careguidelines.com 14. Mastectomy, Complete, with tissue flap reconstruction : S-864. MCG Health, 29 th ed. Updated June 13, 2025. Accessed January 14, 2026. careweb.careguidelines.com 15. Nahabedian M. Options for autologous flap-based breast reconstruction. UpToDate. Updated April 29, 2024 . Accessed January 15, 2026 . www.uptodate.com 16. Nahabedian M. Overview of breast reconstruction. UpToDate. Updated July 10, 2025 . Accessed January 15, 2026 . www.uptodate.com 17. Pappalardo M, Starnoni M, Franceschini G, et al. Breast cancer-related lymphedema: recent updates on diagnosis, severity and available treatments. JPers Med . 2021;11(5):402. doi:10.3390/jpm11050402 18. Sab el MS. Breast conserving therapy. UpToDate. Updated October 30, 2025 . Accessed January 15, 2026 . www.uptodate.com 19. Saldanha IJ, Cao W, Broyles JM, et al. Breast reconstruction after mastectomy: a systematic review and meta-analysis. Comparative effectiveness review No. 245. (Prepared by the Brown Evidence-based Practice Center under Contract No. 75Q80120D00001.) AHRQ Publication No. 21-EHC027. Rockville, MD: Agency for Healthcare Research and Quality; July 2021. doi.org/10.23970/AHRQEPCCER245. 20. Tomita K, Kubo T. Recent advances in surgical techniques for breast reconstruction. Int JClin Oncol . 2023;28(7):841-846. doi:10.1007/s10147-023-02313-1 21. Toyserkani NM, Jorgensen MG, Tabatabaeifar S, Damsgaard T, Sorensen JA. Autologous versus implant-based breast reconstruction: a systematic review and meta-analysis of Breast-Q patient-reported outcomes. JPlast Reconstr Aesthet Surg . 2020;73(2):278-285. doi:10.1016/j.bjps.2019.09.040 22. Zehra S, Doyle F, Barry M, Walsh S, Kell MR. Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis. Breast Cancer . 2020;27(4):534-566. doi:10.1007/s12282-020-01076-1 Approved ODM 2/17/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Trigger Point Injections-OH MCD-MM-0011 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. … 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. .. 4 H. References ………………………….. ………………………….. ………………………….. …………………. 5 Trigger Point Injections-OH MCD-MM-0011Effective 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. SubjectTrigger Point Injections B. BackgroundMyofascial trigger points are self-sustaining hyper-irritative foci in any skeletal muscle, often occurring in response to strain produce d by acute or chronic overload. There is no associated neurologic deficit, and the pain may be aggravated by hyperextension of the spine, standing , and walking. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS) which is responsive to appropriate treatme nt. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor. The purpose of a trigger point injection (TPI) is to treat not only the symptom but also the cause through the injection of a single substance (eg, a local anesthetic) or a mixture of substances (eg, a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Interventional procedures for management of pain should be part of a comprehensive pain management care plan that incorporates an initial trial of conservative treatment utilizing appropriate medications, physical therapy modalities , and behavioral support asneeded.Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers acting within their scope ofpractice who are qualified to deliver these health services.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Physician Supervised Home Exercise Program (HEP) A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. Subacute Pain Pain that has lasted between 4 weeks and 12 weeks. Trigger P oint A hyper excitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. D. PolicyI. Trigger Point Injections Initial Injections A. Trigger point injections of anesthetic and/or corticosteroid for back pain, neck pain , or myofascial pai n syndrome is considered medically necessary when pain has persisted despite appropriate medical management and ALL the following criteria are met: Trigger Point Injections-OH MCD-MM-0011Effective 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 1. Patient presents with new (acute or subacute) localized pain, occurring in the last 3 months . 2. Patient has been refractory or intolerant of conservative therapies for at least 1 month, including at least 1 of the following: a. bed rest b. active exercise c. ultrasound d. range of motion e. heating or cooling treatments f. massage 3. TPIs are being given as a part of an overall conservative management (usually short term) plan, including at least 1 of the following: a. physical therapy b. occupational therapy c. physician supervised home exercise plan (HEP) d. manipulative therapy 4. Pharmacotherapies are being administered, including at least 1 of the following : a. non-steroidal anti-inf lammatory drugs ( NSAIDS ) b. muscle relaxants c. non-narcotic analgesics d. anti-depressants 5. The patient must have a diagnosis for which the trigger point injection is an appropriate treatment . ALL the following information must be documented in the patient’s medical record: a. proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point b. reason (s) for select ing this therapeutic option c. affected muscle or muscles d. muscle or muscles injecte d and the number of injections e. frequency of injections required f. name of the m edication used in the injection g. results of any prior treatment h. corroborating evidence that the injection is medic ally necessary B. Localization techniques to image or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. II. Trigger Point Injections Subsequent InjectionsA. Trigger point injections should be repeated only if doing so is reasonable and medically necessary. No more than 8 dates of service per calendar year per member may be reimbursed . B. Injections may be repeated only with documented positive results to the most recent trigger point injection of the same anatomic site. Documentation should Trigger Point Injections-OH MCD-MM-0011Effective 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 indicate a decrease in pain, improvement in function, and/or increase in activity tolerance .III. There is no laboratory or imaging test for establishing the diagnosis of trigger points .Diagnosis is dependent upon a detailed history and a thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis: A. history of onset and its cause (injury, sprain, etc.) B. distribution of pain C. restriction of movement D. mild muscle specific weakness E. focal tenderness of a trigger point F. palpable taut band of muscle in which trigger point is located G. local taut respo nse to snapping palpitation H. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point IV. Payment InformationA. Certain trigger point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. B. Payment may be made for 1 unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a particular date. C. A trigger point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (eg, in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. D. Dry needling is not an acceptable alternative to trigger point injections by an appropriately licensed clinician. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/10/2015Date Revised 03/06/2019 06/10/2020 Annual Update: No changesAnnual Update: Prior authorization is now required; removal of payment information defer policy PY-1100. Trigger Point Injections-OH MCD-MM-0011Effective 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 09/01/202105/26/202104/12 /202203/29/202302/28/202402/12/202501 /14 /2026Revisions include: such as was changed to ONE of the following : I. B. 2. and 3. Annual Update: Removed PA language. Annual Review; updated references, formatting, separated criteria into initial and subsequent injections, added active conservative therapy options Annual review: updated references, added definition and payment information. Approved at Committee Annual review: editorial changes, updated references, approved at Committee Review: updated references, approved at Committee. Review: updated references. App roved at Committee. Date Effective 05/01/2026 Date Archived H. References1. Appasamy M, Lam C, Alm J, et al . Trigger point injections. Phys Med Rehabil Clin N Am . 2022;33(2):307-333. doi:10.1016/j.pmr.2022.01.011 2. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate . Updated April 29 , 202 5. Accessed December 12 , 202 5. www.uptodate.com 3. Hammi C, Schroader JD, Yeung B. Trigger point injection. StatPearls . StatPearls Publishing; 2024. Updated July 24, 2023. Accessed December 12 , 202 5. www.ncbi.nlm.nih.gov 4. Hamzoian H, Zograbyan V. Trigger point injections versus medical management for acute myofascial pain: a systematic review and meta-analysis. Cureus. 2023;15(8):e43424. doi:10.7759/cureus.43424 5. Immunizations, Injections and Infusions ( Including Trigger-Point Injections), Skin Substitutes, and Provider-Administered Pharmaceuticals , OHIO ADMIN CODE 5160-4- 12 (2022). 6. Isaac Z. Management of non-radicular neck pain in adults. UpToDate . Updated Deptember 30, 2025 . Accessed December 12 , 202 5. www.uptodate.com 7. Khoury AL, Keane H, Varghese F, et al. Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief. NPJ Breast Cancer . 2021;7:123. doi:10.1038/s41523-021-00321-w 8. Meyer GW. Anterior cutaneous nerve entrapment syndrome. UpToDate . Updated February 14, 2025 . Accessed December 12 , 202 5. www.uptodate.com 9. Moynihan LK, Elkadry E. Myofascial pelvic pain syndrome in females: treatment. UpToDate. Updated January 11, 2023 . Accessed December 12 , 202 5. www.uptodate.com 10. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate . Updated September 4, 2025 . Accessed December 12 , 202 5. www.uptodate .com Independent Medical Review January 2025ODM Approved 02 /11/2026
MEDICAL POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230 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 Policies/Rules ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 5 H. References ………………………….. ………………………….. ………………………….. …………………….. 5 Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective 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. SubjectPeripheral Nerve Blocks for Treatment of Pain B. BackgroundPeripheral n erve blocks are injection s of medication into a specific area of the body where nerves cause pain to a specific organ or body region . Nerve block s cause the temporary interruption of impulse conduction in peripheral nerves or nerve trunks and may or may not contain a steroid , which can be used to treat pain. Various areas of pain require different types of nerve blocks that can be administered in numerous parts of the body , with some of the most common blocks being sympathetic, peripheral , and occipital. Sacroiliac and facet j oint interventions , epidural steroid injections , and trigger pointinjections are addressed in other policies.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Ambulatory Surgery Surgery performed in a hospital-based or freestanding ambulatory surgery center (ASC) with patient discharge the same day . Chronic Pain Pain lasting more than 3 months, which is considered beyond normal healing time. Conservative Therapy A multimodality plan of care including both active and inactive conservative therapies . o Active Conservative Therapies Action or activit ies that strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational therapy, a physician-supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion , or documentation of the inability to complete HEP due to a stated physical reason (ie , increased pain, inability to physically perform exercise). Patient inconvenience and/or noncompliance without explanation does not constitute an inability to complete . o Inactive Conservative Therapies Passive activities that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, acupuncture, a TENS device, and/or pharmacotherapy (prescription or over the counter [non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins . Its u se, frequency, duration, and start dates must be documented in the medical record. Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective 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 Emergent Medically necessary care, which is immediately needed to preserve life,prevent serious impairment to bodily functions, organs, or parts, or prevent placing the physical or mental health of a patient in serious jeopardy. Low-Risk Procedure Procedures associated with minimal physiologic effect and excludes any intrathoracic, intra-abdominal, vascular, or orthopedic procedures. Sub-Acute Pain Pain lasting between 4 to 12 weeks. D. PolicyI. CareS ource considers p eripheral nerve blocks (PNB) , single injection , medically necessary when appropriate documentation for the treatment of acute pain or chronic pain are included , only as part of an active component of a comprehensive pain management program . CareSource uses MCG Health guidelines to address criteria for specific nerve blocks. Documentation must include indications that ALL the following criteria are met: A. PNB is performed as an a mbulatory or outpatient procedure that (1) is not treating an emergent condition, (2) is a low risk procedure , and (3) requires no inpatient care for a preoperative disease or condition (eg, altered mental status , hypotension, hypoxemia, tachycardia) . B. Acute, sub-acute or c hronic, neuropathic or radicular pain, as indicated by ONE or more of the following: 1. cancer-related pain 2. Complex regional pain syndrome (CRPS) 3. peripheral neuropathy with pain that limits activit ies of daily living , e xcluding diabetic neuropathy 4. peripheral vascular disease with rest pain 5. acute herpes zoster of face or neck and prevention of postherpetic neuralgia 6. pancreatic pain, pelvic pain, or abdominal pain related to malignancy 7. chronic, relapsing pancreatitis C. Symptoms poorly controlled by maximum medical therapy or intolerable side effects to such therapy D. Failure of non-invasive treatment (s) (eg, non-steroidal anti-inflammatory drugs (NSAIDs), exercise, physical therapy, spinal manipulation therapy) E. No coagulopathy or thrombocytopenia F. No infection at or underlying the injection site II. Acute or Sub-Acute PainPNB may provide means of analgesia for acute pain in the following (not an all – inclusive list): A. Patients at risk of respiratory depression related to systemic or neuraxial opioids (eg, obstructive sleep apnea, severe obesity, underlying pulmonary disease, advanced age) . B. Patients with another indication to minimize opioid use (eg, chronic opioid use, intolerance to opioids) . C. Patients with acute, severe pain poorly managed with systemic medication . Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective 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 D. Patients who cannot tolerate chiropractic or other physical and/or manipulative therapies . III. Chronic PainCareSource considers PNB , single injection, medically necessary when appropriate documentation for the treatment of chronic pain is included, only as part of an active component of a comprehensive pain management program when the re has been a failure of conservative therapy, as evidenced by ALL the following: A. Documentation in the medical record of at least 6 weeks of active conservative therapy 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 inactive conservative therapy within the past 6 months. Insufficient evidence support s the following use s of PNB for chronic pain and is notconsidered medically necessary:A. Genicular nerve or branches for chronic knee pain. B. Cluneal nerve injections or blocks for chronic low back pain or pelvic pain. C. Pudendal blocks for chronic pelvic pain conditions. IV. Radiofrequency Ablation (RFA) or NeurotomyRadiofrequency ablation and/or neurotomy are considered experimental and investigational , or unproven for any indication, including but not limited to the treatment of acute or chronic pain due to insufficient evidence of efficacy in the peer reviewed literature. V. Limitations and ExclusionsA. A member can receive a maximum of 6 injections in a rolling 12 month period .B. Up to 2 anatomic sites (eg, specific nerve, plexus, or branch as defined by CPT code descripti on) can be injected at any one session . C. Nerve blocks used as part of a surgical procedure or other medical procedure are not separately reimbursable but an inclusive component of that procedure . These injections will not be compensated separately or unbundled for coverage. D. Any procedure submitted for payment with an incorrect CPT code or description will be denied. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provide d. If requesting a block to a specific part of the body, coding to the highest level of specificity should be used. E. Exclusions 1. Treatment of peripheral neuropathy due to diabetes. 2. Use of nerve blocks with or without use of electrostimulation for treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases. Medical management using systemic medications is clinically indicated for the treatment of these conditions. Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective 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 E. Conditions of Coverage Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers within their scope of practice who are qualified to deliver these health services . F. Related Policies/RulesEpidural Steroid Injections Experimental or Investigational Item or Service Facet Joint Interventions Sacroiliac Joint Procedures Trigger Point Injections G. Review/Revision HistoryDATE ACTIONDate Issued 10/01/2022Date Revised 02/15/2023 02/28/202402/26/202501/28/2026 Annual review. Changed conservative therapy from 6 months in past 12 months to 6 weeks in past 6 months. Annual review-editorial changes ; Approved at Committee Annual review-references updated. Approved at Committee. Annual review, approved at Committee. Date Effective 05/01/2026 Date Archived H. References1. Ailani J, Burch RC, Robbins MS; American Headache Society. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache . 2021;61(7):1021-1039. doi:10.1111/head.14153 2. Allen SM, Mookadam F, Cha SS, et al. Greater occipital nerve block for acute treatment of migraine headache: a large retrospective cohort study. JAm Board Fam Med . 2018;31(2):211-218. doi:10.3122/jabfm.2018.02.170188 3. American Headache Society. AHS consensus statement: The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache . 2019;59(1):1-18. doi:10.1111/head.13456 4. Antolak S, Antolak C, Lendway L. Measuring the quality of pudendal nerve perineural injections. Pain Physician . 2016;19:299-306. Accessed January 13, 2026 . www.pubmed.ncbi.nlm.nih.gov 5. Caponnetto V, Ornello R, Frattale I, et al. Efficacy and safety of greater occipital nerve block for the treatment of cervicogenic headache: a systematic review. Expert Rev Neurotherapeutics . 2021; 21(5):591-597. doi:10.1080/14737175.2021.1903320 6. Chang A, Dua A, Singh K, et al . Peripheral nerve blocks. StatPearls . StatPearls Publishing; 202 5. Accessed January 13, 2026 . www.ncbi.nlm.nih.gov Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective 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 7. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated April 29, 2025 . Accessed January 12, 2026 . www.uptodate.com8. Dowell D, Ragan KR, Jones CM, et al . CDC clinical practice guideline for prescribing opioids for pain. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1 9. Evidence Analysis Research Brief: Genitofemoral Nerve Block or Ablation for Treatment of Groin Pain. Hayes; 2024. Accessed January 13, 2026 . www.evidence.hayesinc.com 10. Evidence Analysis Research Brief: Local Injection Therapy for Cervicogenic Headache and Occipital Neuralgia. Hayes; 2023. Accessed January 13, 2026 , 2025. www.evidence.hayesinc.com 11. Evidence Analysis Research Brief: Peripheral Nerve Stimulation for the Treatment of Superior Cluneal Neuralgia. Hayes; 2024. Accessed January 13, 2026 . www.evidence.hayesinc.com 12. Evidence Analysis Research Brief: Radiofrequency Ablation of Cluneal Nerve for Treatment of Chronic Low Back Pain. Hayes; 2023. Accessed January 13, 2026 . 13. Evolving Evidence Review: Middle Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2022. Reviewed February 7, 2025. Accessed January 13, 2026 . www.evidence.hayesinc.com 14. Evolving Evidence Review: Percutaneous Conventional Radiofrequency Ablation of Medial Branch Nerve(s) for Treatment of Thoracic Spinal Pain. Hayes; 2025. Accessed January 13, 2026. www.evidence.hayesinc.com 15. Evolving Evidence Review: Pulsed Radiofrequency for the Treatment of Pudendal Neuralgia. Hayes; 2024. Reviewed November 13, 2025. Accessed January 13, 2026. www.evidence.hayesinc.com 16. Evolving Evidence Review: Superior Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2021. Reviewed December 18, 2024. Accessed January 13, 2026 . www.evidence.hayesinc.com 17. Frank FT, Sawsan A. Chronic pelvic pain in adult females: treatment. UpToDate. Updated August 16, 2024. Accessed January 13, 2026 . www.uptodate.com 18. Garza I. Occipital neuralgia. UpToDate. Updated March 3, 2025 . Accessed January 13, 2026 . www.uptodate.com 19. Garza I, Schwedt TJ. Chronic migraine. UpToDate. Updated October 3, 2024. Accessed January 13, 2026 . www.uptodate.com 20. Gautam S, Gupta N, Khuba S, et al. Evaluation of the efficacy of superior cluneal nerve block in low back pain: a prospective observational study. JBodyw Mov Ther . 