Airway Clearance Devices

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Airway Clearance Devices-OH MCD-MM-1578 11/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Airway Clearance Devices-OH MCD-MM-1578Effective Date: 11/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectAirway Clearance Devices B. BackgroundHealthy individuals typically produce 10 100 mL of airway secretions daily. The clearance of these secretions from the respiratory tract is accomplished primarily through ciliary action, called the mucociliary escalator and the cough reflex. Secretion retention can occur because of an increased production of secretions due to a number of conditions, including asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), mucociliary disorders, neuromuscular disease (NMD), and metabolic disorders that make it more difficult to clear the airway. In patients with a weak cough, retention of these secretions is a major cause of mortality and morbidity. Conventional chest physical therapy has been shown to result in improved respiratory function through the use of percussion and postural drainage. These techniques are usually taught to family members so therapy may be continued at home when needed for chronic disease. However, this highly labor-intensive activity requires the daily intervention of a trained caregiver and may lead to poor compliance with the recommended treatment plan. Airway clearance devices can aid secretion mobilization and expectoration and assist coughing. Educating patients and families on the use of these devices and secretion management are within the scope of practice of respiratory therapists, physical therapists, nurses, and other clinicians. C. Definitions High Frequency Chest Compression Device An inflatable vest connected by tubes to a small air-pulse generator. The air-pulse generator rapidly inflates and deflates the vest, compressing and releasing the chest wall up to 20 times per second. Mechanical Insufflation-Exsufflation Device A device with a facemask that covers the nose and mouth, allowing air to be pumped into the lungs and then rapidly evacuated, facilitating the expulsion of secretions. D. PolicyI. Mechanical Insufflation-Exsufflation Devices (E0482) A. CareSource considers mechanical in-exsufflation devices medically necessary when all of the following clinical criteria are met: 1. There is a presence of neuromuscular or chest wall disease (eg, amyotrophic lateral sclerosis, congenital muscular dystrophies, Duchenne muscular dystrophy, multiple sclerosis, post-poliomyelitis, spinal cord injury, spinal muscle atrophy). Airway Clearance Devices-OH MCD-MM-1578Effective Date: 11/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 2. The condition causes a significant impairment of chest wall and/or diaphragmatic movement, resulting in an inability to clear retained secretions. 3. The member has an inadequate response or intolerance to chest percussion and postural drainage. 4. Member has no bullous emphysema, pneumomediastinum, or pneumothorax. B. A mechanical insufflation-exsufflation device for any indication not listed above is not covered or reimbursable. II. High Frequency Chest Compression Devices (E0483)A. CareSource considers high frequency chest compression devices medically necessary when any of the following clinical criteria is met: 1. cystic fibrosis when there is failure, intolerance or contraindication to home chest physiotherapy, or it cannot be provided 2. a diagnosis of bronchiectasis which has been confirmed by a high resolution, spiral, or standard CT scan and which is characterized by a. daily productive cough for at least 6 continuous months or b. frequent (eg, more than 2 per year) exacerbations requiring antibiotic therapy B. Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion. C. It is not reasonable and necessary for a member to use both a high frequency chest compression device and a mechanical in-exsufflation device. D. Per Ohio Administrative Code (OAC) 5160-10-08, purchase of a high-frequency chest wall oscillation (HFCWO) device will not be considered: 1. without an initial trial period lasting at least 2 months, excluding any portion that coincides with an inpatient hospital stay 2. Payment for rental may be made during this trial period. E. If use of the HFCWO device is to be continued in a residential setting after the initial trial period, a Certificate of Medical Necessity (CMN) is included that contains 1. an attestation to the effectiveness of the device during the trial period and every previous rental period 2. if applicable, specification of a change in the duration or frequency of therapy 3. a recommendation either for additional rental or for purchase F. The Volara device is not approved for outpatient use. E. Conditions of Coverage NA F. Related Policies/Rules NA Airway Clearance Devices-OH MCD-MM-1578Effective Date: 11/01/2025The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 G. Review/Revision HistoryDATE ACTIONDate Issued 01/17/2024 New policy. Approved at Committee.Date Revised 11/20/2024 06/18/2025 Updated references. Approved at Committee. Updated references. Approved at Committee. Date Effective 11/01/2025 Date Archived H. References1. Bach JR. Noninvasive respiratory management of patients with neuromuscular disease. Ann Rehabil Med . 2017;41(4):519-538. doi:10.5535/arm.2017.41.4.519 2. Basavaraj A, Choate R, Addrizzo-Harris D, et al. Airway clearance techniques in bronchiectasis: analysis from the United States Bronchiectasis and Non-TB Mycobacteria Research Registry. Chest . 2020;158(4):1376-1384. doi:10.1016/j.chest.2020.06.050 3. Chatwin M, Wakeman RH. Mechanical insufflation-exsufflation: considerations for improving clinical practice. JClin Med . 2023;12(7):2626. doi:10.3390/jcm12072626 4. DMEPOS: High-Frequency Chest Wall Oscillation (HFCWO) Devices, O HIO ADMIN . C ODE 5160-10-08 (2024). 5. Ferreira de Camillis ML, Savi A, Goulart Rosa R, et al. Effects of mechanical insufflation-exsufflation on airway mucus clearance among mechanically ventilated ICU subjects. Respir Care . 2018;63(12):1471-1477. doi:10.4187/respcare.06253 6. Finder JD, Birnkrant D, Carl J, et al. Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement. Am JRespir Crit Care Med. 2004;170(4):456-465. doi:10.1164/rccm.200307-885ST 7. High Frequency Chest Compression Device: A-0356 (AC). MCG Health. 28th ed. 2024. Updated March 14, 2024. Accessed May 12, 2025. www.careweb.careguidelines.com 8. Mechanical Insufflation-Exsufflation Device: A-0884 (AC). MCG Health. 28th ed. 2024. Accessed May 12, 2025. www.careweb.careguidelines.com 9. Raywood E, Shannon H, Filipow N, et al. Quantity and quality of airway clearance in children and young people with cystic fibrosis. JCyst Fibros . 2023;22(2):344-351. doi:10.1016/j.jcf.2022.09.008 10. Strickland SL, Rubin BK, Drescher GS, et al. AARC clinical practice guideline: effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients. Respir Care . 2013;58(12):2187-2193. doi:10.4187/respcare.02925 Approved by ODM on 7/22/2025

Private Duty Nursing

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Private Duty Nursing-OH MCD-MM-1510 10/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilizati on 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 ne cessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discom fort. 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 defin ed 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 o f services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 4 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 17 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……. 17 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 17 H. References ………………………….. ………………………….. ………………………….. …………………… 17 Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPrivate Duty Nursing B. BackgroundPrivate duty nursing (PDN ) is a Medicaid State Plan service that provides in-home skilled nursing care to Medicaid members of any age who require continuous nursing services beyond the Medicaid State Plan Home Health benefit. PDN provides care for members with complex medical need s under the direction of the members physician if it can be provided safely in a residence unless it is medically necessary for a nurse to accompany the member in the community . For individuals who have a medical need for part-time , intermittent , and skilled nursing or aide care and therapies, home health services may also be provided. Refer to the Home Health Services medical policy for further guidance on intermittent skilled nursing or aide care. PDN services are covered by the Ohio Department of Medicaid (ODM) when certified asmedically necessary and only when at least 4 hours of continuous skilled care that requires the skills of either a registered nurse (RN) or licensed practical nurse (LPN) under the direction of an RN are performed. A covered PDN visit must meet the conditions imposed in 5160-12-02 of the Ohio Administrative Code (OAC) and all other applicable state regulations. Providers of PDN include a Medicare certified home health agency (MCHHA) that meets the requirem ents in accordance with OAC 5160-12-03, an otherwise accredited agency and a non-agency nurse that meets the requirements in accordance with OAC 5160-12-03.1. In order for PDN to be covered, providers must:1. Provide appropriate PDN given the members diagnosis, prognosis, functional limitations, and medical conditions as documented by the members treating physician, physicians assistant, or advance practice nurse. 2. Provide PDN as specified in the plan of care in accordance with OAC 5160-12-03. PDN services not specified in a plan of care are not reimbursable. For individuals enrolled on a home and community-based services (HCBS) waiver, the providers of PDN services must provide the amount, scope, duration, and type of PDN service within the plan of care as: a. Documen ted on the all-services plan approved by ODM or its designee when an individual is enrolled on an ODM administered HCBS waiver. PDN services not identified on the all-services plan are not reimbursable . b. Documented on the services pl an when an individual is enrolled on an Ohio Department of Aging (ODA) or an Ohio Department of Developmental Disabilities (DODD) administered HCBS waiver. PDN services not documented on the services plan are not reimbursable. 3. Bill for provided PDN servic es using an appropriate procedure code and applicable modifiers in accordance with OAC 5160-12-06. 4. Bill for provided PDN services in accordance with the visit policy in OAC 5160-12-04, except as provided for in paragraph (A) of OAC 5160-12-02. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 5. Bill after a ll documentation is completed for services rendered during a visit in accordance with OAC 5160-12-03. The below guidelines identify clinical information that CareSource uses to determinemedical necessity and quantity of care for PDN . The guidelines are based on generally accepted standards of practice, review of medical literature, as well as federal and state pol icies and laws applicable to Medicaid programs. Providers should consult OAC Chapter 5160-12 for details about coverage, limitations, service conditions, and prior – authorization requirements. C. Definitions HealthChek Program The Ohio-administered version of the early and periodic screening, diagnosis, and treatment (EPSDT) program, which is a federally mandated program of comprehensive preventive health services available to Medicaid-eligible individuals from birth through age 20 years and is administered by the County Department of Job and Family Services (CDJFS). Home Health Agency A person or government entity, other than a nursing home, residential care facility, or hospice care program , that has a primary function of providing any of the following services to a patient at a place of residence used as the patients home: o skilled nursing care o physical therapy o speech language pathology o occupational therapy o medical social services o home healt h aide services Maintenance Care Care given to a member for the prevention of deteriorating or worsening medical conditions or the management of stabilized chronic diseases or conditions. Services are considered maintenance care if the member is no long er making significant improvement with a medical condition. Medical Necessity Procedures, items, or services that prevent, diagnose, evaluate, or treat an adverse health condition that meet ALL the following conditions: o meets generally accepted standards of medical practice o is c linically appropriate in type, frequency, extent, duration, and delivery setting o is a ppropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome o is the lowest cost alternative that effectively addresses and treats the medical problem o provides unique, essential, and appropriate information if used for diagnostic purposes o is n ot provided primarily for the economic benefit of the provider nor for the convenience of the provider or anyone else other than the recipient Place of Residence Wherever the individual lives, whether the residence is the individuals own dwelling, assisted living facility, relatives home, or other type of Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 living arrangement. This does not inclu de a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Plan of Care The medical treatment plan that is established, approved, and signed by a treating physician, advance practice nurse , or physicia ns assistant in accordance with all applicable federal and state regulations. Skilled Care Procedures that require technical skills and knowledge beyond those the untrained person possesses and that are commonly employed in providing for the physical, mental, and emotional needs of the ill or otherwise incapacitated. “Skilled nursing care” includes, but is not limited to, the following: o irrigations, catheterizations, application of dressings, and supervision of special diets o objective observation of cha nges in the resident’s condition as a means of analyzing and determining the nursing care required and the need for further medical diagnosis and treatment o special procedures contributing to rehabilitation o administration of medication by any method ordered by a physician or other licensed health care professional acting within their applicable scope of practice, such as hypodermically, rectally, or orally, including observation of the resident after receipt of the medication o carrying out other treatm ents prescribed by the physician or other licensed health care professional acting within their applicable scope of practice, that involve a similar level of complexity and skill in administration D. PolicyI. Private duty nursing (PDN) services are provided to any CareSource Ohio Medicaid member when considered medically necessary. II. This policy is not intended to restrict or contradict EPSDT services.III. Duplicative services are not covered. If the member is receiving other assistance (eg, family caregiver, home health services, additional supportive services), this information and the hours involved must be provided to adequately evaluate medical necessity of PDN services. IV. PDN services must meet ALL the following:A. Services performed must be within the nurses sc ope of practice as defined in Chapter 4723. of the Ohio Revised Code (ORC ) and rules adopted there under . B. Services provided must be documented in accordance with the individuals plan of care . C. Services must be medically necessary to care for the individuals condition, illness, or injury . D. Service must b e provided in person in the individuals place of residence unless it is medically necessary for a nurse to accompany the individual in the community. The place of service in the community cannot in clude the business location of the Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 provider of PDN. The place of service in the community cannot include the residence of the provider of PDN unless it is the same as the individual.V. PDN services do not include any of the following :A. services provided for the provision of habilitative care (this is reviewed for medical necessity for EPSDT members ) B. RN assessment services C. RN consultation services VI. Individuals who receive PDN must meet ALL the following :A. Be under the supervision of a treating physician, physician’s assistant (PA) , or advance practice nurse (APN) who is providing care and treatment to the individual. The treating physician, PA , or APN is not a physician, PA , or APN not only sign s and authorize s plans of care but are als o direct ly involved in the care or treatment of the individual. A treating physician, PA or APN may also substitut e temporarily on behalf of a treating physician. B. Participate in the development of a plan of care with the treating physician, PA , or APN and the MCHHA , other accredited agencies , or non-agency registered nurse. An authorized representative may participate in the development of the plan of care in lieu of the individual. C. Access PDN in accordance with the program for the all-inclusive care of the elderly (PACE) if the individual participates in the PACE program. D. Access PDN in accordance with the individual’s provider of hospice services if the individual has elected hospice. E. Access PDN in accordance with the individual’s m anaged care plan’s process if the individual is enrolled in a Medicaid managed care plan. VII. Post hospital PDNA. Any individual receiving Medicaid, whether adult or child, may receive PDN services up to 56 hours per week and up to 60 consecutive days from the date of discharge from an inpatient hospital stay of 3 or more covered days in accordance with OAC 5160-2-03. A covered inpatient hospital stay is considered 1 hospital stay when an individual is transferred from 1 hospital to another hospital, either with in the same building or to another location. The member must still meet medical necessity criteria for PDN . 1. The 60 days will begin when the individual is discharged from the hospital to the individual’s place of residence from the most recent inpatient stay in an inpatient hospital or inpatient rehabilitation unit of a hospital. 2. The 60 days will begin when the individual is discharged from a hospital to a nursing facility. PDN is not available while residing in a nursing facility. B. The treating physician, PA , or APN will certify the medical necessity of PDN services using the ODM 07137 “Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services” (rev. 7/2014). PDN is available to individuals only with a medical need comparable to a sk illed level of care as evidenced by a medical condition that temporarily reflects the skilled level of care Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 as defined in OAC 5160-3-08. In no instance do these requirements constitute the determination of a level of care for waiver eligibility purposes or admission into a Medicaid covered long-term care institution. VIII. Children may qualify for additional PDN services beyond the post-hospitalization service when the following criteria are met: A. The individual is under age 21 years and requires services for tre atment in accordance with the HealthChe ck program. B. Needs, as ordered by the treating physician, PA , or APN , continuous nursing services, including the provision of on-going maintenance care (services for habilitative care are inappropriate). C. Has a comparab le level of care as evidenced by either: 1. Enrollment on a HCBS waiver . 2. For a child not enrolled on a HCBS waiver, a comparable institutional level of care, including a nursing facility-based level of care pursuant to OAC 5160-3- 08 or an ICF-IID level of car e pursuant to OAC 5123:2-8-01, as evaluated initially and annually by ODM or its designee. D. The provider of PDN services ensures and documents the child meets all requirements for PDN services prior to providing and billing for the services. E. The child has a PDN authorization obtained in accordance with OAC 5160-12 – 02.3 to establish medical necessity and the childs comparable level of care. A request for additional, recertification, and/or a change of PDN authorization is made as follows: 1. For a child not enrolled on a HCBS waiver, the provider of PDN shall submit the request to ODM or its designee. Any documentation required by ODM or its designee for the review of medical necessity shall be provided by the provider of PDN services. ODM or its designee wil l notify the provider of the amount, scope and duration of services authorized. 2. For a child enrolled on a DODD administered waiver, the provider of PDN must submit the request to the case manager of the HCBS waiver, who will forward the request to DODD. An y documentation required by DODD for the review of medical necessity shall be provided by the provider of PDN services. DODD will notify the provider and the case manager of the amount, scope and duration of services authorized. 3. For a child enrolled on an ODM administered waiver, the ODM case manager will authorize PDN services through the person-centered services plan. IX. Adults may qualify for additional PDN services beyond the post-hospitalization service when the following criteria are met: A. The adult is age 21 years or older. B. The adult needs, as ordered by the treating physician, PA , or APN , continuous nursing services, including the provision of on-going maintenance care (services for habilitative care are inappropriate). C. The adult has a co mparable level of care as evidenced by either: 1. Enrollment on a HCBS waiver. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 2. A comparable institutional level of care, including a nursing facility-based level of care as evaluated initially and annually by ODM or its designee for an adult not enrolled on a HCBS waiver. The criteria for a nursing facility-based level of care are defined in OAC 5160-3-08 or ICF-IID level of care as defined in OAC 5123-8-01. D. The provider of PDN services ensures and documents that the adult meets all requirements for PDN servic es prior to providing and billing for services. E. The adult must have a PDN authorization obtained in accordance with OAC 5160-12-02.3 and approved by ODM or its designee to establish medical necessity and the adults level of care. A request for additional, recertification, and/or a change of PDN authorization is made as follows: 1. For an adult not enrolled on a HCBS waiver, the provider of PDN shall submit the request to ODM or its designee. Any documentation required by ODM or its designee for the review of medical necessity shall be provided by the provider of PDN services. ODM or its designee will notify the provider of the amount, scope , and duration of services authorized. 2. For an adult enrolled on a DODD administered waiver, the provider of PDN must submit the request to the county board of DD, who will forward the request to DODD. Any documentation required by DODD for the review of medical necessity shall be provided by th e provider of PDN services. DODD will notify the provider and the county board of DD of the amount, scope, and duration of services authorized. 3. For an adult enrolled on an ODM administered waiver, the case manager will authorize PDN services through Utiliz ation Management . X. Additional PDN services beyond what ODM or its designee has authorized may be provided to an individual in an emergency when the provider has an existing PDN authorization to provide PDN services to that individual. For the purposes of this rule, emergency services are provided outside of normal state of Ohio office hours when prior authorization cannot be obtained. A. PDN services may be delivered in an emergency and a new PDN authorization obtained after the delivery of services. The PDN services must be medically necessa ry in accordance with OAC 5160-1-01, and the services must be necessary to protect the health and welfare of the individual. B. The provider shall notify ODM, or the ODA case manager, as applicable, in writing using the ODM 02374, or the county board SSA for individuals enrolled on a DODD administered waiver when emergency PDN services are delivered. Notification shall be immediate, or no later than the first business day following the emergency provision of PDN services. XI. For billing information, refer to OAC 5160-12-06. XII. The PDN acuity scale is intended to be used in conjunction with the assessment tool and the clinical and professional judg ement of the nurse completing the tool. It is not intended to be the sole determinant of all the skilled nursing needs o f the individual. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 Normal age-appropriate care and parental responsibility should be considered (ie, all3-year-olds need assistance with bath ing and dress ing , therefore needs assist, in this category is not scorable , as it is an age-appropriate need and not a medical need ). A. Skilled nursing care acuity guidelines 1. Mechanical ventilation: acuity measurement is based on number of hours used per day . 1.0 point is scored when the ventilator is listed as standby (eg, just in case it would be needed) . 2.5 points are scored when the member requires a ventilator 12 hours or less per day (eg, while sleeping) . 5.0 points are scored when the member requires a ventilator for greater than 12 hours per day . 2. CPAP/BiPAP: acuity measurement is based on number of ho urs used per day . 2.0 points are scored when the member is on CPAP or BiPAP 12 hours or less per day . 4.0 points are scored when the member is on CPAP or BiPAP for greater than 12 hours per day . 3. Tracheostomy: acuity measurement is used to indicate special care needed for tracheostomy (note: dre ssing changes are included in the below) . 1.5 points are scored when the member is able to tolerate the use of a speaking valve, or having the tracheostomy capped for a period of time and/or receives routine care. If a PMV is used in-line with the vent/PAP, do not mark this option if they are still replacing the trach . 3.0 points are scored when the member breathes continuously through an open tracheostomy and requires special care (eg, frequent tube changes, current infection at trach site, irritation, mucous plugs requiring intervention, muco sal bleeding) . 4. Oxygen: acuity measurement is based on the order for administration, either continuous or determined by pulse oximeter. 1.0 point is scored when the members oxygen use is routine and predictable (ie, member has COPD and requires oxygen when ever necessary when walking or upon exertion) . 3.0 points are scored when the members oxygen use is unpredictable (eg, unstable airways). 5. Tracheal suctioning: acuity measurement is based on frequency the skilled nurse performs this service and is only app licable when the member be unable to self-suction . 1.0 point is scored when the member requires suctioning once per day . 2.0 points are scored when the member requires suctioning 2 10 times per day . 3.0 points are scored when the member requires suctioni ng 11 20 times per day . Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.9 4.0 points are scored when the member requires suctioning more than 20times per day. 6. Humidification: acuity measurement is based upon the need for humidification treatment: 0.5 points is scored when humidification is performed an d completed by skilled nurse. 7. Pulse oximetry monitoring: acuity measure is based on treatment that is done on a routine basis . 1.0 point is scored if monitoring is completed by the nurse 3 times per day. 2.0 points are scored if monitoring is completed b y the nurse > 3 times per day or continuous. 8. Injectable medications: acuity measurement is based on number of injections per day on medication that is routinely ordered or as needed ( PRN ) only when the skilled nurse has administered the injectable. Insulin/sub cutaneous injections are not included in this scoring . 1.0 point is scored if 1 injection is administered per day . 2.0 points is scored if more than 1 injection is administered per day. 9. Medication schedule: acuity measurement is based on the complexity of the medication . 1.0 point is scored for r outine medication schedule . This includes medications that do not require dosage adjustments, regardless of the number of medications . 2.0 points are scored for complex medication schedule . This includes medications which are PRN and/or require dosage adju stments by a skilled nurse. Members who have more than 3 medications which are PRN and/or requir e adjustment delivered within an 8-hour window by a skilled nurse would qualify for complex. 10. CPT/ vest/ nebulizer treatments: include treatment that is done on a routine basis, whether there is a standing or PRN order. If the treatments are done together (ie, nebulizer treatments followed by chest physiotherapy, and/or vest therapy), consider points based on the therapy provided at the highest frequency (eg, if neb ulizer 2 times per day and pulmonary vest 3 times per day, count as therapy 3 times per day). 1.0 point is scored when CPT/vest/nebulizer (PRN) . 2.0 points are scored when CPT/vest/nebulizer 1 2 times per day . 3.0 points are scored when CPT/vest/nebulizer 3 4 times per day . 4.0 points are scored when CPT/vest/nebulizer 5 times per day. 11. Blood draws : acuity measurement is based upon the number of blood draws per week . 1.0 point is scored for peripheral blood d raw routinely p erformed by skilled nurse during the week. 1.5 points are scored for central line blood draw routinely performed by skilled nurse during the week. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.10 12. Blood products : acuity measurement is based upon the number of times per month it was documen ted that the member received any blood products provided by the skilled nurse during the PDN visit. 1.0 point is scored for blood products administered once per month . 1.5 points are scored for blood products administered 2 3 times per month . 2.0 points are scored for blood products administered more than 3 times per month. 13. Nasogastric (N/G), gastrostomy (G), or jejunostomy (J/J) tube feedings: acuity measurement is based upon the complexity of the enteral feeding and the associated care needed from the n urse. 2.0 point is scored for G/J and N/G tube bolus or continuous. 3.0 points are scored for G/J and N/G tube combination (bolus and continuous) . 4.0 points are scored for G/J and N/G tube complicated . In order to score for complicated, there must be required residual checks, aspiration precautions, postural changes , and frequent rate adjustments or formula changes. 14. Special diet, prolonged feedings: 1.0 point is scored if there is a threat of aspiration and it requires the assessment, observations, and interventions of a skilled nurse. Documentation of how long it took to feed the member must be present in the nurses notes. This is not applicable for tube feedings. 15. Reflux, dysphagia, aspiration: to receive points for reflux, the member must meet at lea st one of the following criteria: 1) a positive swallowing study performed within the last 12 months; 2) documented current and ongoing treatment for reflux (eg, medications such as Reglan, Zantac, or Prevacid); 3) documented treatment for aspiration pneum onia within the last 12 months; or 4) a need for suctions due to reflux at minimum daily (this does not include suctioning of oral secretions). Must also have the diagnosis of dysphagia or difficulty swallowing, and documentation in the medical record on h ow the member is progressing. Aspiration precautions should be noted in the clinical record by the skilled nurse, as well as the interventions done to prevent aspiration. 1.0 point is scored for aspiration precautions . 1.5 points are scored for reflux or d ysphagia. 16. Seizures: acuity measurement is based upon the frequency of the seizure activity, the severity of the seizure activity, and intervention(s) required. In all instances, seizure monitoring must be recorded in the nurses notes and/or maintained in a seizure logbook. The description of the seizure should be addressed (ie, type, duration, intervention). There must also be seizure medications that are scored on a routine basis. The number of seizures per day, week, month, etc. must be documented and the average number occurring should be known. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.11 0.0 points are scored if there is a seizure diagnosis or history of seizures, but there is no active seizure activity . 1.0 point is scored if there is observation/monitoring only, but no skilled nursing inter vention . 2.0 points are scored if there are moderate interventions required, no injury, and Diastat has to be administered, or a magnet and vagus nerve stimulator is used to stop seizure activity. 3.0 points are scored if there is an injury, Diastat has to be administered or a magnet and vagus nerve stimulator is used to stop seizure activity, and apnea is present. 17. General assessments: acuity measurement is based on the frequency a complete nursing assessment is being performed and documented in the nurses notes. This does not include general statements (eg, sleeping soundly, respirations quiet, r estless), but may be a targe ted assessment if there is a concern (eg, respiratory assessment, neurological checks). Points are not considered under this section if just vital signs are taken, but if targeted vital signs are taken (eg, temperature), as well as the targeted assessment, then points could be scored under this assessment. 1.0 point is scored if the assessment is completed and documented in the nurses notes at least once per shift . 1.5 points are scored if the assessment is completed and documented in the nurses notes eve ry 4 hours . 18. Vital signs: acuity measurement is based on complete sets of vitals being taken at specific frequencies (otherwise use the general assessment section above). 1.5 points are scored if a complete set of vital signs are taken 2 3 times per shift AND documented in the clinical record . 2.0 points are scored if a complete set of vital signs are taken 4 times per shift AND documented in the clinical record. 19. Peripheral intravenous therapy (PIV) 1.0 point is scored when peripheral IV infuses less than 4 hours . 2.0 points are scored when there is IV therapy ordered and the skilled nurse gives the IV solution while on the visit and the IV infuses for 4 8 hours . 3.0 points are scored when there is IV therapy ordered and the skilled nurse gives the I Vsolution while on the visit and the IV infuses for greater than 8 hours. 20. Total parenteral nutrition (TPN), central line care, chemotherapy, IV pain control 2.0 points are scored if there is a physician order for chemotherapy and its administered by the skilled nurse during the visit . 2.0 points are scored if there is a physician order for IV pain meds and the skilled nurse gives the IV medication during the visit . Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.12 2.5 points are scored if only central line care is scored and no IV is infusing. 3.0 points are scored if TPN is ordered by a physician and it is administered by the skilled nurse during the visit . 21. Blood sugar /ketones checks 1.0 point is scored when the blood sugar or ketones are checked by the skilled nurse and there is no insulin scored. It do es not matter how many times it is checked. 2.0 points are scored when the blood sugar or ketones are checked by the skilled nurse and insulin is administered by the nurse. It does not matter how many times it is scored. 22. Medicated skin treatment: 1 .0 point is scored when medicated skin treatment is scored by the nurse. This does not include lotions, powders, nonmedicated creams, etc. 23. Stoma/ wound care: acuity measurement includes dressing changes /stoma care (eg , Mitrofanoff, Malone, Chait tube) . Member s with a tracheostomy or gastrostomy will not receive additional points for tracheostomy or gast rostomy dressing changes, as this task is included in the score for the tracheostomy or gastrostomy. 1.5 points are scored when the member has general stoma/wound care and care is documented in the nurses notes once per day, noting condition of the wound/stoma. 2.0 points are scored when the member has the above performed greater than once per day. 24. Decub itus care: 3.0 points are scored when the member has an order for decubitus care and it is performed by the nurse during the home visit. The member would not also receive points for wound/stoma care/medicated skin treatment in addition to this score if the y just have a decubitus. 25. Complex dressing changes/ burn care: 3.0 points are scored when the member has an order for burn care/complex dressing change and it is performed by the nurse during the home visit. The member would not also receive points for wound /stoma care/medicated skin treatment in addition to this score. 26. Catheter , in-dwelling and intermittent 1.5 points are scored when the member has an in-dwelling catheter and catheter care is performed by the nurse during the home visit. 2.5 points are sco red when the member has an in-dwelling catheter and the care is performed by the nurse during the home visit. This would include more complex/complicated care, (eg, flushes, insertion of catheter) . 1.0 point is scored if there is an order for a straight ca theter AND the skilled nurse completes the task during the home visit AND it is no more than once per 8-hour shift AND it is documented in the nurses notes. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.13 2.0 points are scored if there is an order for a straight cath eter AND the skilled nurse completes the task during the home visit AND it is more than once per 8-hour shift AND it is documented in the nurse s notes. 27. Peritoneal dialysis: 2.0 points are scored if peritoneal dialysis is performed by the skilled nurse during the home visit. 28. Hemodialysis: 4.0 points are scored if hemodialysis is performed by the skilled nurse during the home visit. 29. Strict intake and output (I&O): 1.0 point is scored when the I&O requires interventions (ie, the skilled nurse has to make adjustments to feedings o r IV fluids based on the intake and output data) , or diapers are routinely weighed . 30. Acute care episodes 1.5 points are scored if the member has had bone surgery in the last 45 days from the time of assessment. 2.0 points are scored if the member has a new or revised trach within the last 30 days from the assessment date. 2.0 points are scored if the member has had abdominal/thoracic surgery with the last 45 days from the date of assessment. 2.5 points are scored if member has had a ventriculoperitoneal ( VP ) shunt new or revised within the last 30 days . 3.0 points are scored if the member has acute/post-procedure hospitalization at least 3 times per year one year from the date of assessment (this does not include admissions for testing or ER visits). For lon g-term hospitalizations (over 1 month), this section may be counted if the member is admitted for at least 3 months (eg, premature infants). 2.0 points are scored if the member has had an acute/post-procedure hospitalization (does not include admissions fo r testing or ER visits) within the last 30 days from time of assessment. 1.0 point is scored if the member has been discharged from an ECF within the last 30 days . 2.0 points are scored if the member has had documented by the physician at least 2 episodes of any respiratory issue (to include apnea, respiratory distress, etc.) within the last year from the date of the assessment . B. Non-skilled nursing care: can be used if the member does not meet for PDN based on the skilled score alone, but there are extenuating psychosocial circumstances. The non-skilled nursing score is not ro utinely added to the skilled score when a member has a skilled score less than 15. It is only added when there are significant e xtenuating circumstances. When these circumstances occur, the score from this section is added to the skilled nursing care score for the total number of hours that the member would need per day/week. 1. Caregiver availability: acuity measurement requires do cumented evidence of the employment and/or school status of the primary caregivers before this is scored. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.14 1.0 point is scored when there are 2 caregivers and neither is employed or attends school. 2.0 points are scored when there are 2 caregivers and at le ast one is employed or attends school . 2.5 points are scored when there is only 1 caregiver and the caregiver is not employed or attends school . 3.5 points are scored when there is only 1 caregiver and the caregiver is employed or attends school. 8.0 point s are scored when there is no caregiver that lives in the home with the member . This does not mean that the consumer lives with an individual who takes primary responsibility for the consumer but refuses to deliver any care. An example of this would be a m ember that assumes responsibility for their own care and lives alone or is on a waiver and has supplemental staffing from agencies and independent providers . 2. Sleeping status: acuity measurement is based on the amount of time the member is awake during the night. Nurse/caregiver waking the member over the course of the night is not scored. 1.0 point is scored if the member is awake 1 3 times per night. 1.5 points are scored if the member is awake 4 or more times per night. 1.5 points are scored if the member sleeps less than 5 hours consecutively . 2.0 points are scored if the member sleeps less than 3 hours consecutively . 3. Number of dependents: acuity measurement takes into consideration the number and ages of dependents the caregiver is directly responsible for and does not include episodic visits. 1.0 point is scored if the caregiver is directly responsible for 1 2 dependents at least 5 years old . 1.5 points are scored if the caregiver is directly responsible for 1 2 dep endents under 5 years old . 2.0 points are scored if the caregiver is directly responsible for 3 or more dependents. 4. Communication ability: acuity measurement is based on the cognitive ability of the member to communicate or make their needs known. 1.0 poin t is scored if the member has a limited ability to communicate their needs. 2.0 points are scored if the member is unable to communicate their needs. 5. Orientation/ cognition impairment (N/A for children under age 3 years): acuity measurement is based on the members ability to be oriented in all 3 spheres (person, time, place). Members with episodic confusion requiring reminders and members with cognitive impairment who are completely dependent on the caregiver may be scored here. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.15 0.5 points are scored for me mbers who do not meet all 3 spheres of orientation . 1.0 point is scored if the member experiences confusion requiring reminders. 1.5 points are scored if the member has cognitive impairment and is dependent upon the caregiver. 6. Personal care/ activities of d aily living (A DL ) (N/A for children under 3 years) : 2.0 points are scored if the member requires assistance with personal care/ADLs including bathing, dressing, and grooming. 7. Oral feedings/ assist/ supervision (N/A for children under 3 years): 1.5 points are scored if the member requires assistance and supervision with oral feeds. Documentation in the clinical record on how the member tolerated the feeding should be recorded. 8. Weight/ transfers : acuity measurement is based on the members weight and their ability to transfer from one surface to another, with 1 2 person s, and/or Hoyer lift/trapeze. 0.5 points are scored if the member weighs less than 65 pounds and requires no or partial lift wi th 1 person. 1.0 point is scored if the member weighs at least 65 pounds and requires no or partial lift with 1 person. 1.0 point is scored if the member weighs less than 55 pounds and requires a total lift with 1 person. 2.0 points are scored if the membe r weighs at least 55 pounds and requires a total lift with a Hoyer and/or 2 persons. 2.5 points are scored if the member weighs greater than 125 pounds and requires partial lift with 1 person. 3.5 points are scored if the member weighs greater than 125 pou nds and requires a total lift with a Hoyer and/or 2 persons. 9. Spasticity or tremors, quadriplegia, paraplegia, hemiplegia, dysfunctional limbs : select a maximum of one of the below when applicable . 1.0 point is scored if the member has spasticity or tremors . 1.5 points are scored if the member has hemiplegia. 1.5 points are scored if the member has a dysfunctional limb. 2.0 points are scored if the member has paraplegia. 2.5 points are scored if the member has quadriplegia. 10. AFO/ splint/ orthotics application: 0.5 points are scored if there is a physician order for the device and the skilled nurse applies them to the member during the visit, which is documented in the clinical notes. 11. Range of motion: 1.0 point is scored if range of motion is ordered by the physi cian and is documented as being performed by the nurse in the clinical record. 12. W heelchair /walker dependent : 2.0 points are scored if the member does not have the ability to walk unaided and is either wheelchair-or walker – dependent. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.16 13. Turn every 2 hours : 1.5 points are scored if there is a physician order and the nurse performs during the visit. Skin assessment should be documented by the nurse in the clinical record. 14. Ambulation/ assists: 1.0 point is scored if the member requires hand-in-hand assist or gui dance with turning a wheelchair/walker . 15. Weakness /fall risk : 1.0 point is scored if the member has weakness and/or is a fall risk. There must be a protocol in place to decrease the fall risk of the member which is monitored by the nurse. 16. Recording of I&O: 0.5 points are scored if normal daily measurement of intake and output is recorded by the nurse without the need to assess for fluid replacement or restriction. This may include weighing diapers. 17. Oral suctioning: 1.0 point is scored if suctioning of the n ose, mouth, or upper throat with a bulb syringe, yankaeur, or suction catheter. 18. Ostomy care: 1.0 point is scored if the member has a n ileostomy , vesicostomy, or colostomy. 19. Impairments 0.5 points are scored for visual impairments not correctable by glasses or another assistive device. 0.5 points are scored for auditory impairments not correctable by hearing aid or another assistive device. 0.5 points are scored for tactile impairments (eg, member has the need to put everything in their mouth or has an avers ion to different touch stimuli). 1.0 point is scored if the member if blind and there is no modification they have used to compensate. 1.0 point is scored if the member is deaf and there is no modification they have used to compensate. 20. Behaviors/ developmentally delay 1.0 point is scored if the member demonstrates self-abusive behavior with no injury. 1.5 points are scored if the member demonstrates self-abusive behavior with moderate injury. 2.0 points are scored if the member demonstrates with sev ere injury. 1.5 points are scored if the member demonstrates combative behavior. 0.5 points are scored if the member requires occasional redirection. 1.0 point is scored if the member requires frequent redirection. 21. Global delays : acuity measurement is scor ed as documented by the physician on the members care plan. 1.0 point is scored if the members current age is age 4 years or under and has documentation of global delays. 2.0 points are scored if the members current age is over age 4 years and has docum entation of global delays. 22. Incontinence, toilet program (N/A for children under age 3 years) 0.5 points are scored if the member experiences occasional incontinence. 1.5 points are scored if the member experiences daily incontinence. Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.17 1.0 point is scored if the member has a toilet program documented in the clinical record. C. The following point/care guideline may be adjusted based on a case-by-case review : 1. 15-24 points equate to 4 to 8 hours of care per day, or less than 56 hours per week. 2. 25-34 point s equate to 8 to 12 hours of care per day, or between 56 and 84 hours per week. 3. 35-40 points equate to 12 to 14 hours of care per day, or between 85 and 98 hours per week. 4. 40+ points equate up to 16 hours of care per day, or between 99 and 112 hours per we ek. 5. PDN above 112 hours per week are not routinely approved. However, PDN may be extended beyond 112 hours per week based on medical necessity . E. Conditions of CoverageNA F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 07/19/2023 New policy. Approved at Committee.Date Revised 06/19/2024 05/07 /2025Review: added examples to criteria, updated references,approved at Committee. Review: Added clarif ying statements in D.XII, updated references, approved at Committee. Date Effective 10/01/2025 Date Archived H. References1. Burgdorf JG, Arbaje AI, Chase J, et al . Current practices of family caregiver training during home health care: a qualitative study. JAm Geriatr Soc . 2022;70(1):218-227. doi:10.1111/jgs.17492 2. Centers for Medicare and Medicaid Services (CMS). Home-and Community-Based Services. Modified September 6, 2023. Accessed April 23, 2025. www.cms.gov 3. Definitions , OHIO ADMIN . CODE 3701-16-01 (2 024 ). 4. Developmental Disabilities Level of Care, OHIO ADMIN . CODE 5123-8-01 (2024). 5. Home Health and Private Duty Nursing: Visit Policy, OHIO ADMIN . CODE 5160-12-04 (2021). 6. Honsberger K, Holladay S, Kim E, et al . How States Use Medicaid Managed Care to Deliver Long-Term Services and Supports to Children with Special Health Care Private Duty Nursing-OH MCD-MM-1510Effective Dat e: 10/01/2025The ME DICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.18 Needs . National Academy for State Health Policy. November 2018. Accessed April23, 2025 . www.nashp.org 7. Kusma JD, Davis MM, Foster C. Characteristics of Medicaid policies for children with medical complexity by state. JAMA Netw Open . 2022;5(10):e223927 0. doi:10.1001/jamanetworkopen.2022.39270 8. Managed Care: Definitions , OHIO ADMIN . CODE 5160-26-01 (2022). 9. Medicaid Medical Necessity: Definitions and Principles, OHIO ADMIN . CODE 5160-1- 01 (2022 ). 10. Medicare Certified Home Health Agencies: Qualifications and Requirements, OHIO ADMIN . CODE 5160-12-03 (2015). 11. Non-Agency Nurses and Otherwise-Accredited Agencies: Qualifications and Requirements, OHIO ADMIN . CODE 5160-12-03.1 (2015). 12. Ohio Department of Medicaid. HCBS Waivers (n.d.) Accessed April 23, 2025 . www.medicaid.ohio.gov 13. Ohio Department of Medicaid. Private Duty Nursing (n.d.). Accessed April 23, 2025 . www.medicaid.ohio.gov 14. Private Duty Nursing: PDN-2001. MCG Health, 28th ed. Updated March 14, 2024. Accessed April 23, 2025 . www.careweb.careguidelines.com 15. Private Duty Nursing: Procedures for Service Authorization, OHIO ADMIN . CODE 5160 – 12-02.3 (2017). 16. Private Duty Nursing Services, 42 C.F.R. 440.80 (2022). 17. Private Duty Nursing Services: Provision Requirements, Covera ge and Service Specification, OHIO ADMIN . CODE 5160-12-02 (2021). 18. Registered Nurse Assessment and Registered Nurse Consultation Services . OHIO ADMIN . CODE 5160-12-08 (2021). 19. Reimbursement: Exceptions , OHIO ADMIN . CODE 5160-12-07 (2015). 20. Reimbursement: Private Duty Nursing Services, OHIO ADMIN . CODE 5160-12-06 (202 4). 21. Sobotka SA, Lynch E, Peek ME, et al . Readmission drivers for children with medical complexity: home nursing shortages cause health crises. Pediatr Pulmonol . 2020;55( 6):1471-1480. doi:10.1002/ppul.24744 22. Sobotka SA, Dholakia A, Berry JG, et al. Home nursing for children with home mechanical ventilation in the United States: key informant perspectives. Pediatr Pulmonol . 2020;55(12):3465-3476. doi:10.1002/ppul.25078 This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC. Independent med ical review July 2023Approved by ODM 0 6/25/2025