2022;30:221-225. doi:10.1016/j.jbmt.2022.03.001 21. Headaches in Over 12s: Diagnosis and Management . National Institute for Excellence; 20 21 . NICE Guideline No 150 . Updated June 3, 2025. Accessed January 13, 2026 . www.nice.org 22. Health Technology Assessment: Cooled or Pulsed Radiofrequency for Chronic Low Back Pain Arising From the Sacroiliac Joint. Hayes; 2022. Reviewed December 10, 2024. Accessed January 13, 2026. www.evidence.hayesinc.com Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective 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 23. Health Technology Assessment: Genicular Nerve Block for the Treatment of KneeOsteoarthritis. Hayes; 2023. Reviewed December 4, 2025 . Accessed January 13, 2026 . www.evidence.hayesinc.com 24. Health Technology Assessment: Greater Occipital Nerve Blocks for Treatment of Migraine. Hayes; 2019. Reviewed October 10, 2022. Accessed January 13, 2026 . www.evidence.hayesinc.com 25. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain. Hayes; 2021. Reviewed April 17, 2024. Accessed January 13, 2026 . www.evidence.hayesinc.com 26. Health Technology Assessment: Pulsed Radiofrequency for Treatment of Chronic Shoulder Pain. Hayes; 2022. Reviewed September 16, 2025. Accessed January 13, 2026. www.evidence.hayesinc.com 27. Health Technology Assessment: Radiofrequency Nerve Ablation for the Management of Osteoarthritis of the Knee. Hayes; 2020. Reviewed December 28, 2023. Accessed January 13, 2026. www.evidence.hayesinc.com 28. Hui J, Seko K, Shrikhande G, et al. A novel, nonopiod-based treatment approach to men with urologic chronic pelvic pain syndrome using ultrasound-guided nerve hydrodissection and pelvic floor musculature trigger point injections. Neurourol Urodyn . 2020;39(2):658-664. doi:10.1002/nau.24242 29. Inan L, Inan N, Unal-Artik H, et al. Greater occipital nerve block in migraine prophylaxis: narrative review. Cephalalgia . 2019;39:908-920. doi:10.1177/0333102418821669 30. Isu T, Kim K, Morimoto D, et al . Superior and middle cluneal nerve entrapment as a cause of low back pain. Neurospine . 2018;15(1):25-32. doi:10.14245/ns.1836024.012 31. Jeng C, Rosenblatt M. Overview of peripheral nerve blocks. UpToDate. Updated July 30, 2025 . Accessed January 13, 2026 . www.uptodate.com 32. Matsumoto J, Isu T, Kim K, et al. Middle cluneal nerve entrapment mimics sacroiliac joint pain. Acta Neurochir (Wien) . 2019;161(4):657-661. doi:10.1007/s00701-019 – 03861-0 33. Mustafa A, Brooks B, Leishear K, et al. A novel treatment approach for women with chronic pelvic pain syndrome leading to increased pelvic functionality. JWomens Health Gyn . 2020;7:1-10. doi:10.17303/jwhg.2020.7.402 34. Nielsen TD, Moriggl B, Barckman J, et al. Randomized trial of ultrasound-guided superior cluneal nerve block. Reg Anesth Pain Med . 2019;44:772-780. doi:10.1136/rapm-2018-100174 35. Ornello R, Lambru G, Caponnetto V, et al. Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic review and meta – analysis. Expert Rev Neurotherapeutics . 2020;20(11):1157-1167. doi:10.1080/14737175.2020.1809379 36. Plavnik K, Tenaglia A, Hill C, et al. A novel, non-opioid treatment for chronic pelvic pain in women with previously treated endometriosis utilizing pelvic-floor musculature trigger-point injections and peripheral nerve hydrodissection. PM R . 2020;12(7):655 – 662. doi:10.1002/pmrj.12258 Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective 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 37. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on chronic pain management and theAmerican Society of Regional Anesthesia and Pain Medicine. Anesthesiology . 2010;112(4):810-833. doi:10.1097/ALN.0b013e3181c43103 38. Shauly O, Gould DJ, Sahai-Srivastava S, et al. Greater occipital nerve block for the treatment of chronic migraine headaches: a systematic review and meta-analysis. Plast Reconstr Surg . 2019;144(4):943-952. doi:10.1097/PRS.0000006059 39. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: evaluation. UpToDate. Updated September 11, 2025 . Accessed January 13, 2026 . www.uptodate.com 40. Watson JC. Cervicogenic headache. UpToDate. Updated September 9, 2025 . Accessed January 13, 2026 . www.uptodate.com 41. Wray JK, Dixon B, Przkora R. Radiofrequency ablation. StatPearls . StatPearls Publishing; 2025. Accessed January 13, 2026 . www.ncbi.nlm.nih.gov Approved by ODM 02/04/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Sacroiliac Joint Procedures-OH MCD-MM-0010 04/01/2026 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/Rules ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectSacroiliac Joint Procedures B. BackgroundNearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent. Persistent pain is categorized as subacute when lasting between four and twelve weeks , and chronic when persisting for at least three months. Up to 10% to 30 % of patients with persistent low back pain may have a component ofpain related to sacroiliac joints (SIJ) . Comprehensive pain management care plans are most effective in managing a patients chronic pain. These plans focus on a person – centered approach and incorporate conservative treatment with other modalities. These multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a pat ients daily life, even if the pain cannot be relieved completely. In addition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic tre atments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be effective for diagnostic purposes but provide limited short-term relief from pain resulting from SI Jdysfunction. Long-term use has not be en adequately studied to establish standards of care. Radiofrequency ablation (RFA) is another treatment method, which uses heat to destroy nerves. RFA for the treatment of low back pain has inconsistent results in the peer-reviewed medical literature with limited fol low – up. However, clinical experience suggests that some patients obtain more significant relief from these procedures, making it reasonable to offer SIJ injections and/or RFA when conservative management has failed. C. Definitions Conservative Therapy A multimodality plan of care includ ing both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational therapy, physician supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Inactive Conservative Therapies Passive activities that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS unit, and/or pharmacotherapy (prescription or over the counter [non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphin s. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. Sacroiliac Joint (SIJ) Injections Corticosteroid and local anesthetic therapeutic injections into the SIJ to treat pain that hasnt responded to conservative therapies. Functional Disability Acquired difficulty in performing basic everyday tasks or more complex tasks needed for independent living. D. PolicyI. Sacroiliac Joint Injections A. Diagnostic i njections: CareSource considers up to 2 diagnostic SIJ injection s for the treatment of chronic low back pain medically necessary when ALL the following criteria are met: 1. somatic or nonradicular low back and lower extremity pain experienced for at least 3 months 2. severe pain (ie. at least a 6 out of 10 on pain scale) and tenderness are located in SIJ region and cause functional disability 3. positive response to at least 3 SIJ pain provocation test (eg, distraction, compression, thigh thrust, Gaenslens, Patricks test/FABER test, sacral thrust) 4. failure of conservative therapy, as evidenced by ALL the following: a. documentation in the medical record of a t 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 a t least 6 weeks of inactive conservative therapy ( as defined above ) within the past 6 months 5. If a second diagnostic injection is requested, at least 1 week has passed since the initial injection. B. Therapeutic i njections : CareSource considers therapeutic SIJ injections medically necessary when ALL the following criteria are met: 1. previous SIJ injection led to significant functional pain relief as measured by a decrease in pain level (demonstrated on a qualitative pain scale), decrease in pain medications, and/or increase in physical function Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 2. member experiences return of severe pain or deterioration in function3. injection is used in conjunction with conservative therapy (as defined above) 4. injections should not be repeated more frequently than every 2 months 5. no more than 4 injections total ( diagnostic and therapeutic ) have been administered at the same site the last 12 months C. Exclusions/Limitations: 1. Codes 64451 and 27096 may not be billed together (on the same date for the same side of the body). Only one code will be reimbursed . 2. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately. 3. If neural blockade is applied for different regions or different sides, injections are performed at least one week apart. 4. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated injections of the SI Jto be effective as a long-term management modality. Long-term continuation may be subject to medical necessity review. 5. Monitored anesthesia and conscious sedation are not medically necessary. 6. The use of SI Jinjections for the treatment of pain as a result of Herpes Zoster is not indicated due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. II. Radiofrequency Ablation of the SIJA. Initial radiofrequency ablation of the SI J 1. Radiofrequency ablation is considered medically necessary when ALL the foll owing have been met in the last 6 month s: a. The clinical criter ia above for failed conservative therapy (I.A. 4.a. and I.A.4. b.) has been met . b. One diagnostic injection per joint to evaluate pain and attain therapeutic effect has been performed , with significant functional pain relief as measured by a decrease in pain level (demonstrated on a qualitative pain scale), decrease in pain medications, and/or increase in physical function . B. Repeat radiofrequency ablation of the SI J 1. Conservative therapy and diagnostic injections are not required if there has been a reduction in pain for at least 12 months or more from the initial RFA within the last 36 months. 2. When there has not been a repeat RFA in the last 36 months, a diagnostic injection is required. 3. A maximum of 1 RFA for SI Jpain per side per rolling 12 months is considered medically necessary. C. Exclusions/Limitations 1. Codes 64451 and 27096 are considered the same procedure and may not be billed together. Only one code will be reimbursed. Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 2. The use of cooled RFA for SI J-mediated low back pain is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. 3. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated the effectiveness of RFA as a long-term management modality. Long-term continuation may be subject to medical necessity review. III. Implantable Spinal Cord StimulatorsPatients with indwelling implanted spinal cord stimulators or pain pumps should have a device interrogation report submitted with medical records for a prior authorization request for proposed interventional pain injections. If a device is not functioning properly, an escalation in pain may warrant evaluation and management of the implanted device. E. Conditions of CoverageNA F. Related Polices/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/10/2015 New PolicyDate Revised 07/28/2015 07/26/2016 02/08/2018 03/06/2019 10/8/201905/13/202004/28/202103/29/202203/01 /202301/31 /202401/29/2025Removed Herpes CriteriaAnnual Update: Removed start and end dates. Addition of PA clarification and documentation requirements. Revision of injection frequency. Removed joint fusion denial language. This service will be addressed in the Sacroiliac Joint Fusion policy. Annual Update: Added clinical criteria for coverage of radiofrequency ablation of the SI Joint. Added coding information. Annual Update: Removed PA language. Annual Review: Updated background and references, re – organized criteria into initial and subsequent procedures, type of procedure. Annual Review: restructured conservative management and clinical criteria, added provocation tests Annual review: updated formatting and references, approved at Committee. Review: updated references, approved at Committee Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 12/17 /2025 Review: added pain level criteria, increased number of positive provocation test positives and updated references . Approved at Committee. Date Effective 04/01/2026 Date Archived H. References1. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med . 2017;166(7):493-505. doi:10.7326/M16-2459 2. Chou R, Cohen SP. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated April 29 , 202 5. Accessed November 24 , 2025 . www.uptodate.com 3. Cine HS, Uysal E, Demirkol M, Cetin E. Under what conditions is the intra-articular steroid injection superior to nonsteroidal anti-inflammatory drugs for treating sacroiliac joint pain? Eur Rev Med Pharmacol Sci . 2023;27(21):10539-10546. doi:10.26355/eurrev_202311_34331 4. Immunizations, injections and infusions ( including trigger-point injections), skin substitutes, and provider-administered pharmaceuticals , OHIO ADMIN . CODE 5160-4- 12 (2022 ). 5. Jamjoom AM, Saeedi RJ, Jamjoom AB. Placebo effect of sham spine procedures in chronic low back pain: a systematic review. JPain Res . 2021;14:3057-3065. doi:10.2147/JPR.S317697 6. Janapala RN, Knezevic E, Knezevic NN, et al. Systematic review and meta-analysis of effectiveness of therapeutic sacroilic joint injections. Pain Phys ician . 