ProACT Adjustable Continence Therapy

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective ProACT Adjustable Continence Therapy-OH MCD-MM-1305 09/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 3 H. References ………………………….. ………………………….. ………………………….. …………………….. 4 ProACT Adjustable Continence Therapy-OH MCD-MM-1305Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectProACT Adjustable Continence Therapy B. BackgroundUrinary i ncontinence is a known complication of prostate surgery which can impact quality of life. The incidence of incontinence varies by procedure, but it is transient for most indi viduals. Incontinence after prostate surgery is a dynamic condition that can greatly improve in the first one to two years with conservative therapies. Conservative management may include lifestyle modification, pads , compression , catheters, and pelvic floor exercises. An estimated 5% of men whose incontinence fails to resolve undergo an additional pro cedure for the treatment of incontinence. Surgical management , which is usually deferred for at least 12 months post-prostatectomy , may involve adjustable balloon devices for mild stress incontinence, male slings for mild to moderate stress incontinence, and artificial urinary sphincters for severe stress incontinence . ProACT is a minimally invasive adjustable continence therapy for stress urinaryincontinence utilizing a proprietary balloon device. Under fluoroscopic guidance, implantation instruments are advanced via transverse perineal incisions to the area of the bladder neck . T he tissue is then dilated to create space for the balloon device. Aballoon is inserted bilaterally and inflated with isotonic solution. Titanium ports are placed under the skin to allow for future inflation or deflation of the balloons. While the device has demonstrated efficacy in peer-reviewed medical literature, device migration requiring revision surgery or explantation has also been documented. A shared decision – making approach between physician and patient is recommended. C. Definitions Urinary Incontinence Involuntary leakage of urine , including the following types : o Stress Urinary Incontinence (SUI) Occurs in the absence of a bladder contraction due to inadequate urethral sphincter function, either from mechanical damage to the urethral sphincter or from physiologic effects that limit sphincter function. o Urge Urinary Incontinence (UUI) A sudden and compelling desire to pass urine that is difficult to defer and is accompanied by involuntary leakage, typically associated with bladder outlet obstruction or detrusor overactivity. o Overflow Urinary Incontinence (OUI) Urine is retained in the bladder due to incomplete voiding after an attempt to urinate , potentially caused by bladder outlet obstruction or detrusor underactivity. o Mixed Urinary Incontinence A combination of stress urinary incontinence and urge urinary incontinence , occur ring when both the bladder and urinary sphincter have impaired function . ProACT Adjustable Continence Therapy-OH MCD-MM-1305Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 D. PolicyI. CareSource considers ProACT adjustable continence therapy medically necessary when ALL the following clinical criteria are met: A. Member underwent radical prostatectomy or transurethral resection of the prostate at least 12 months prior without radiation therapy . B. Member has documented primary stress urinary incontinence arising from intrinsic sphincter deficiency of at least 12 months duration . C. Member has documentation of conservative therapy failure . D. Member experiences at least 3 incontinence episodes per day . E. Member has positive 24-hour pad weight test (at least 8-gram pad weight increase demonstrated in two 24-hour pad weight tests). II. Limitations/ExclusionsProACT is contraindicated in patients with any of the following: A. urge incontinence B. detrusor instability or over-activity C. residual volume of at least 100ml or at least 25% of the total bladder capacity after voiding D. active systemic or urinary tract infections E. history of b ladder stones F. hemophilia or other bleeding disorders G. UI resulting from detrusor instability H. UI resulting from overactive bladder I. reduced bladder compliance J. residual urine volume exceeding 100 cubic centimeters after voiding K. suspected bladder cancer L. radiotherapy within the past 6 months E. Conditions of CoverageN/A F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 04/13/2022 New PolicyDate Revised 03/29/2023 02/14/2024 02/12/202506/04/2025 Annual review: updated references. Approved at Committee. Annual review : editorial changes to document language and updated references . Approved at Committee. Annual review: updated references. Approved at Committee. Review: removed age criteria. Approved at Committee Date Effective 09/01/2025 Date Archived ProACT Adjustable Continence Therapy-OH MCD-MM-1305Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 H. References1. Angulo JC, Schnburg S, Giamm A , et al. Systematic review and meta-analysis comparing adjustable transobterator male system (ATOMS) and adjustable continence therapy (ProACT) for male stress incontinence. PLoS One . 2019;14 (12) :e0225762. doi:10.1371/journal.pone.0225762 2. Artificial urinary sphincter : A-0267 (AC) . MCG . 29th ed draft . Updated January 25, 2025. Accessed May 8, 2025. www.careweb .careguidelines.com 3. Clemens JQ. Urinary incontinence in men. UpToDate. Updated March 6, 2024 . Accessed May 6, 2025 . www.uptodate.com 4. Comiter CV, Speed J. Urinary incontinence after prostate treatment. UpToDate. Updated May 16, 2024 . Accessed May 6, 2025 . www.uptodate.com 5. Finazzi Agr E, Gregori A, Bianchi D, et al. Efficacy and safety of adjustable balloons (ProACT) to treat male stress urinary incontinence after prostate surgery: medium and long-term follow-up data of a national multicentric retrospective study. Neurourol Urodyn . 2019;38(7):1979-1984. doi:10.1002/nau.24103 6. Klock JA, Palacios AR, Leslie SW, et al. Artificial urinary sphincters and adjustable dual-balloon continence therapy in men. Updated November 2, 2023. Accessed May 6, 2025 . www.ncbi.nlm.nih.gov 7. Larson T, Jhaveri H, Yeung LL. Adjustable continence therapy (ProACT) for the treatment of male stress incontinence: a systematic review and meta-analysis. Neurourol Urodyn . 2019;38 (8) :2051-2059 . doi:10.1002/nau.24135 8. Munier P, Nicolas M, Tricard T, et al. What if artificial urinary sphincter is not possible? Feasibility and effectiveness of ProACT for patients with persistent stress urinary incontinence after radical prostatectomy treated by sling. Nurourol Urodyn . 2020;39(5):1417-1422. doi:10.1002/nau.24355 9. Musco S, Ecclestone H, Hoen L, et al. Efficacy and safety of surgical treatments for neurogenic stress urinary incontinence in adults: a systematic review. Eur Urol Focus . 2022;8(4):1090-1102. doi:10.1016/j.euf.2021.08.007 10. Nash S, Aboseif S, Gilling P, et al. Four-year follow-up on 68 patients with a new post-operatively adjustable long-term implant for post-prostatectomy stress incontinence: ProACT. Neurourol Urodyn . 2019;38(1):248-253. doi:10.1002/nau.23838 11. Premarket approval (PMA) P130018: FDA summary of safety and effectiveness data. Food and Drug Administration. November 24, 2015. Accessed May 6, 2025 . www.accessdata.fda.gov 12. ProACT : patient brochure. Food and Drug Administration. Accessed May 6, 2025. www.accessdata.fda.gov 13. ProACT: physician instructions for use. Food and Drug Administration. Accessed May 6, 2025. www.accessdata.fda.gov 14. ProACT adjustable continence therapy (Uromedica) for treatment of post-surgical incontinence in men. Hayes. Updated May 24, 2023. Accessed May 6, 2025 . www.evidence.hayesinc.com ProACT Adjustable Continence Therapy-OH MCD-MM-1305Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 15. ProACT therapy for the treatment of stress urinary incontinence in males (ProACT). National Library of Medicine. Updated May 31, 2018. Accessed May 6, 2025 .clinicaltrials.gov 16. Sandhu JS, Bryer B, Comiter C, et al. Incontinence after prostate treatment: AUA/SUFU guideline. JUrol . 2019;202 (2) :369-378. doi:10/1097/ju.00000000000314 Independent med ical review February 2025ODM approved 06/11/2025

Noninvasive Home Mechanical Ventilation

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Noninvasive Home Mechanical Ventilation-OH MCD-MM-1588 09/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 8 Noninvasive Home Mechanical Ventilation-OH MCD-MM-1588Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNoninvasive Home Mechanical Ventilation B. BackgroundThis document outlines the medical necessity criteria for a noninvasive home ventilator for a member with stable, chronic respiratory failure. This device does not treat the underlying cause of respiratory failure but functions as supportive therapy, which may include reducing symptoms, improving quality of life, or sustaining or extending life. It may be used intermittently during the day and/or during sleep. A noninvasive home ventilator will not be reimbursed as such when its sole purpose is to function as a respiratory assistance device, including continuous positive airway pressure (CPAP), auto-titrating PAP, and bilevel airway pressure (BiPAP).C. Definitions Apnea-Hypopnea Index (AHI) The combined average number of apneas and hypopneas that occur per hour of sleep to determine the severity of obstructive sleep apnea (OSA) . Apnea-Hypopnea Index (AHI) Adult AHI Pediatric AHIMild OSA 5-14 1-4.9Moderate OSA 15 – 30 5-9.9 Severe OSA > 30 > 10 Bi-level Positive Airway Pressure (B iPAP) Device A device that uses mild bi – level or 2 levels of air pressure to keep breathing airways open. Continuous Positive Airway Pressure (CPAP) Device A device that uses mild continuous air pressure to keep breathing airways open. Home Mechanical Ventilation (HMV) A device used in the home setting for patients with chronic respiratory failure that delivers respiratory assistance via an invasive (ie, tracheostomy) or noninvasive (ie, nose/mouth mask, mouthpiece , nasal prongs) interface. These devices possess more advanced features than a CPAP/BiPAP machine, which include monitoring, rate control, safety, and backup power features. The ventilator can custom control a ll phases of the breathing cycle . D. PolicyI. CareSource utilizes Ohio Administrative Code and MCG Health criteria to determine medical necessity for noninvasive HMV (E0466) . An initial approval for HMV is valid for a maximum of 3 months. A new medical necessity determination thereafter is required every 6 months for continued rental use. II. Initial Rental of HMVMedical necessity for the initial coverage of noninvasive HMV is based upon the following conditions in II – IV being met : Noninvasive Home Mechanical Ventilation-OH MCD-MM-1588Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 A. Congenital central hypoventilation syndromeB. Chronic lung disease of infancy (eg, bronchopulmonary dysplasia), and patient unable to maintain acceptable pH and PCO 2 without ventilator support C. Chronic obstructive pulmonary disease (COPD) and ONE OR MORE of the following: 1. Chronic hypercapnia with PaCO 2 of 50 mm Hg (6.7 kPa) to less than 52 mm Hg (6.9 kPa) and at least ONE of the following: a. Arterial oxygen saturation 88% for 5 consecutive minutes during nocturnal oximetry while on at least 2 liters of oxygen per minute . b. Invasive or noninvasive ventilation for acute exacerbation required during 2 or more hospitalizations per year . 2. Chronic hypercapnia with PaCO 2 of 52 mm Hg (6.9 kPa) or greater 3. Palliative care for end-stage disease and advance directive states no desire for intubation D. Neuromuscular disorder accompanied by chronic respiratory failure , as indicated by the following: Documentation of respiratory failure, as indicated by ONE OR MORE : 1. Arterial O2 saturation less than 88% for 5 consecutive minutes during nocturnal oximetry 2. Daytime PCO 2 (arterial or capillary) greater than 45 mm Hg (6.0 kPa) 3. Forced vital capacity less than 50% of predicted 4. Forced vital capacity less than 80% of predicted and symptoms of respiratory failure 5. Maximum inspiratory pressure 60 cm H 2O (5884 Pa) or lower 6. Maximum sniff nasal inspiratory pressure less than 40 cm H 2O (3923 Pa) 7. Polysomnography demonstrates sleep hypoventilation, as indicated by ONE OR MORE of the following: a. Adult with sleep-related hypoventilation (ie, arterial, end-tidal, or transcutaneous PCO 2 greater than 55 mm Hg (7.3 kPa) for 10 minutes or longer, or increase in arterial, end-tidal, or transcutaneous PCO 2 of 10 mm Hg (1.3 kPa) or greater above awake supine value resulting in PCO 2 greater than 50 mm Hg (6.7 kPa) for 10 minutes or longer) . b. Child with sleep-related hypoventilation (ie, sleeping arterial, end-tidal, or transcutaneous PCO 2 of greater than 50 mm Hg (6.7 kPa) for greater than 25% of total sleep time, or peak sleep end-tidal PCO 2 of 55 mm Hg (7.3 kPa) or greater) . E. Obesity hypoventilation syndrome , as indicated by ALL of the following: 1. BMI > 30 2. CPAP unsuccessful or not appropriate , as indicated by ONE OR MORE of the following: a. Comorbid sleep-related hypoventilation (ie, arterial, end-tidal, or transcutaneous PCO 2 greater than 55mm Hg (7.3 kPa) for 10 minutes or longer, or increase in arterial, end-tidal, or transcutaneous PCO 2 of 10 mm Hg (1.3 kPa) or greater above awake supine value resulting in PCO 2 greater than 50 mm Hg (6.7 kPa) for 10 minutes or longer ) Noninvasive Home Mechanical Ventilation-OH MCD-MM-1588Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 b. Intolerance of CPAP pressures necessary to correct obstructive sleep apnea (OSA) component (ie, difficulty exhaling against fixed airway pressure) c. Lack of resolution of hypercarbia, nocturnal desaturation, and OSA despite 3 months of CPAP use d. Titration study demonstrates OSA despite CPAP 15 cm H 2O (1471 Pa) that is responsive to BiPAP 3. Daytime hypercapnia with PaCO 2 greater than 45 mm Hg (6.0 kPa) without other etiology (eg, kyphoscoliosis, lung parenchymal disease, myopathy, severe hypothyroidism) 4. Sleep-disordered breathing or hypoventilation on polysomnography, as indicated by ONE OR MORE of the following: a. Apnea-hypopnea index of 5 or greater b. Increase in PaCO 2 during sleep by more than 10 mm Hg (1.3 kPa) above value while awake c. Significant oxygen desaturation (eg, less than 90%) not explained by obstructive apneas or hypopneas 5. TSH level does not demonstrate hypothyroidism F. OSA in child or adolescent and ONE OR MORE of the following: 1. Mild OSA (ie, apnea-hypopnea index from 1 to 5) and ONE OR MORE of the following: a. achondroplasia b. behavioral problems c. cardiovascular disease (eg, elevated blood pressure, pulmonary hypertension) d. Chiari malformation e. craniofacial abnormalities f. Down Syndrome g. excessive daytime sleepiness h. impaired cognition i. inattention or hyperactivity j. mucopolysaccharidoses k. neuromuscular disorders l. Prader-Willi syndrome 2. Moderate or severe OSA (ie, apnea-hypopnea index greater than 5) 3. Residual apnea-hypo pnea index greater than 5 in pediatric patient after adenotonsillectomy G. Restrictive disorder of chest wall , as indicated by ALL of the following: 1. Appropriate chest wall disorder as indicated by ONE OR MORE of the following: a. asphyxiating thoracic dystrophy b. kyphoscoliosis c. other chest wall disorder accompanied by chronic respiratory failure (eg, ankylosing spondylitis, fibrothorax, post-tuberculous chest wall deformity) Noninvasive Home Mechanical Ventilation-OH MCD-MM-1588Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 2. Documentation of respiratory failure as indicated by ONE OR MORE of the following : a. Arterial O 2 saturation less than 88% for 5 consecutive minutes during nocturnal oximetry b. Daytime PCO 2 (arterial or capillary) greater than 45 mm Hg (6.0 kPa) c. Forced vital capacity less than 50% of predicted d. Forced vital capacity less than 80% of predicted and symptoms of respiratory failure e. Maximum inspiratory pressure 60 cm H 2O (5884 Pa) or lower f. Polysomnography demonstrates sleep hypoventilation, as indicated by ONE OR MORE of the following: 01. Adult with sleep-related hypoventilation (ie, arterial, end-tidal, or transcutaneous PCO 2 greater than 55 mm Hg (7.3 kPa) for 10 minutes or longer, or increase in arterial, end-tidal, or transcutaneous PCO 2 of 10 mm Hg (1.3 kPa) or greater above awake supine value resulting in PCO 2 greater than 50 mm Hg (6.7 kPa) for 10 minutes or longer) . 02. Child with sleep-related hypoventilation (ie, sleeping arterial, end-tidal, or transcutaneous PCO 2 of greater than 50 mm Hg (6.7 kPa) for greater than 25% of total sleep time, or peak sleep end-tidal PCO 2 of 55 mm Hg (7.3 kPa) or greater ). III. Respiratory status is STABLE , as indicated by ALL of the following:A. Airway interface is safe with a n oninvasive interface with acceptable fit . B. Airway pressure requirement appropriate, as indicated by ONE OR MORE of the following: 1. BiPAP expiratory positive airway pressure requirement is to 10 cm H 2O (981 Pa). 2. CPAP pressure requirement in child is 15 cm H 2O (1471 Pa). 3. Ventilator positive end-expiratory pressure requirement is 10 cm H 2O (981 Pa). C. Oxygen requirement does not exceed FiO 2 of 40%. D. Settings are stable on chosen device. E. No continuous invasive monitoring is required. IV. A BiPAP or CPAP device must not be clinically appropriate as indicated by ONE ORMORE of the following. A. Chronic respiratory insufficiency fails to improve with simple BiPAP device. B. Infant or child does not meet the minimum body weight requirement for CPAP device. C. Infant or child is not appropriate for simple BiPAP device due to setting or performance requirements, as indicated by ONE OR MORE of the following: 1. Breath rates delivered by device not appropriate for patient . 2. Compatible ventilator circuits not appropriate for patient (eg, circuit compliance, compressed volume, dead space) . Noninvasive Home Mechanical Ventilation-OH MCD-MM-1588Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 3. Inspiratory flows delivered by device not appropriate for patient .4. Patient does not meet ventilator minimum body weight requirements. 5. Pressure range (eg, expiratory pressure, inspiratory pressure) not appropriate for patient . 6. Tidal volume range delivered by device not appropriate for patient . 7. Ventilator inspiratory trigger delay (ie, airway pressure rise time) not appropriate for patient . 8. Ventilator inspiratory trigger sensitivity not appropriate for patient . D. The following setting or functionality is required by the member and is not available with simple BiPAP device: 1. Alarms required by member are not available on the device . 2. Daytime ventilation using mouthpiece is required . 3. Pressure range delivered by device is not appropriate for member . 4. Member requires volume-assured pressure support or volume control mode (eg, obesity hypoventilation syndrome). E. Ventilated patient requires cough assistance via volume ventilator’s breath stacking capability. F. Ventilation is required 24 hours per day. V. HMV Continued UseFor HMV continued use beyond the initial 3-month determination, medical necessity must be reestablished every 6 months thereafter . The following is to be provided for continued use: A. Re-evaluation by the treating medical professional must be completed no earlier than 61 days after initiating therapy. B. Documentation of the persistence of the disease process for which HMV has been prescribed. C. Medical records must document that the member is compliant with and benefitting from HMV. D. At least 30 consecutive days of device data, beginning after 31 days of initiation, demonstrating that the member is utilizing the device an average of 4 hours per 24-hour period. NOTE: Failure of the member to consistently use HMV for an average of 4 hours per 24-hour period would demonstrate non-compliant utilization of the device for its intended purpose and expectation of benefit, which would constitute a denial in continued coverage as not reasonable and necessary . E. Additional information as requested. VI. In accordance with Rule 5160-10-01 for each claim, the provider cannot legitimately receive payment until necessary supporting documents have been obtained and placed in the providers files. These documents include the prescription and the following items: A. A completed CMN form: ODM 01902 . Noninvasive Home Mechanical Ventilation-OH MCD-MM-1588Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 B. Practitioner order and chart notes , which support the determination of medical necessity , including ventilator settings . VII. Regardless of its authorized length, a rental period ends when the rented item is no longer medically necessary.VIII. ExclusionsAny application for a noninvasive home ventilator (E0466) not meeting the criteria above will be denied as being not medically necessary, including but not limited to when its sole purpose is to function as a respiratory assistance device, including settings of CPAP, auto-titrating PAP, Bilevel positive airway pressure (BiPAP, BPAP), average volume assured pressure support (AVAPS) with or without auto EPAP (AE), or intelligent volume assured pressure support (iVAPS). E. Conditions of CoverageI. Claims for ventilators being utilized to provi de CPAP or BiPAP therapy for conditions described above and are submitted with HCPCS code E0466, will be denied as not being reasonable and necessary. If a HMV is dispensed to a Member for CPAP or BiPAP therapy, the claim must be coded in accordance with CareSource policy, Positive Airway Pressure Devices for Pulmonary Disorders Continued Rental . All requirements in D. I. -V. of this policy must be satisfied for HMV to be considered medically necessary. II. CareSource may verify the use of the equipment through post-payment audit andrequest additional supporting medical record documentation. If the use of a more appropriate code or piece of equipment is warranted, CareSource may request recoupment.F. Related Policies/RulesDMEPOS: Positive Airway Pressure Devices, OHIO ADMIN . CODE 5160-10-19 (2021). Positive Airway Pressure Devices for Pulmonary Disorders Continued Rental Overpayment Recovery G. Review/Revision HistoryDATE ACTIONDate Issued 05/22/2024 New Policy, Approved at CommitteeDate Revised 06/04/2025 Annual review: Added E.II. , Updated Exclusions to include AVAPS, EPAP, iVAPS; Approved at Committee Date Effective 09/01/2025 Date Archived Noninvasive Home Mechanical Ventilation-OH MCD-MM-1588Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 H. References 1. Coleman JM, Wolfe LF, Kalhan R. Noninvasive ventilation in chronic obstructive pulmonary disease. Ann Am Thorac Soc . 2019;16(9):1091-1098. doi: 10.1513/AnnalsATS.201810-657CME 2. DMEPOS: Ventilators, OHIO ADMIN . CODE 5160-10-22 (2021). 3. Dudgeon D. Assessment and management of dyspnea in palliative care. UpToDate. Updated April 04, 2025 . Accessed April 16, 2025 . www.uptodate.com 4. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, OHIO ADMIN . CODE 5160-10-01 (2024). 5. Ferrell BR, Twaddle ML, Melnick A, et al. National Consensus Project clinical practice guidelines for quality palliative care guidelines, 4th edition. JPalliative Med . 2018;21(12): 1684-1689. doi:10.1089/jpm.2018.04311684 6. Freedman N. Treatment of obstructive sleep apnea: choosing the best positive airway pressure device. Sleep Med Clin . 2020;15(2):205-218. doi:10.1016/j.jsmc.2020.02.007 7. Gay PC. Nocturnal ventilatory support in COPD. UpToDate. Updated February 5, 2025 . Accessed April 16, 2025 . www.uptodate.com 8. Gay PC, Owens RL; ONMAP Technical Expert Panel. Executive summary: optimal NIV Medicare access promotion: a technical expert panel report from the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society. Chest . 2021;160(5):1808-1821. doi: 10.1016/j.chest.2021.05.074 9. Hansen-Flaschen J, Ackrivo J. Practical guide to management of long-term noninvasive ventilation for adults with chronic neuromuscular disease. Resp Care . 2023;68(8):1123-1157. doi:10.4187/respcare.10349 10. Hill NS, Kramer NR. Noninvasive ventilation in adults with chronic respiratory failure from neuromuscular and chest wall diseases: patient selection and alternative modes of ventilatory support. UpToDate. Updated November 13, 2024 . Accessed April 16, 2025 . www.uptodate.com 11. Home Ventilator (Invasive or Noninvasive Interface ): ACG A-0893. MCG Health . 2 8th ed. Accessed May 16 , 2024. www.careweb.careguidelines.com 12. Khan A, Frazer-Green L, Amin R, et al. Respiratory management of patients with neuromuscular weakness: an American College of Chest Physicians clinical practice guideline and expert panel report. Chest . 2023;164(2):394-413. doi:10.1016/j.chest.2023.03.011 13. Kline LR. Clinical presentation and diagnosis of obstructive sleep apnea in adults. UpToDate . Updated October 9, 202 4. Accessed April 16, 2025 . www.uptodate.com 14. Macrea M, Oczkowski S, Rochwerg B, et al. Long-term noninvasive ventilation in chronic stable hypercapnic chronic obstructive pulmonary disease: an official American Thoracic Society clinical practice guideline. Am JResp Crit Care Med . 2020;202(4):e74-e87. doi: 10.1164/rccm.202006-2382ST 15. Martin TJ. Noninvasive positive airway pressure therapy for obesity hypoventilation syndrome. UpToDate. Updated March 4, 2024. Accessed April 16, 2025 . www.uptodate.com Noninvasive Home Mechanical Ventilation-OH MCD-MM-1588 Effective Dat e: 09/01/2025 The MEDICAL Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the MEDICAL Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 9 16. Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolargtngology Head Neck Surg. 2019;160(1S):S1-S42. doi: 1 0.1177/019459981880175717. Raveling T, Vonk J, Struik FM, et al. Chronic non-invasive ventilation for chronic obstructive pulmonary disease: review. Cochrane Database Syst Rev .2021;8:CD002878. doi:10.1002/14651858.CD002878.pub318. Restrepo RD, Walsh BK. Humidification during invasive and noninvasive mechanical ventilation 2012: AARC clinical practice guideline. Respir Care . 2012;57(5):782-788. doi:10.4187/respcare.0176619. van den Biggelaar RJM, Hazenberg A, Cobben NAM, et al. A randomized trial of initiation of chronic noninvasive mechanic ventilation at home vs in-hospital in patients with neuromuscular disease and thoracic cage disorder. Chest .2020 ;158(6):2493-2501. doi: 10.1016/j.chest.2020.07.007I nd e pe n de nt Med i ca l Re v iew 05/08/24 Approved by ODM 06/10/2025