2023;26:E413-E435. Accessed November 24 , 2025 . www.painphysicianjournal.com 7. Lee DW, Pritzlaff S, Jung MJ, et al. Latest evidence-based application for radiofreq uen cy neurotomy (LEARN): best practice guidelines from the American Society of Pain and Neuroscience (ASPN). JPain Res . 2021;14:2807-2831. doi:10.2147/JPR.S235665 8. Liu Y, Suvithayasiri S, Kim JS. Comparative efficacy of clinical interventions for sacroiliac joint pain: systematic review and network meta-analysis with preliminary design of treatment algorithm. Neurospine . 2023 Sep;20(3):997-1010. doi: 10.14245/ns.2346586.293. 9. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint inerventions 2020 guidelines. Pain Phys ician . 2020;23(3S):S1-S127. Accessed November 24 , 2025 . www.painphysicianjournal.com 10. Sacroiliac Joint Injection: A-1048 (AC). MCG. 29 th ed. Updated June 23, 2025. Accessed December 1, 2025. www.careweb.careguidelines.com 11. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 12. Stevens AC, Carroll DD, Courtney-Long EA, et al. Adults with one or more functional disabilisties United States, 2011-2014. MMWR Morb Mortal Wkly Rep Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 2016;65:1021-1025. doi:10.15585/mmwr.mm6538a113. Szadek K, Cohen SP, de Andres Ares J, et al. Sacroiliac joint pain. Pain Pract. 2023 ;00:1-20. doi:10.1111/papr.13338 14. Wu L, Tafti D, Varacallo M. Sacroiliac joint injection. StatPearls . StatPearls Publishing; 2023. Updated August 4, 2023. Accessed November 24, 2025 . Independent Medical Review January 2025Approved by ODM 01/08/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Neonatal Discharge Criteria-OH MCD-MM-1229 04/01/2026 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 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Neonatal Discharge Criteria-OH MCD-MM-1229Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNeonatal Discharge Criteria B. BackgroundInfants who require neonatal admission remain at increased risk for morbidity and mortality following discharge. These infants require comprehensive discharge planning to ensure a smooth transition from the neonatal intensive care unit (NICU) and reduce mo rbidity and mortality after discharge. Despite the inability to predict the exact timing of a NICU discharge, discharge planning should begin at NICU admission in an effort to avoid overwhelming parents and hospital staff. This planning will aid in minimizing discharge delays and will promote s afe andhealthy discharges to home.Discharge may be appropriate when the establishment of physiologic competencies, including, but not limited to, thermoregulation, feeding, respiratory control, and stability regardless of weight or corrected gestational age, have been achieved.C. Definitions Acceptable Bilirubin Level Defined per American Academy of Pediatrics (AAP) guidelines. Bilirubin Blood test to measure liver function. Car Seat Test Eligibility An infant tolerance test for sitting usually occurring 36.4 Caxillary while clothed in an open bed/crib. D. PolicyI. CareSource considers neonatal discharge medically appropriate for non-technology dependent infants when ALL of the following clinical criteria are met: A. Thermoregulation Stability 1. Infant demonstrates the ability to maintain normal body temperature while clothed in an open crib. Up to 48 hours of stable body temperature is typically adequate for infants born
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295 04/01/2026 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 ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectIntraosseous Basivertebral Nerve Ablation B. BackgroundInterventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self – manag ement and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualifie d to deliver these health services. Chronic low back pain (CLBP) is a common disabling condition, estimated to afflict 80%of adults at some point. Degenerative disc disease (DDD) is an important cause ofCLBP. While discs are avascular with limited nerve distribution, vertebral endplates have the potential to trigger a cascade of degenerative events if there is a loss of integrity. Vertebral endplates are a thin interface between bone marrow and discs and contain neural elements. Breakdown of the endplate is believed to cause v ertebrogenic chronic low back pain , a type of chronic low back pain . Endplate degeneration can be observed on MRI through Modic changes (MC). Histologically in MC type I (MC I) lesions, the endplate is disrupted as fibrous tissuereplaces bone marrow causing the disc-bone interface to be filled with vascularized granulation tissue. MC I represents bone marrow edema and inflammation. In MC t ype II (MC II) lesions, there is demonstration of fatty marrow replacement in addition to MC type I findings. MC II represents conversion of hematopoietic marrow into fatty, yellow bone marrow. MC type III (MC III) lesions are related to subchondral bone sclero sis. Analysis of Modic lesion s shows that MC I is characterized by high bone turnover, MC II is characterized by decreased bone turnover, and MC III are stable. Radiofrequency ablation (RFA) is a minimally invasive, percutaneous treatment which uses heat to ablate the nerve pathway that conducts the pain signal. The goal of RFA is to interrupt the pain pathway without causing excessive sensory loss, motor dysfunct ion,or other complications. Intracept is an RFA system designed to ablate the basivertebral nerve of the vertebral endplate. C. Definitions Chronic Low Back Pain Persistent pain in the lumbar region lasting for more than 12 weeks. Conservative Therapy A multimodality plan of care including both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen muscle groups and target key spinal structures, including physical therapy, occupational Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 therapy, physician supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS u se , acupuncture, and/or pharmacotherapy (prescription or over the counter [eg, non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorph ins. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Modic Changes Vertebral bone marrow signal intensity changes that are observable on MRI and are commonly associated with degenerative disc disease. o Modic Change Type I Characterized by hypo-and hyper-intense signal intensities on T1-and T2-weighted spin-echo (T1W1 and T2W1), respectively. o Modic Change Type II Characterized by hyper-intense signal intensities on both T1W1 and T2W1. o Modic Change Type III Characterized by hypo-intense signal intensities on both T1W1 and T2W1. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial or lateral branches of the dorsal spinal nerves. D. PolicyI. CareSource considers intraosseous basivertebral nerve ablation medically necessary when ALL the following clinical criteria are met: A. Member has a diagnosis and documentation of chronic low back pain of at least 6 months duration . B. Failure of conservative therapy, as evidenced by ALL the following: 1. documentation in the medical record of at least 6 weeks of active conservative therapy (see definition above) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance 2. documentation in the medical record of at least 6 weeks of inactive conservative therapy (see definition above) within the past 6 months C. MRI demonstrates Type I or Type II mo dic changes at one or more vertebra l endplates from level L3 to S1 , as demonstrated by Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 1. hypointense T1-weighted signal and hyperintense T2-weighted signal (ie,bone marrow edema and inflammation) , or 2. hyperintense T1-weighted signal and hyperintense T2-weighted signal (ie, bone marrow ischemia) D. Device is FDA-approved (eg, Intracept System) . E. Member does not have any of the following contraindications: 1. severe cardiac or pulmonary compromise 2. targeted ablation zone less than 10mm from a sensitive structure not intended to be ablated (including vertebral foramen) 3. active systemic infection or localized infection in the area to be treated 4. member is currently pregnant 5. skeletal immaturity 6. implantable pulse generator (eg, pacemaker, defibrillator) or other electronic implant 7. scoliosis 8. spinal instability II. Repeat or additional intraosseous basivertebral nerve ablation is not considered medically necessary, as it has not been adequately studied in the peer-reviewed medical literature. III. Monitored anesthesia and conscious sedation during intraosseous basivertebral nerve ablation are considered not medically necessary and will therefore not be reimbursed.IV. Coverage is limited to the above criteria. Intraosseous basivertebral nerve ablation is considered not medically necessary for all other indications.E. Conditions of Coverage NA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/30/2022 New PolicyDate Revised 03/01/2023 01/31/202401/29 /202512/17 /2025 Annual review: restructured conservative therapy, added HEP and TENS to definitions . Annual review: updated references. Approved at Committee Review: updated references, approved at Committee. Review: updated references. Approved at Committee. Date Effective 04/01/2026 Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 Date ArchivedH. References1. Evidence Ba sed Clinical Guidelines for Multidisciplinary Spine Care : Diagnosis and Tr eatment of Low Back Pain . North American Spine Society ; 2020 . Accessed December 2, 2025. www.spine.org 2. Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: a prospective randomized double-blind sham-controlled multi-center study. Euro Spine J. 2018;27:1146-1156. doi:10.1007/s00586-018-5496-1 3. Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 2-year results from a prospective randomized double-blind sham-controlled multicenter study. Int JSpine Surg. 2019;13(2):110-119 . doi:10.14444/6015 4. Fischgrund JS, Rhyne A, Macadaeg K, et al. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham – controlled multi-cent er study. Eur Spine J. 2020;29:1925-1934. doi:10.1007/s00586 – 020-06448-x 5. Health Technology Assessment: Intracept Intraosseous Nerve Ablation System (Relievant Medsystems Inc.) for Treatment of Adults with Low Back Pain. Hayes; 2025. Reviewed November 20, 2025. Accessed December 2, 2025. www.evidence.hayesinc.com 6. Khalil JG, Smuck M, Koreckij T, et al. A prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J. 2019:1620-1632. doi:10.1016/j.spinee.2019.05.598 7. Lorio M, Clerk-Lamalice O, Beall DP, Julien T. ISASS guideline : intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain. Int JSpine Surg . 2020;14(1):18-25. doi:10.14444/7002 8. Lorio M, Clerk-Lamalice O, Rivera M, Lewandrowski K. ISASS policy statement 2022: literature review of intraosseous basivertebral nerve ablation. Int JSpine Surg. 2022;16(6):1084-1094. doi:10.14444/8362 9. McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain-related healthcare utilization following intraosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. Pain Med . 2024;25:20-32. doi:10.1093/pm/pnad114 10. Nwosu M, Agyeman WY, Bisht A, et al. The effectiveness of intraosseous basivertebral nerve ablation in the treatment of nonradiating vertebrogenic pain: a systematic review. Cureus . 2023;15(4):e37114. doi:7759/cureus.37114 11. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 12. Sayed D, Naidu RK, Patel KV, et al. Best practice guidelines on the diagnosis and treatment of vertebrogenic pain and basivertebral nerve ablation from the American Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 Society of Pain and Neuroscience. JPain Res . 2022;15:2801-2819. doi:10.2147/JPR.S378544 13. Smuck M, Khalil J, Barrette K, et al. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month result. Reg Anesth Pain Med. 2021;46:683-693. doi:10.1136/rapm-2020 – 102259 14. Smuck M, McCormick ZL, Gilligan C, et al. A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J . 2024;S1529-9430(24)01040-4. doi:10.1016/j.spinee.2024.09.016 15. U.S. Food and Drug Administration. 510(k) Premarket Notification: Intracept Intraosseous Nerve Ablation System , 510( k) approval K 222281; 2022. Accessed December 2, 202 5. www.accessdata.fda.gov 16. U.S. Food and Drug Administration. 510(k) Premarket Notification: Relievant Medsystems RF Generator , 510( k) number: K171143; 201 7. Accessed December 2, 202 5. www.accessdata.fda.gov 17. Viswanathan VK, Shetty AP, Rajasekaran S. Modic changes an evidence-based, narrative review on its pathophysiology, clinical significance and role in chronic low back pain. JClin Orthop Trauma . 2020;11(5):761-769. doi:10.1016/j.jcot.2020.06.025 Independent med ical review March 2022 Approved by ODM 01/07/ 2026
MEDICAL POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Medical Interventions for Gender Dysphoria-OH MCD-MM-0034 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 ………………………………………………………………………………………………………………. 3 E. Conditions Of Coverage ……………………………………………………………………………………… 4 F. Related Policies/Rules ……………………………………………………………………………………….. 4 G. Review/Revision History …………………………………………………………………………………….. 4 H. References ………………………………………………………………………………………………………. 4 02/07/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 2 Medical Interventions for Gender Dysphoria-OH MCD-MM-0034 Effective Date: 02/07/2026A.SubjectMedical Interventions for Gender DysphoriaB.BackgroundState Medicaid programs have a responsibility to ensure that payments are consistent with efficiency, economy, and quality of care under Section 1902(a)(30)(A) of the Social Security Act. Section 1902(a)(19) requires that states provide such safeguards as may be necessary to ensure that covered care and services are provided in a manner consistent with the best interests of recipients. Agencies have a basic obligation to ensure the quality of Medicaid-covered care and that such care is provided in a manner consistent with the best interest of beneficiaries.Federal matching funds may not be claimed for any sterilization procedure performed on an individual under age 21, 42 C.F.R 441.253(a). Specifically, federal financial participation is unavailable for any procedure, treatment or operation done for the purpose of permanently rendering an individual incapable of reproducing, 42 C.F.R. 441.251. Additionally, 42 C.F.R. 441.255(a) prohibits financial federal participation for any hysterectomy performed solely for sterilization. All sterilization procedures must also meet the consent and waiting-period requirements set forth in 42 C.F.R. 441.252.254.C.Definitions Cross-Sex Hormone Testosterone, estrogen, or progesterone given to a minor individual in an amount greater than would normally be produced endogenously in a healthy individual of the minor individual’s age and sex. Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program A comprehensive preventive health program for individuals under age 21 that requires coverage of any service necessary to correct or ameliorate defects, physical and mental illnesses and conditions discovered by screening. 42 C.F.R. 441.50 et seq. Gender Dysphoria Affective and/or cognitive discontent accompanying incongruence between experienced or expressed gender and assigned gender, lasting at least 6 months and meeting diagnostic criteria listed in the DSM-5-TR. Gender Reassignment Surgery Any surgery performed for the purpose of assisting an individual with gender transition that seeks to surgically alter or remove healthy physical or anatomical characteristics or features that are typical for the individual’s biological sex, in order to instill or create physiological or anatomical characteristics that resemble a sex different from the individual’s birth sex, including genital or non-genital gender reassignment surgery. Gender-Related Condition Any condition where an individual feels an incongruence between the individual’s gender identity and biological sex, including gender dysphoria. Gender Transition Services Any medical or surgical service (including physician services, inpatient and outpatient hospital services, or prescription drugs or hormones) provided for the purpose of assisting an individual with gender transition The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 3 that seeks to alter or remove physical or anatomical characteristics or features that are typical for the individuals biological sex, or to instill or create physiological or anatomical characteristics that resemble a sex different from the individuals birth sex, including medical services that provide puberty blocking drugs, cross-sex hormones, or other mechanisms to promote the development of feminizing or masculinizing features in the opposite sex, or genital or non-genital gender reassignment surgery. Minor Any member under the age of 18. Puberty-Blocking Drugs Gonadotropin-releasing hormone analogs or other synthetic drugs used to stop luteinizing hormone and follicle stimulating hormone secretion, synthetic antiandrogen drugs used to block the androgen receptor or any drug to delay or suppress normal puberty. D. Policy I. CareSource complies with state and federal regulations for the coverage of medically necessary services. Medically necessary services are health care services needed to diagnose or treat that meet the accepted standards of medicine. 42 C.F.R. 440.230. All requests are reviewed on a case-by-case basis, including any applicable requests under the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. II. For any member under the age of 18, Ohio Revised Code 3129.06 prohibits coverage of gender transition services, subject to certain exceptions as follows: A. mental health services provided for a gender-related condition B. treatment, including surgery or prescribing drugs or hormones, to a minor who 1. was born with a medically verifiable disorder of sex development 2. received a diagnosis of a disorder of sexual development 3. needs treatment for any infection, injury, disease, or disorder that has been caused or exacerbated by the performance of gender transition services III. Any member 18 to 20 years of age, as per 42 CFR 441.56 and 42 U.S.C. 1396d(r), will be reviewed for medical necessity as required by the EPSDT program (ie, Ohio Healthchek). CareSource will cover medically necessary care if deemed essential by a healthcare provider, including gender-related care. IV. For any member 21 years of age or older, Ohio Administrative Code 5160-2-03 establishes that gender transformation services are not covered services (eg, clitoroplasty, intersex surgery, vaginectomy, penectomy, mastectomy, breast augmentation). V. All behavioral health services for gender dysphoria will be subject to the same utilization management and cost-sharing requirements as other behavioral and medical benefits in compliance with Mental Health Parity and Addiction Equity Act. 42 U.S.C. 300gg-26; 45 C.F.R. Part 146. Medical Interventions for Gender Dysphoria-OH MCD-MM-0034 Effective Date: 02/07/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 4 Dates Action Date Issued 05/18/2017 Date Revised 05/29/2019 09/02/2020 07/07/2021 05/19/2022 06/21/2023 07/17/2024 07/02/2025 Updated evidence, changed policy # (MM-0080), removed pharmacy info, added addtl requirements for surgery, specifics on hair removal, items not covered & types of surgery for medical necessary review. Updated definitions, removed research & codes, added references, changed letter recommendation requirement, changed title. Removed endocrinologist rule, added psych NP & safety info. Annual review. Updated definitions. Added PCP to hormone therapy requirement. Removed conception counseling for genital surgery. Removed breast augmentation from the exclusion list. Annual review. Updated background, definitions, reference list. Approved at Committee. Annual review. Top changed to chest, bottom to genital. Updated background & definitions. Combined letter info. Updated references. Approved at Committee. Rewrote background to comply with 2025 CMS letter. Revised all sections re: compliance with regulations. Approved at Committee. Date Effective Date Archived H. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revised (DSM-5-TR). Arlington, VA; 2022. 2. Conditions and Limitations. OHIO ADMIN. CODE 5160-2-03 (2022). 3. Definitions. 42 U.S.C. 1396d(r) (2024). 4. Gender Transition Services for Minors. OHIO REV. CODE Chapter 3129 (2024). 5. Healthchek: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Covered Services. OHIO ADMIN. CODE 5160-1-14 (2017). 6. Medicaid Medical Necessity: Definitions and Principles. OHIO ADMIN. CODE 5160-1-01 (2022). 7. Puberty Blockers, Cross-sex Hormones, and Surgery Related to Gender Dysphoria. Centers for Medicare and Medicaid Services; April 11, 2025. Accessed June 11, 2025. www.cms.gov. 8. Required Activities. 42 C.F.R. 441.56 (1984). Approved by Ohio Department of Medicaid 10/24/2025. Medical Interventions for Gender Dysphoria-OH MCD-MM-0034 Effective Date: 02/07/2026E.Conditions Of CoverageNAF.Related Policies/RulesMedical Necessity DeterminationsG.Review/Revision History02/07/2026
© Copyright CareSource 2026. All rights reserved.
System Details