Standing Frames

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Standing Frames-OH MCD-MM-1331 09/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Standing Frames-OH MCD-MM-1331Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectStanding Frames B. BackgroundSupported standing is a common, adjunctive therapeutic practice in which patients with neurological conditions are enabled to assume an upright position. Homebased standing programs are commonly recommended for adults and children who cannot stand and/or walk indepe ndently and are usually part of a postural management program, which plays a role in preventing contracture, deformity, pain, and asymmetry. Standers might include prone, supine, vertical, multi-positional , and sit-to-stand types. Standing frames consist of a simple base with an upright support to which the patient can be strapped. These devices provide no mobility, but research has shown medicalbenefits supporting use, including an enhanced ability to perform tasks, maintained or improved joint range of motion, muscle spasticity and bone density , and an enhanced ability to perform activities of daily living. In recent studies, some adults and children report a decrease in pain, suppository use , decubitus ulcers, urinary tract infections (UTI), and clinical depression, while reporting an increase in improved bowel function , breathing, circulation , and muscle tone. Psychological benefits have also been documented and include improved socialization, patient satisfaction and quality of life due to improved interacti on with others. Additionalbenefits for some patients can include enhanced independence, improved vocational activities, and increased recreational activities with peers and others, which have been reported to instill a heightened sense of confidence and equality and improved self – esteem in children and adults. Acceptance by others and a sense of integration is perceived to be higher among standing frame users. No adverse events or effects have been frequently reported or documented in literature, but some contraindications have been widely discussed. Additionally, many patients do not report pain with use of standing frames. With the added benefit of the enhance mentof functional recovery with early physical rehabilitation, many providers are adding supported standing as a practice in postural management after consideration of contraindications is examined by a medical professional .C. Definitions Activities of Daily Living (ADLs) Fundamental skills required to independently care for oneself, including the following two categories : o Basic ADLs Skills required to manage ones basic physical needs, including ambulation, feeding, dressing, personal hygiene, continence and toileting. o Instrumental ADLs Skills that require more complex thinking skills, including transportation and shopping, finance management, meal preparation, house cleaning and home maintenance, communication management, and medication management. Standing Frames-OH MCD-MM-1331Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Durable Medical Equipment (DME or DMEPOS ) A collective term for a covered durable medical equipment item, prosthetic device, orthotic device, or medical supply item furnished by an eligible provider to an eligible recipient Home Medical Equipment Equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, is not useful to a person in the absence of illness or injury and is appropriate for use in the home. Postural Management A multi-disciplinary approach incorporating a comprehensive schedule of daily and night-time positions, equipment, and physical activity to help maintain or improve body structures and function and increase activity and participation. Technologically Sophisticated Medical Equipment (TSME) Prescribed by an authorized health care professional and requir ing individualized adjustment or regular maintenance by a home medical equipment services provider to maintain a recipients health care condition or the effectiveness of the equipment. Standers are considered TSME. D. PolicyI. CareSource will review medical necessity requests for non-powered standing frames on a case-by-case basis once ALL the following information is submitted for review: A. New Equipment 1. stander information, including ALL the following details: a. manufacturer b. model number c. type of stander d. part number, if applicable and if available e. an itemized list of any additional attachments and accessories with individual prices , if not included with the basic stander or if applicable 2. a face-to-face encounter with a medical professional who has a relationship with the member (a single encounter can serve for 12 months as the basis for a single prescription for more than 1 prescription addressing the same medical condition for which a DM EPOS item is prescribed.) 3. a prescription is valid for 1 year , unless a different length of time is specified, and must include ALL the following: a. dated signature of 1 of t he following appropriately Ohio-licensed and/or certified medical professionals : 01. physician (MD or DO) 03. advanced practice registered nurse (APRN) with a relevant specialty 04. physician assistant (PA) b. specific recipient diagnosis( -es) document ing a neuromuscular condition (eg, multiple sclerosis, cerebral palsy, spinal cord injury, stroke) or documented developmental delay impairing the recipients ability to stand independently Standing Frames-OH MCD-MM-1331Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 4. documentation showing that the member or parent/guardian received training in use of standers or standing frames , which can be completed during a scheduled therapy session for the member, if applicable 5. documentation showing the member or parent/guardian can safely use the device in the home setting (eg, documentation from physical therapy or other therapy sessions documenting trials of use suffice) of member or parent/guardian training in use of standers or standing frames and an ability to safely use the device in the home setting 6. documentation that device use can be reasonably expected to provide therapeutic benefits or enable the member to perform certain tasks unable to perform otherwise due to the diagnosis, such as but not limited to 1 or more of the following: a. aids in the prevention of atrophy in the trunk and leg muscles b. improves strength and/or circulation to the trunk and lower extremities c. prevents formation of decubitus ulcers with changeable positions d. helps maintain bone and/or skin integrity e. reduces swelling in the lower extremities f. improves range of motion and/or aids normal skeletal development g. improves function of kidneys, bladder, and/or bowels h. decreases muscle spasms i. strengthens the cardiovascular system and builds endurance j. prevents or decreases muscle contractures and/or progressive scoliosis k. improves social interaction and psychological well-being l. increase performance of activities of daily living (ADLs) 7. no contraindications to supported standing, such as but not limited to a. healing fracture or severe osteoporosis preclud ing weight bearing of any kind b. significant hip or knee flexion or ankle plantarflexion contractures in which stretch or pressure prevents standing c. compromised cardiovascular or respiratory systems requir ing frequent monitoring of circulation and function while in a stander d. significant inflexible skeletal deformities e. lack of standing tolerance (ie, cannot maintain a standing position due to little or no residual strength in the hips, legs and lower) f. postural hypotension B. Replacement of a non-powered standing frame is considered medically necessary after 5 years when both the following criteria have been met: 1. medical necess ity criteria above are met 2. device is out of warranty or not functioning properly and cannot be refurbished or adequately repaired II. The following items or services are not covered or separately reimbursable :A. electric, motorized , or powered standing frames B. items or services covered under manufacturer or dealer warranty Standing Frames-OH MCD-MM-1331Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 C. DME items that duplicate or conflict with another item currently in the recipient’s possessionD. replacement items or previously approved equipment that have been damaged because of perceived misuse, abuse , or negligence E. Conditions of CoverageAdditional instructions regarding reimbursement of DME items may be located in OAC 5160-10-01. F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATE ACTIONDate Issued 08/31/2022 New policy.Date Revised 07/19/2023 07/17/202405/07/2025Annual review. Updated formatting to AMA style. Updated references. Approved at Committee. Annual review. Updated prescription validity to 1 year. Added face to face encounter with provider. Updated references. Approved at Committee. Annual review: references updated. Approved at Committee. Date Effective 09/01/2025 Date Archived H. References1. Arva J, Paleg G, Lange M, et al. RESNA position on the application of wheelchair standing devices. Assist Technol. 2009;21(3):161-171. doi:10.1080/1044393175622 2. Capati V, Covert SY, Paleg G. Stander use for an adolescent with cerebral palsy at GMFCS level with hip and knee contractures. Assist Technol . 2020;32(6):335-341. doi:10.1080/10400435.2019.1579268 3. Definitions , OHIO REV . CODE ANN . 4752.01 (20 18 ). 4. Durable Medical Equipment, Prosthesis, Orthoses, and Supplies (DMEPOS): General Provisions , OHIO ADMIN . CODE 5160-10-01 (202 4). 5. Edemekong PF, Bomgaars DL, Sukumaran S, et al . Activities of Daily Li ving. In: StatPearls. Updated June 26, 2023. 6. Ferrarello F, Deluca G, Pizzi A, et al. Passive standing as an adjunct rehabilitation intervention after stroke: a randomized controlled trial. Arch Physiother . 2015;5(2). doi:10.1186/s40945-015-0002-05 7. Goodwin J, Lecouturier J, Basu A, et al . Standing frames for children with cerebral palsy: a mixed-methods feasibility study. Health Technol Assess . 2018;22(50):1-232. doi:10.3310/hta22500 8. Ibitoye MO, Hamzaid NA, Ahmed YK. Effectiveness of FES-supported leg exercise for promotion of paralysed lower limb muscle and bone health a systematic review. Biomed Tech (Berl) . 2023;68(4):329-350. doi:10.1515/bmt-2021-0195 Standing Frames-OH MCD-MM-1331Effective Dat e: 09/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 9. Macias-Merlo L, Bagur-Calafat C, Girabent-Farrs M, et al . Standing programs to promote hip flexibility in children with spastic diplegic cerebral pal sy. Pediatr Phys Ther . 2015;27(3):243-249. doi:10.1097/PEP.000000 00 00000150 10. Martinsson C, Himmelmann K. Abducted standing in children with cerebral palsy: effects on hip development after 7 years . Pediatr Phys Ther . 2021;33(2):101-107. doi:10.1097/PEP.0000000000000789 11. Newman M, Barker K. The effect of supported standing in adults with upper motor neurone disorders: a systematic review. Clin Rehabil . 2012;26(12):1059-1077. doi:10.1177/0269215512443373 12. ODA Provider Certification: Home Medical Equipment and Supplies. OHIO ADMIN . CODE 173-39-02.7 (2022). 13. Paleg G, Livingstone R. Evidence-informed clinical perspectives on postural management for hip health in children and adults with non-ambulant cerebral palsy. J Pediatr Rehabil Med . 2022;15(1):39-48. doi:10.3233/PRM-220002 14. Paleg G, Livingstone R. Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury and other neurological conditions. BMC Musculoskelet Disord . 2015;16:358. doi:10.1186/s12891-015-0813-x 15. Paleg GS, Smith BA, Glickman LB. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatr Phys Ther . 2013;25(3):232-247. doi:10.1097/PEP.0b013e318299d5e7 16. Pedlow K, McDonough S, Lennon S, et al. Assisted standing for Duchenne muscular dystrophy . Cochrane Database Syst Rev . 2019;10(10):CD011550. doi:10.1002/14651858. CS011550.pub2 17. Standing frame : A-0996. MCG . 29th ed draft . Updated January 25, 2025 . Accessed April 10, 2025 . www.careweb.careguidelines.com 18. Synnot A, Chau M, Pitt V, et al . Interventions for managing skeletal muscle spasticity following traumatic brain injury. Cochrane Database Syst Rev . 2017;11(11):CD008929. doi:10.1002/14651858.CD008929.pub2 Independent med ical review 08/2022Approved Ohio Department of Medicaid 05/13/2025

Autonomic Nerve Testing

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Autonomic Nerve Testing-OH MCD-MM-1783 09/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Autonomic Nerve Testing-OH MCD-MM-1783 Effective Date: 09/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Autonomic Nerve Testing B. Background The autonomic nervous system (ANS) coordinates multiple reflex actions which are essential for life. It controls the heart rate, blood pressure, digestion, respiration, pupillary reactivity, sweating, urination, sexual arousal, and regulates the functions of internal organs. This system provides the homeostasis of the cells, tissues, and organs throughout the body and protects against the disturbances imposed by the external and internal stressors. The ANS has three main divisions: the sympathetic nervous system (SNS), the parasympathetic nervous system (PNS), and the enteric nervous system. In general, the SNS and PNS have opposing effects. Each region belonging to the 'pain matrix' interacts with ANS. The descending system regulates pain and creates a regulatory effect by the contribution of aminergic neurotransmitters. Disorders of the ANS can affect any system of the body; they can originate in the peripheral or central nervous system and may be primary or secondary to other disorders. Symptoms suggesting autonomic dysfunction include orthostatic hypotension, heat intol erance, nausea, constipation, urinary retention or incontinence, nocturia, impotence, and dry mucous membranes. If a patient has symptoms suggesting autonomic dysfunction, cardiovagal, adrenergic, and sudomotor tests are usually done to help determine seve rity and distribution of the dysfunction. Autonomic testing using automated devices, in which software automatically generates an interpretation, has not been validated. Most of these devices generate reports automatically and do not allow physician interpretation of the raw data, which is a serio us design flaw when evaluating patients who have, for example, cardiac rhythm abnormalities that mislead the testing results. C. Definitions Autonomic Nervous System The part of the nervous system that controls involuntary visceral actions . Cardiovagal innervation A test that provides a standardized quantitative evaluation of vagal innervation to parasympathetic function of the heart. Responses are based on the interpretation of changes in continuous heart recordings in response to standardized maneuvers and include heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio heart rate responses to standing. A tilt table may be used but is not required. Vasomotor adrenergic innervation A test that evaluates adrenergic innervation of the circulation and of the heart in autonomic failure. The following tests are included: beat-to-beat blood pressure and R-R interval response to Valsalva Autonomic Nerve Testing-OH MCD-MM-1783 Effective Date: 09/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.3maneuver, sustained hand grip, and blood pressure and heart rate responses to tilt-up or active standing and must be performed with a tilt table. Sudomotor Function testing is used to evaluate and document neuropathic disturbances that may be associated with pain. The quantitative sudomotor axon reflex test (QSART), thermoregulatory sweat test (TST), sympathetic skin responses, and silastic sweat imprints are tests of sympathetic cholinergic sudomotor . Sympathetic Skin Response A test to measure a provoked change in the electrical potential of the skin. D. Policy I. CareSource considers autonomic nerve testing medically necessary to evaluate autonomic nerve function and aid in the diagnosis of ANY of the following conditions : A. distal small fiber neuropathy B. postural tachycardia syndrome C. reflexive sympathetic dystrophy D. recurrent variants of syncope E. one or more of the following progressive autonomic neuropathies : 1. diabetic autonomic neuropathy 2. amyloid neuropathy 3. Sjogrens syndrome 4. idiopathic neuropathy 5. pure autonomic failure 6. multiple system atrophy II. Limitations Properly trained physicians with the necessary expertise should perform and interpret these tests. Training can be obtained through accredited residency/fellowship programs or AMA-approved continuing medical education courses. III. Exclusions A. Autonomic nerve function testing to aid in the diagnosis of ANY other condition not list ed above may not be covered or reimbursable. B. Screening patients without signs or symptoms of autonomic dysfunction, including patients with diabetes, hepatic or renal disease. C. Testing results that are not used in clinical decision-making or patient management D. The use portable automated devices for autonomic nerve testing, including ANSAR ANX 3.0 , VitalScan ANS, ANSiscope or any similar device is considered experimental, investigational and non-covered. E. Conditions of Coverage NA Autonomic Nerve Testing-OH MCD-MM-1783 Effective Date: 09/01/2025 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d.4F. Related Policies/Rules Experimental or Investigational Item or Service G. Review/Revision History DATE ACTIONDate Issued 05/21/2025 New policy. Approved at Committee.Date Revised Date Effective 09/01/2025 Date Archived H. References 1. Baker JR, Hira R, Uppal J, et al . Clinical Assessment of the Autonomic NervousSystem. Card Electrophysiol Clin . 2024;16(3):239-248. doi:10.1016/j.ccep.2024.02.0012. Cheshire WP, Freeman R, Gibbons CH, et al. Electrodiagnostic assessment of the autonomic nervous system: A consensus statement endorsed by the American Autonomic Society, American Academy of Neurology, and the International Federation of Clinical Neurophys iology Clin Neurophysiol . 2021;132(2):666-682. doi:10.1016/j.clinph.2020.11.024 3. Gutirrez J. Electrophysiological assessment of peripheral and central autonomic disorders. Handb Clin Neurol . 2023;195:301-314. doi:10.1016/B978-0-323-98818-6.00015-7 4. Illigens BMW, Gibbons CH. Autonomic testing, methods and techniques. Handb Clin Neurol . 2019;160:419-433. doi:10.1016/B978-0-444-64032-1.00028-X . 5. Lee HJ, Lee KH, Moon JY, et al. Prevalence of autonomic nervous system dysfunction in complex regional pain syndrome. Reg Anesth Pain Med. 2021;46(3):196-202. doi:10.1136/rapm-2020-101644 6. Novak P. Quantitative autonomic testing. JVis Exp . 2011;(53):2502. doi:10.3791/2502 7. Panigrahi B, Srivastava AK, Garg D, et al . Examination of the autonomic nervous system at the bedside. Acta Neurol Belg. Published online December 5, 2024. doi:10.1007/s13760-024-02654-2 Approved ODM 06/04/2025

Penile Implants In The Treatment Of Erectile Dysfunction

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Penile Implants in the Treatment of Erectile Dysfunction-OH MCD-MM-0033 09/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical 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 ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Polic ies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Penile Implants in the Treatment of Erectile Dysfunction-OH MCD-MM-0033 Effective Date: 09/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Penile Implants in the Treatment of Erectile Dysfunction B. Background Erectile dysfunction (ED) is the consistent or recurrent inability to acquire or sustain an erection, and the most common sexual problem affecting males. Surveys suggest 5-10% of men between the age s of 20 to 30 are a ffected, and that number increas es to 35-40 % of men aged 70 or older . The National Institutes of Health (NIH) estimates that up to 30 million men experience erectile dysfunction. Various treatment modalities exist for ED. One treatment option is a surgical penile implant (also called a penile prosthesis) . A penile implant is indicated when there is a clear medical cause for ED and when the problem is unlikely to resolve or improve naturally or with other medical treatments. A basic penile prosthesis consists of a pair of bendable, silicone rods that are surgically implanted within the erection chambers of the penis. Identification of the underlying etiology is an important first step. This includes ruling out the adverse effects of medication(s), identifying, and treating risk factors. C. Definitions Erectile Dysfunction The consistent or recurrent inability to acquire or sustain an erection. Neurogenic Impotence Nervous system issues affecting the ability to maintain or have an erection . Vascular Impotence Restricted or d ecreased blood flow to the penis causing impotence . D. Policy I. Medication is the f irst line of treatment for ED , including A. oral phosphodiesterase type 5 inhibitors B. intra-urethral alprostadil C. intracavernous vasoactive drug injections Ohio Medicaid does not cover m edications including oral, injectable, and transdermal varieties for the treatment of erectile dysfunction. II. External penile pumps or vacuum constr iction devices (VCD) are the s econd line of treatment after first line therapy has failed. III. Ohio Medicaid does not cover e xternal penile pumps and vacuum constr iction d evices . Penile Implants in the Treatment of Erectile Dysfunction-OH MCD-MM-0033 Effective Date: 09/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.3IV. Internal penile prosthetic implants are covered in extraordinary circumstances . They are consi dered medically necessary when ALL of the following conditions are met: A. First and second line therapy have been documented as ineffective , or there is a compelling, well documented reason to proceed with surgery without a failed trial of first and second-line therapies. B. Absence of active alcohol or substance use disorder as documented in the medical record. C. Absence of drug induced impotence related to ALL of the following: 1. anabolic steroid use 2. anticholinergics 3. antidepressants 4. antipsychotics or central nervous system depressants D. Neurogenic impotence due to ONE of the following: 1. diabetes 2. fractured pelvis 3. m ajor surgery of the pelvis, retroperitoneum, radical prostatectomy, or colorectal surgery 4. m ultiple sclerosis 5. spina bifida 6. spinal cord injury/disease 7. syringomy elia OR E. Vascular impotence due to ONE of the following: 1. hypertension 2. intrapenile arterial disease 3. penile fracture 4. Peyronies disease 5. smoking 6. status post cavernosal infection 7. impotence due to radiation therapy to the pelvis or retroperitoneum V. Internal penile prosthetic implant removal is considered medically necessary when ANY of the following occur: A. infection B. mechanical failure C. urinary obstruction D. intractable pain E. Conditions of Coverage N/A F. Related Polic ies/Rules N/A Penile Implants in the Treatment of Erectile Dysfunction-OH MCD-MM-0033 Effective Date: 09/01/2025 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d.4G. Review/Revision History DATE ACTIONDate Issued 07/26/2016Date Revised 05/13/2020 05/11/2022 05/10/2023 05/08/2024 06/18/2025Updated References, Updated Background information, condensed medical criteria. Added penile implant information to Background; updated references. No changes. Updated references. Approved at Committee. No changes. Updated references. Approved at Committee. No changes. Updated references. Approved at Committee.Date Effective 09/01/2025 Date Archived H. References1. Burnett AL, Nehra A, Breau RH, et al. Erectile dysfunction: AUA guideline. JUrology. 2018;200:633-641. doi:10.1016/j.juro.2018.05.004 2. Khera M. Treatment of male sexual dysfunction. UpToDate. Updated October 24, 2023. Accessed June 3, 2025. www.uptodate.com 3. Lazarou S. Surgical treatment of erectile dysfunction. UpToDate. Updated November 14, 2023. Accessed June 3, 2025. www.uptodate.com 4. Pharmacy Services: Covered Drugs and Associated Limitations, O HIO ADMIN . CODE 5160-9- 03(B)(3) (2024). 5. Urologic Surgery or Procedure GRG: SG-US. MCG Health. 28th ed. Updated February 1, 2024. Accessed June 3, 2025. www.careweb.careguidelines.com Inde pendent med ica l rev iew 05/2020Approved by ODM on 6/23/2025 .

Peripheral Nerve Stimulators for Treatment of Pain

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333 08/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPeripheral Nerve Stimulators for Treatment of Pain B. BackgroundThe role of peripheral nerves as sources of pain and avenues of treatment when conservative therapy has failed is being more extensively explored than in previous years. Neuromodulation of peripheral nerves to treat refractory pain is one such area of interest. The neuromodulation of peri pheral nerves to reduce pain, known as peripheral nerve stimulation (PNS), has been developed as a minimally invasive pain management modality intended to manage acute and chronic pain. The proposed mechanism of action, referred to as the gate control theory, involves a method by which stimulation of large-diameter sensory neurons reduces transmission ofpainful stimuli from small nociceptive fibers to the brain. The stimulation system is placed adjacent to the nerve, a process commonly known as remote selective targeting. The lead is connected to a small, wearable stimulator. Depending on the device, the wearer may be able to adjust the level of stimulation using Bluetooth technology. C. DefinitionsAcute Pain Pain lasting 4 weeks or less. Chronic Pain A distressing feeling often caused by intense or damaging stimuli (pain) lasting more than 3 months, which is considered beyond normal healing time. Conservative Therapy A multimodality plan of care for treating pain non – surgically, including active and inactive conservative therapies. o Active A type of action or activity to 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. o Inactive Lack of activity on behalf of the patient that aids in treating symptoms associated with pain but not necessarily the underlying source, including rest, ice, heat, medical devices, acupuncture, and/or prescription medications. Minimally Invasive Procedures involving entry into the living body through a small incision to lessen recovery time, level of pain, and risk of infection . Sub-Acute Pain Pain lasting between 4 and 12 weeks. D. PolicyI. Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply used in or directly related to the diagnosis, evaluation, or treatment of a disease, injury, illness, or other health condition which CareSource determines in its sole discretion to be experimental or investigational is not covered by CareSource. II. Peripheral nerve stimulators are considered experimental and investigational and are unproven for all indications for the reduction of acute, sub-acute, and chronic pain.Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 III. Peripheral nerve stimulators are not covered. This includes, but is not limited to:A. IB-Stim B. SPRINT PNS System C. Nalu Neurostimulation System D. StimRouter Neuromodulation System E. Moventis PNS F. StimQ PNS System E. Conditions of CoverageN/A F. Related Policies/RulesMedical Necessity Determinations Experimental and /or Investigational Item or Service G. Review/Revision HistoryDATE ACTIONDate Issued 10/01/2022Date Revised 07/29/2022 02/15/202301/17/202406/05/2024 05/07/2025 Converted from administrative policy (AD-1201) to medical policy. Annual review. Updated definitions. Annual review : references updated ; approved at Committee. Revised Background, added D. III. A. Approved at Committee Annual review-references updated , approved at Committee. Date Effective 08/01/2025 Date Archived H. References1. Abd-Elsayed A, Keith MK, Cao NN, Fiala KJ, Martens JM. Temporary peripheral nerve stimulation as treatment for chronic pain. Pain Ther . 2023;12(6):1415-1426. doi:10.1007/s40122-023-00557-3 2. Albright-Trainer B, Phan T, Trainer RJ, et al. Peripheral nerve stimulation for the management of acute and subacute post-amputation pain: a randomized, controlled feasibility trial. Pain Manage . 2022;12(3):357-369. doi:10.2217/pmt-2021-0087 3. Char S, Jin MY, Francio VT, et al. Implantable peripheral nerve stimulation for peripheral neuropathic pain: a systematic review of prospective studies. Biomed . 2022;10(10)2606. doi:10.3390/biomedicines10102606 4. DSouza RS, Jin MY, Abd-Elsayed A. Peripheral nerve stimulation for low back pain: a systematic review. Curr Pain Headache Rep . 2023;27:117-128. doi:10.1007/s11916-023-01109-2 5. Evidence Analysis Research Brief: Peripheral Nerve Stimulation for the Treatment of Superior Cluneal Neuralgia. Hayes; 2024. Accessed April 10, 2024. www.evidence.hayesinc.com Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 6. Evolving Evidence Review: IB-Stim (NeurAxis) for Treatment of Pain Associated withIrritable Bowel Syndrome in Adolescents. Hayes; 2022. Reviewed July 17 , 202 4. Accessed April 10 , 202 5. www.evidence.hayesinc.com 7. Evolving Evidence Review: SPRINT PNS System (SPR Therapeutics) for Chronic Pain. Hayes; 2021. Updated February 27, 2025 . Accessed April 10, 2025 . www.evidence.hayesinc.com 8. Hatheway J, Hersel A, Song J, et al. Clinical study of a micro-implantable pulse generator for the treatment of peripheral neuropathic pain: 3-month and 6-month results from the COMFORT-randomised controlled trial. Reg Anesth Pain Med . 2024 ;0:1-7. doi:10.1136/rapm-2023-105264 9. Health Technology Assessment: Percutaneous Peripheral Nerve Stimulation for Treatment of Chronic Pain. Hayes; 2022. Reviewed May 8, 2024 . Accessed April 10, 2025 . www.evidence.hayesinc.com 10. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain. Hayes; 2021. Reviewed April 17, 2024. Accessed April 10, 2025. www.evidence.hayesinc.com 11. Helm S, Shirsat N, Calodney A, et al. Peripheral nerve stimulation for chronic pain: a systematic review of effectiveness and safety. Pain Ther . 2021;10(2):985-1002. doi:10.1007/s40122-021-00306-4 12. Huntoon MA, Slavin KV, Hagedorn JM, et al. A retrospective review of real-world outcomes following 60-day peripheral nerve stimulation for the treatment of chronic pain. Pain Physician . 2023;26(3):273-281. Accessed April 10, 2025. www.painphysicianjournal.com 13. Kaye AD, Ridgell S, Alpaugh ES, et al. Peripheral nerve stimulation: a review of techniques and clinical efficacy. Pain Ther . 2021;10(2):961-972. doi:10.1007/s40122 – 021-00298-1 14. Li AH, Gulati A, Leong MS, et al. Considerations in permanent implantation of peripheral nerve stimulation (PNS) for chronic neuropathic pain. an international cross-sectional survey of implanters. Pain Pract . 2022;22(5):508-515. doi:10.1111/papr.13105 15. Luna D, Hettie G, Pirrotta L, et al. Real-world long-term outcomes of peripheral nerve stimulation: a prospective observational study. Pain Manag . 2025 ;15(1):37-44. doi: 10.1080/17581869.2025.2451605 16. McCullough M, Kenney D, Curtin C, et al. Peripheral nerve stimulation for saphenous neuralgia. Reg Anesth Pain Med . 2024;49(6):455-460. doi:10.1136/rapm-2023 – 104538 17. Smith BJ, Twohey EE, Dean KP, DSouza RS. Peripheral nerve stimulation for the treatment of postamputation pain: a systematic review. Am JPhys Med Rehabil . 2023;102(9):846-854. doi:10.1097/PHM.0000000000002237 18. Strand N, DSouza RS, Hagedorn JM. Evidence-based clinical guidelines from the American Society of Pain and Neuroscience for the use of implantable peripheral nerve stimulation in the treatment of chronic pain. JPain Res . 2022;15:2483-2504. doi:10.2147/JPR.S362204 Peripheral Nerve Stimulators for Treatment of Pain-OH MCD-MM-1333Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 19. Vangeison CT, Bintrim DJ, Saha AK, et al. The role of peripheral nerve stimulation in refractory non-operative chronic knee osteoarthritis. Pain Manag . 2023;13(4):213-218. doi:10.2217/pmt-2023-0025 20. West T, Hussain N, Bhatia A, et al. Pain intensity and opioid consumption after temporary and permanent peripheral nerve stimulation: a 2-year multicenter analysis. Reg Anesth Pain Med . 2024. doi:10.1136/rapm-2024-105704 21. Xu J, Sun Z, Wu J, et al. Peripheral nerve stimulation in pain management: a systematic review. Pain Physician . 2021;24(2):E131-E152. Accessed April 10, 2025 . www.painphysicianjournal.com Approved by ODM on 05/13/2025

Genetic Testing and Counseling

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Genetic Testing and Counseling-OH MCD-MM-0003 08/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Polices/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Genetic Testing and Counseling-OH MCD-MM-0003Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectGenetic Testing and Counseling B. BackgroundAdvancements in technology have contributed to the rapid expansion of identified genetic variations . Some of these variations have been identified as disease-causing, while others are considered common variants with no clinical impact . With the ev er- expanding number of genetic tests available , it can be clinically difficult to determine the most appropriate tests for a particular patient. When clinically appropriate, genetic testing may provide diagnostic and/or actionable therapeutic results which can impact a patients outcome. Due to the complexity of genetic tests and th eir results , consultation with m edical genetics professionals and counselors may be required to assist members. According to the National Society of Genetic Counselors of the United States, genetic counseling is meant to integrate the following goals: 1) interpretation of family and medical histories to assess the chance of disease occurrence or recurrence; 2) education about the natural history of the condition, inheritance pattern, testing,management, prevention, support resources, and research; 3) counseling to promote informed choices in view of risk assessment, family goals, ethical and religious values; and 4) support to encourage the best possible adjustment to the disorder in an affected family member and/or to the risk of recurrence of that disorder. Genetic counselors are healthcare professionals trained to provide this care ; however , access issues may require other healthcare professionals to assume this role. Genetic counseling , whether provided by a certified genetic counselor or other qualified healthcare professional, is an integral component of genetic testing that is informative and supportive to memb ers, both before and after they undergo testing. C. Definitions Genetic Screening Th e process of testing a population for a genetic disease to identify a subgroup of people who either have the disease or the potential to pass it to offspring. Genetic Testing A medical test that identifies changes in genes, chromosomes, or proteins to confirm or rule out a suspected genetic condition , either hereditary or acquired. Human Leukocyte Antigen (HLA) Typing A test used to match patients and donors for bone marrow or cord blood transplants. Inherited Genetic Variant A type of DNA sequence change passed from parent to offspring (ie, germline). Precision Medicine A field of medicine that selects pharmacotherapies based on the patients genetics. Somatic Gene Variant A type of DNA sequence change that is not inherited from a parent but acquired during a persons life. Genetic Testing and Counseling-OH MCD-MM-0003Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 D. PolicyI. Prior authorization may be required for genetic testing . This includes both somatic and germline genetic testing. II. CareSource will review for medical neces sity using published MCG criteria whenavailable and the Medical Necessity Determinations administrative policy . This policy does not apply to requests that have MCG guidelines with clear genetic counseling requirements/recommendations. III. Proprietary panel testing requires evidence-based documentation per the MedicalNecessity Determinations administrative policy. Individual genetic tests may be requested separately based on the Medical Necessity Determinations administrati ve policy for panels not meeting medical necessity requirements. IV. Genetic counseling is required for all germline genetic testing , as indicated by ALLthe following: A. Counseling is provided by a healthcare professional with education and training in genetic issues relevant to the genetic tests under consideration . B. Counseling is provided to enable members informed decision making concerning proposed testing (eg, purpose of testing, management that may be informed by result, heritable nature informed by 3-generation family history, range of possible results, potentia l benefits and risks of testing (eg, psychological, social, economic). V. Somatic genetic testing (eg, cancer testing) does not require genetic counseling described above. VI. Human leukocyte antigen (H LA ) typing is not part of the genetic testing policy and do es not require pre-authorization. VII. W hile most inherited genetic testing is only necessary on ce in a lifetime, CareSource recognizes that a germline genetic test could be appropriately repeated in extraordinary circumstances due to changes in technology. This situation will be considered with the proper medical necessity documentation. E. Conditions of CoverageNAF. Related Polices/RulesMedical Necessity Determinations Cystic Fibrosis Testing Genetic Testing and Counseling-OH MCD-MM-0003Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 G. Review/Revision HistoryDATE ACTIONDate Issued 02/24/2015 New PolicyDate Revised 06/05/2019 09/03/2020 07/07/2021 05/25/2022 05/10 /202304/10/202407/03/2024 04/23 /2025Revised title, removed MCG table, condensed backgroundReviewed, updated referencesAnnual review: updated definitions, background, and references, re-organized criteria Annual review: updated background, definitions, and references , rephrased genetic counseling process. Approved at Committee. Review: updated references, approved at Committee Review: clarified genetic counseling requirements, added language regarding MCG. Approved at Committee Review: updated references, approved at Committee. Date Effective 08/01/2025 Date Archived H. References1. Ambulatory care : genetic medicine. MCG Health . 28 th ed. Accessed April 8, 2025 . www.careweb.careguidelines.com 2. Cohen SA, Bradbury A, Henderson V, et al. Genetic counseling and testing in a community setting: quality, access, and efficiency. Am Soc Clin Oncol Educ Book . 2019;e34-e44. doi:10.1200/EDBK_238937 3. Crooke A, Jacobs C, Newton-John T, et al. Genetic counseling and testing practices for late-onset neurodegenerative disease: a systematic review. JNeurol. 2022;269(2):676-692. doi:10.1007/s00415-021-10461-5 4. Kohlmann W, Slavotinek A. Genetic testing. UpToDate. Updated July 22, 2024 . Accessed April 8, 2025 . www.uptodate.com 5. Mundy J, Davies HL, Radu M, et al. Research priorities in psychiatric genetic counselling: how to talk to children and adolescents about genetics and psychiatric disorders. Eur JHum Genet . 2023;31(3):262-264. doi:10.1038/s41431-022-01253-0 6. National Center for Biotechnology Information (NCBI). Genetic Testing Registry (GTR) National Library of Medicine. Accessed April 8, 2025 . www.ncbi.nlm.nih.gov 7. National Human Genome Research Institute. Coverage and Reimbursement of Genetic Tests. National Institutes of Health. Updated February 6, 2024 . Accessed April 8, 2025 . www.genome.gov 8. National Human Genome Research Institute. Regulation of Genetic Tests. National Institutes of Health. Updated February 19, 2024 . Accessed April 8, 2025 . www.genome.gov 9. Raby BA, Kohlmann W. Genetic counseling: family history interpretation and risk assessment. UpToDate. Updated April 9 , 2024. Accessed April 8, 2025 . www.uptodate.com Genetic Testing and Counseling-OH MCD-MM-0003Effective Dat e: 08/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 10. Sarata AK. Genetic Testing: Background and Policy Issues . Congressional ResearchService Report ; 2015 . RL33832. Accessed April 8, 2025 . www.sgp.fas.org 11. Senter L, Austin JC, Carey M, et al. Advancing the genetic counseling profession through research: identification of priorities by the National Society of Genetic Counselors research task force. JGenet Couns. 2020;29(6):884-887. doi:10.1002/jgc4.1330 12. White S, Jacobs C, Phillips J. Mainstreaming genetics and genomics: a systematic review of the barriers and facilitators for nurses and physicians in secondary and tertiary care. Genet Med. 2020;22(7):1149-1155. doi:10.1038/s41436-020-0785-6 Approved by ODM 05/13/2025

Applied Behavior Analysis for Autism Spectrum Disorder

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 07/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standar ds, 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 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 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 ………………………….. ………………………….. ………………………….. ………………… 4 D. Policy ………………………….. ………………………….. ………………………….. ………………………. 5 E. Conditions Of Coverage ………………………….. ………………………….. ………………………… 13 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. 14 G. Review/Revision History ………………………….. ………………………….. ……………………….. 15 H. References ………………………….. ………………………….. ………………………….. …………….. 15 Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectApplied Behavior Analysis Therapy for Autism Spectrum Disorder B. BackgroundThe Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition, Text Revised (DSM-5-TR) classifies Autism Spectrum Disorder (ASD) as a neurodevelopmental disorder var ies widely in severity and symptoms, depending on the developmental level and chronological age of the individual . ASD is characterized by specific developmental deficits that affect socialization, communication, academic and personal functioning . Individuals are typically diagnosed before entering grade school, and symptoms are noticed acr oss multiple contexts, including social reciprocity, nonverbal communicative behaviors, and skills in developing, maintaining and understanding relationships. Restricted, repetitive patterns of behavior, interests or activities are also often present. Currently, th ere is no cure for ASD, nor is there any single treatment for the disorder.The diagnosis may be managed through a combination of therapies, including behavioral, cognitive, pharmacological, and educational interventions with a goal of minimiz ing the severity of ASD symptoms, maximiz ing learning, facilitat ing social integration, and improv ing quality of life for the member and fami ly/caregiver (s). Applied behavior analysis (ABA), one such therapy, may be provided in centers or at home and provi des an evidence-ba se d practice for the treatment of ASD. ABA is based on the science of behavior, which was founded on the premise that understanding behavior functioning, how it is affected by the environment, and how learning to change behavior can improve the human condition. It is a flexible treatment in tha t it should always be adapted to the needs of each individual, teaches skills that areuseful and generalizable, and involves individual, group and family training. Qualified and trained practitioners provide and/or oversee ABA programs and are accountable to state boards for registration, certification, or licensure requirements. Clinical decisions on telehealth service delivery models should be selected based on the individual needs, strengths, preference of service modality, caregiver availability , and environmental support available. CareSource follows the Ohio Administrative Code (OAC) and Ohio Department of Medicaid (ODM) guidelines in the provision of ABA services, based on a diagnosis from the DSM-5-TR . Severity levels are divided into 2 domains, social communication and restricted, repetitive behaviors: Severity Levels for Autism Spectrum DisorderSeverity Level Social Communication Restricted, repetitive behaviors Level 3 Requiring very substantial support Severe deficits in verbal & nonverbal social communication skills cause severe impa irments in functioning, very limited initiation of social interactions, Inflexibility of behavior, extreme difficulty coping with change, or other restricted/ repetitive behaviors markedly interfere with functioning in all spheres. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 and minimal response to social overtures from others. Great distress/difficulty changing focus or action. Level 2 Requiring substantial support Marked deficits in verbal and nonverbal social communication skills, social impairments apparent even with supports in place, limited initiation of social interactions, and reduced or abnormal responses to social overtures from others. Inflexibility of behavior, difficulty coping with change, or other restricted/ repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing f ocus or action. Level 1 Requiring support Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions and clear examples of atypical or unsuccessful responses to social overtur es of others. May appear to have decreased interest in social interactions. Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence. Social skills instruction is an important component of management of the diagnosis.Although additional studies are necessary, a 2012 meta-analysis of five randomized trials (196 participants) found evidence that participation in social skills groups improved overall social competence and friendship quality in the short term. A 2020 study demonstrated efficacy of a modified group cognitive behavioral therapy program in children delivered in a community context. A 2021 study demonstrated benefits of group cognitive behavioral treatment in adolescents diagnosed with autism and intellectual disabilities. As children near entry in a public or private school system, research supports the use of group therapy for school readiness and improved social skills. Training must be an integral component of the management of the underlying disorder and in clude clearly defined goals, teach desired behaviors, provide prompting for natural display of desired behaviors, provide reinforcement of demonstrated behaviors, and include practice of desired behaviors with goals of generalizability outside the therapeu tic setting (eg, impairments in social-emotional reciprocity, restrictive or obsessional interests, aggressive behaviors). As the child becomes eligible for school-based services (the age varies depending uponthe state), the public school system becomes responsible for the provision of services and education. The services provided are outlined in an individualized education program (IEP), which is reviewed at a minimum of once a year, for children eligible. ASD services do not include education services otherwise available through a program funded under 20 US Code Chapter 3, section 1400 of the Individuals with Disabilities Ed ucation Act (IDEA). Congress reauthorized the IDEA in 2004 and most recently amended the IDEA through Public Law 114-95, Every Student Succeeds Act, in December 2015 Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 C. Definitions Applied Behavior Analysis (ABA ) The design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. Caregiver/Family Trainin g Therapist teaches parents/caregivers to implement methods utilized in a clinical setting i nto other environments, such as the home or community, to maximize member outcomes by furthering the generalization of skills and reinforcing methods being taught to the member in other sessions. Functional Assessment The determination of underlying function or purpose of behavior to develop an effective treatment plan, including a variety of systematic, information gathering techniques regarding factors influencing behavior occurrence (eg, antecedents, consequences, s etting events and motivating operations), such as interview, indirect assessment, direct observation, descriptive assessment, experimental analysis, and systematic manipulation of environmental variables to demonstrate a relationship between an event and t argeted behavior. Independent Practitioner All ABA services must be provided by a provider/practitioner compliant with Ohio Revised Code 4783.02 with approved supervision, as applicable , including the following (not an all-inclusive list): o Board Certified Assistant Behavior Analyst (BCaBA) o Certified Ohio Behavioral Analyst (COBA) or Board-Certified Behavior Analyst (BCBA) o Board Certified Behavior Analyst – Doctoral (BCBA-D) o Registered Behavior Technician (RBT) Medically Unlikely Edit (MUE) Maximum units of service for 1 Current Procedural Terminology (CPT) code a provider can report for 1 member on 1 date of service. Standardized Diagnostic Assessment Tool s Direct assessment, e vidence – based tools designed to assist with identification of symptoms and criteria for a diagnosis or disorder. SMART Goal s Goals that are specific (S) , measurable (M) , attainable (A) , relevant (R) , and time-bound (T) . Supervisio n Directing, guiding, training , and assessing individuals who provide behavior-analytic services with responsibilities in accordance with the board from which the practitioner received a license. o BCaBAs ervices must be supervised by a COBA/ BCBA, BCBA-D, or a licensed psychologist who has tested in ABA and is certified by the American Board of Professional Psychology in Behavioral and Cognitive Psychology . Treatment Plan A written document describing presenting behavior problem(s) and behavioral goals and interventions selected to alter behavior based on information gathered from in-person assessments, review of records from other professionals, direct observation, and clinical interview data, including an estimate of the length of time and/or number of sessions anticipated to achieve goals and specific statements about the measurement of progress toward achieving goals. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 D. PolicyI. General Guidelines A. Medical necessity review is required for all ABA services initially with a baseline and then, again, every 6 months. Medical review must be submitted with appropriate documentation as indicated in this policy and align with the States definition of medical necessity that includes that treatment is not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results. B. ABA therapy should begin early in life, ideally by the age of 2, typically lasting up to 3 to 4 years and is subject to the members response to treatment. C. Members under the age of 21 will be assessed. Treatment goals and intensity will be based on individual needs and progress in treatment with a focus on remediation of symptoms. D. The members treatment record (eg, plans of care, treatment plans, behavior support plans, functional assessments ) must be completed by the provider or practitioner and submitted to CareSource prior to claim submission. Claims will not be accepted without accompanying treatment documentation. II. Initia tion of ABA ServicesA. Documentation: CareSource must receive documentation that confirms the following medical criteria: 1. definitive, primary diagnosis of ASD made by one of the following practitioner s upon evaluation : a. child and adolescent psychiatrist b. psychologist c. child neurologist d. developmental pediatrician 2. standardized diagnostic assessment tools that are considered multidisciplinary evaluations, including a. Autism Diagnostic Observation Schedule (ADOS) b. Autism Diagnostic Interview Revised (ADI-R) c. Childhood Autism Rating Scale, 2 nd edit. (CARS-2) 3. written documentation ( eg, provider letter ) that d escri bes DSM clinical symptoms present within the past year requir ing treatment if the submitted diagnostic evaluation was completed more than 24 months from date of request B. Initial Behavior Assessment: Before services are provided, an initial behavior identification assessment will be performed by a fully credentialed BCBA with state licensure, if available, and devel op a treatment plan. Generally, b ehavioral assessments are not to exceed 6-10 hours every 6 months , unless additional justification is provided. C. Initial Treatment Plan: An initial ABA treatment plan individualized to the caregiver/family needs, values, priorities and circumstances for member goals and parent/caregiver training will be developed by the member, family/caregiver, and provide r and m ust include the following: Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 1. biopsychosocial information, including, but not limited to:a. current family structure b. medication history, including dosage and prescribing physician c. medical history d. school placement and hours in school per week, including homeschool instruction and any individualized education plans (IEP) e. history of ABA services, including service dates and progress notes f. all behavioral health diagn oses and services, including any hospitalizations g. other services member is receiving (eg, speech therapy [ST] , occupational therapy [OT], physical therapy [PT]) , including evidence of coordination with other disciplines involved in the assessment h. caregiver proficiency and involvement in treatment i. any major life changes 2. rationale for ABA services (eg, how ABA addresses current areas of need ), including the following : a. history with symptom intensity and symptom duration, including how symptoms affect the members ability to function in various settings b. evidence of previous therapy ( eg, outcomes from previous ABA treatment, ST, OT, PT) and how result s influence proposed treatment c. type, duration, frequency for services 3. goals related to core deficits ( eg, communication problems, relationship development, social and problem behaviors) must includ e the following: a. outcome driven , performance-based, and individualized measures focused on targeted symptoms, behaviors, and functional impairments b. based on the direct behavioral assessment and a standardized developmental and functional skills assessment/curriculum ( eg, Verbal Behavior Milestones Assessment and Placement Program [VB-MAPP ], Assessment of Basic Language and Learning Skills [ABLLS-R]). c. a description of treatment activities and documentation of active participation by member and caregiver/family in the implementation of treatment OR documentation detailing barriers to family/ caregiver participation and how those barriers are being actively addressed d. SMART goals that define how improvement will be noted, frequency of treatment (number of hours per week), and duration of treatment 4. Behavioral Intervention Plan and/or a Plan of Care (POC) 5. requested number of ABA hours per week based on the members specific needs , not on a general program structure , as evidenced by all of the following: a. Treatment is provided at the lowest level of intensity appropriate to the members clinical needs and goals with the number of hours requested reflecting the actual number of hours intended to be provided . b. A d etailed description of problems, goals and interventions support the requested intensity of treatment . Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 6. a plan to modify the intensity and duration of treatment over time based on the members progress, including an individualized discharge plan specific to treatment needs7. coordination with other behavioral health and medical providers III. Continuation of ABARequests for continuation of ABA services are to be submitted every 6 months, and documentation must meet EITHER of the following criteria: A. A d efinitive diagnosis of ASD persists , and m ember continues to demonstrate ASD symptoms that will benefit from treatment in at least 2 set tings . B. A t reatment plan as noted in D. II. C., including the following: 1. an updated progress report with assessment scores that note improvement and member response to treatment from baseline targeted symptoms, behaviors, and functional impairments using the same modes of measurement utilized for baseline measurements 2. a plan to transition services in intensity over time C. Parent/caregiver(s) are involved and making progress in development of behavioral interventions. OR D. When requesting continuation with inadequate progress on targeted symptoms or behaviors or no demonstrable progress within a 6-month period, an assessment of the reasons for lack of progress should be documented and provided. Treatment interventions should be modified to achieve adequate progress. Documentation should include 1. change in possible treatment techniques 2. increased parent/caregiver training 3. increased time and/or frequency working on specific targets 4. identification and resolution of barriers to treatment efficacy 5. any newly identified co-existing disorders and possible treatment 6. modified or removed goals and interventions IV. Discontinuation of ABA TherapyTitration or discontinuation of ABA therapy should occur when any of the following conditions are met (not an all-inclusive list): A. Treatment ceases to produce significant meaningful progress or maximum benefit has been reached . B. Member behavior does not demonstrate meaningful progress for two successive 6-month authorization periods as demonstrated via standardized assessments. C. ABA therapy worsens symptoms, behaviors or impairments. D. Symptoms stabilize allowing member to transition to less intensive treatment or level of care. E. Parents/caregivers have refused treatment recommendations, are unable to participate in the treatment program, and/or do not follow through on treatment recommendations to an extent that compromises the effectiveness of the services for member progress. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 V. Parent/ Caregiver TrainingTraining will evolve as goals are met . Parent/caregiver should be actively working on at least 1 unmet goal . ABA services must include documentation of the following: A. understand ing and agree ment to comply with the requirements of treatment B. how the parents/caregivers will be trained in skills that can be generalized to the home and other environments C. methods by which the parents/caregivers will demonstrate trained skills D. barriers to parent involvement and plans to address (eg, are treatment goals addressed when treatment professionals are not present , overall skill abilities ) E. time involvement, including materials or meetings occurring on a routine basis VI. TelehealthParent/caregiver training and supervision may be provided by telehealth . 1:1 ABA services may be provided via telehealth in instances deemed medically necessary with supporting documentation that provides a plan for the provision of service delivery. Providers utilizing telehealth for the delivery of services must make decisions that are consistent with best, currently available evidence and clinical consensus. Clinical rationale must consider assessed needs, strengths, preferences, and available resou rces of members and caregivers. The same professional ethics governing in-person care must be followed and limitations considered, including interstate licensure challenges, state regulatory issues, member or caregiver discomfort with technology, technolog y limitations, and cultural acceptance of virtual visits. Providers must identify protocols for clinical appropriateness (eg, risk assessment, safety planning, patient/caregiver characteristics), ensure therapeutic benefit for recipients, and ensure provid er competence of delivering care via telehealth modalities. Peer reviewed studies and other best evidence literature provides guidance on appropriate screeners and questionnaires for use in the determination of appropriateness of telehealth services for pa rticular clients. VII. Documentation RequirementsThe State of Ohio enacts code related to requirements for documentation expectations for client records maintained for third party billing. Each dated entry in the professional record is maintained for a period of not less than 7 years after the last date of service or not less than the length of time required by other regulations if longer. Records documenting services rendered to minors must be retained for not less than 2 years after the minor reaches the age of majority or for 7 years after the last da te of service, whichever is longer. All written, electronic and other records will be stored and disposed of in such a manner as to ensure confidentiality . All must be legible . A. Minimum documentation requirements for ABA client records include the following: 1. presenting problem, including any relevant diagnosis and any recommendation for ABA services rendered by a licensed professional Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.9 2. date(s) and purpose of each service contact (eg, service note)3. treatment plan and functional assessment on which behavior plan is based 4. data collected to ascertain efficacy of ABA and any subsequent modifications of the plan 5. notation and results of formal contacts with other providers 6. authorizations, if any, by the client for release of records or information B. Minimum documentation requirements for all service s rendered include 1. name of provider organization clearly visible on the record 2. members name on each page (ie, legal name) with date of birth or unique identifier 3. start and stop times of the session , including any pauses in services (must indicate time paused and time resumed) 4. date and location of rendered service and date of note creation if different from date of rendered service 5. type/ code of service provided 6. provider rendering the service with appropriate credentials and dated signature 7. identification of others present, including the relationship to the member and number of individuals participating in group sessions 8. interventions occurring during the session that directly relate to the POC and client response to interventions 9. any needed modifications to treatment or items requiring follow up from previous sessions , including any addendums to the record VIII. Codes of ConductCodes of conduct exist to meet credentialing needs of professionals but also function to protect members by establishing, disseminating, and managing professional standards. Ohio mandates that providers of ABA services understand and follow codes of conduct supporting the profession. CareSource supports professional standards established by licensing and credentialing bodies, and therefore, encourages professional compliance to any and all standards across disciplines for the protection of members and famil ies. The ethics code written by the Behavior Analyst Certificat ion Board includes the following standards (not all-inclusive): A. Family oversight must occur by/with the BCBA or BCaBA. An RBT may be present during a family training session to provide assistance with interventions, but the training or supervision of interventions cannot be completed by the RBT. B. Providers will create a contract for consent to services ( eg, Declaration of Professional Practices and Procedures) at the onset of services that defines and documents, in writing, the professional role with relevant parties. C. Appropriate effort will be made to involve members and stakeholders in treatment, including selecting goals, designing assessments and interventions, and conducting continual progress monitoring. D. Providers will identify and address environmental conditions ( eg, behavior of others, hazards to client or staff) that may interfere with service delivery, Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.10 including the identification of effective modifications to interventions and appropriate documentation of conditions, actions taken, and eventual outcomes.E. Continuity of services will be facilitated to avoid interruption or disruption of services for members, including documentation of actions taken and eventual outcomes. F. Providers will address any possible circumstances when relevant stakeholders are not complying with the behavior-change intervention(s) despite documented and appropriate efforts to address barriers to treatment. IX. Supervision ExpectationsThe State of Ohio enacts code for supervision requirements and documentation expectations for providers within the profession . The BACB provides guidelines for supervision requirements and documentation expectations for providers within the profession. If there are discrepancies with supervision documentation, the associated claims are subject to recoupment. A. At a minimum, supervision must include the following activities : 1. consultation with the supervisee(s) prior to initiation of the treatment plan 2. training regarding implementation of the treatment plan, data collection regarding effectiveness, and measurement of client progress 3. consultation with the supervisee(s) prior to modification of the treatment plan 4. periodic direct observation of each supervisee implementing assessment and treatment procedures with clients, including performance evaluation and additional instruction as necessary B. Record Maintenance Supervision records will be maintained by certified Ohio behavior analysts for a period of 5 years , BCBAs /RBTs for 7 years , following the termination of supervision, which include the following documents , at a minimum: 1. supervision plans for each client treatment plan 2. dates of training on treatment plans, procedures, and interventions 3. supervision provided when treatment plans are reviewed or modified C. General supervision documentation records must include the following information (not an all-inclusive list) : 1. date and start/stop time s of supervision session 2. names, credentials and/or relationship of individuals present at each session 3. type of supervision (general or direct) 4. purpose of supervision, including any collaborati on of care among providers 5. outcome of supervision, including any modification to treatment inventions or plans of care, including the following information: a. review of services provided b. review of data forming basis of a continued treatment plan c. review of client progress, including results of tools noting progress 6. name and credentials of the supervisor (if documenting for billing purposes, the supervisors National Provider Identifier), included dated signature 7. dated signature of supervisee, including credentials Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.11 D. The BACB outlines the following minimum provisions for supervision documentation:1. RBTs must document the following during supervision (not all-inclusive): a. days and times behavior-analytic services were provided b. dates and duration of supervision c. supervision format (individual, group) d. dates of direct observation e. names of supervisors providing supervision f. noncertified RBT supervisor form, if applicable g. proof of supervisors relationship to the client h. additional documentation in the event of discrepant records (session notes) 2. Supervisors must document the following for any supervision hours conducted (not an all-inclusive list): a. date with start and stop times b. fie ldwork type c. supervision type (group, individual) d. activity category (restricted or unrestricted) e. summary of supervision activity, including 01. discussion of activities completed during independent hours and any feedback provided 02. progress toward individual member goals 03. outcome of supervision, including any modification to treatment interventions or plans of care 04. collaboration of care among providers f. dated signatures of supervisor and supervisee, including credentials 3. Observations must include the following (at a minimum): a. date with start and stop times b. fieldwork type c. setting name d. supervisor name e. activity category (restricted or unrestricted) E. CareSource supports BACB published ethical codes related to supervision for the provision of services to clients, including, but not limited to 1. Behavior analysts (BA) are knowledgeable about and comply with all applicable supervisory requirements, funder and organization policies), including those related to supervision modalities and structure. 2. BAs supervise and train others only within an individual identified scope of competence. 3. BAs take on only the number of supervisees allowing effective supervision and training. When a threshold volume for providing effective supervision has been met, documentation of this self-assessment and communication of results to employer(s) and rel evant parties must occur. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.12 4. BAs are accountable for supervisory practices and professional activities(eg, client services, supervision, training, research activity, public statements) of supervisees occurring as part of that relationship. 5. BAs ensure that documentation, and the documentation of supervisees or trainees, is accurate and complete. 6. BAs deliver supervision and training in compliance with applicable requirements (eg, BACB rules, licensure requirements, funder and organization policies) and design and implement supervision and training procedures that are evidence based, focus on p ositive reinforcement, and are individualized for each supervisee and circumstances. 7. BAs actively engage in continual evaluation of supervisory practices using feedback from others and client and supervisee outcomes. Self – evaluations are documented and timely adjustments made to supervisory and training practices as indicated. X. Special Provisions Related to RBTsA. Current Standards for RBTs 1. RBT services must be supervised by a qualified RBT supervisor. RBTs must obtain ongoing supervision for a minimum of 5% of the hours spent providing ABA services per month. Additionally, the BACB publishes information regarding the structure of supervision and parameters for group and individual supervision in the RBT Handbook. 2. An RBT who is certified by the BACB may provide ABA under the supervision of an independent practitioner if enrolled in the Medicaid program and affiliated with the organization under which the provider is employed or contracted. If the independent practitioner leaves the affiliated organization and no longer provides supervision, the RBT may not continue to provide services under that independent practitioner . Additionally, if the RBT leaves the affiliated organization and no longer receives mandated supervision, the RBT may not continue to provide services to the member. 3. RBTs must use appropriate modifiers that indicate qualifications of staff delivering services , if appropriate. B. Upcoming RBT Changes from the Behavior Analyst Certification Board 1. Effective January 1, 2026: In the interest of consumer protection, the BACB Board of Directors approved a recommendation that RBT supervisors must hold BCBA or BCaBA certification. Noncertified supervisors will not be allowed to provide BACB-required supervision to RBTs. During this transition, RBT Requirements Coordinators who currently attest to the qualifications of noncertified supervisors should make preparations to ensure continuity of care for clients. 2. Effective January 1, 2026: New rules regarding e ligibility for and maintenance of certification for RBTs were adopted by the BACB Board of Directors and can be located in the BACB Newsletter: December 2023 at www.bacb.com. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.13 XI. ExclusionsA. reimbursement for the following services or activities is not permitted: 1. any services not documented in the treatment pla n 2. behavioral methods or modes considered experimental 3. education-related services or activities described under Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. 1400 (IDEA) , amended through Public Law 114-95, the Every Student Succeeds Act 4. vocational services in nature or those available through program s funded under Section 110 of the Rehabilitation Act of 1973 5. components of adult day care programs B. treatment solely for the benefit of the family, caregiver , or therapist C. treatment focused on recreational or educational outcomes D. treatment worsening symptoms or prompting member regression E. treatment for sy mptoms and behaviors not part of core symptoms of ASD ( eg, impulsivity due to ADHD, reading difficulties due to learning disabilities, excessive worry due to an anxiety disorder) F. goals focused on academic targets ( eg, treatment should address autistic symptoms impeding deficits in the home environment , such as reduc tion of frequency of self-stimulatory behavior to follow through with toilet training or complet ing a mathematic sorting task) G. treatment unexpected to cause measurable , functional improvement or improvement is not documented H. duplicative t herapy services addressing the same behavioral goals using the same techniques as the treatment plan, including services under an IEP I. services provided by family or household members J. care primarily custodial in nature and not requir ing trained/professional ABA staff K. shadowing, para-professional, or companion services in any setting L. personal training or life coaching M. services more costly than an alternative service(s), which are as likely to produce equivalent diagnostic or therapeutic results for the member N. any program or service performed in nonconventional settings, even if performed by a licensed provider ( eg, spas/resorts, vocational or recreational settings, Outward Bound, wilderness, camp or ranch programs) E. Conditions Of CoverageI. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepayment review. Program Integrity will be engaged for an annual review of data. II. When a member has other insurance, Medicaid is always the pay er of last resort.CareSource will not pay more than the Medicaid rate totals for service. Primary payer must provide evidence of determinations for consideration of Medicaid coverage for services. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.14 III. CareSource reserves the right to request supervision documentation, particularly related to telehealth services.IV. Providers cannot submit multiple dates of service on a single claim line. Each claim line must be specific to a single date of service and the units provided on that single date of service.V. CareSource complies with the Centers for Medicare and Medicaid Services (CMS)medically unlikely edit (MUE) table. If CMS updates the MUE list, the update will take precedence over this policy. The following applies to ABA CPTs: CPT Max imum Unit s Allowed 97151 32 97152 16 97153 32 97154 18 97155 24 97156 16 97157 16 97158 16 0362T 16 0373T 32 VI. Treatment codes are based on daily total units of service in 15-minute increments. A unit of time is att ained when the mid-point is passed. The following are time interval examples: Unit (s) Number of Minutes 1 unit >8-22 minutes 2 units >23 – 37 minutes 3 units >38 – 52 minutes 4 units >53 – 67 minutes 5 units >68 – 82 minutes 6 units >83 – 97 minutes 7 units >98 – 112 minutes 8 units >113 – 127 minutes VII. ODM allows Mental Health Community Behavioral Health Centers (CBHCs), provider type 84, to render and be reimbursed for ABA services using the service code H0036-Community Psychiatric Supportive Treatment (CPST). CareSource strongly encourages CBHCs to use ABA CPT codes outlined above for billing purposes but does accept H0036 when submitted by an appropriately certified CBHC. Expectations of this policy apply to all ABA services , whether billed using ABA CPTcodes or H0036. F. Related Policies/RulesMedical Necessity Determinations Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.15 G. Review/Revision HistoryDATE ACTIONDate Issued 10/04/2018Date Revised 01/27/2020 01/25/202108/04/202103/30/202201/04/202304/ 12 /202303/13 /202409/25/202410/23/202403/26/2025Added program attributes, definitions of provider types and ABA ; title change ; clarified PAd services ; changed NP to healthcare provider trained in ASD ; added IV , willingness to participate , description of p oc, ages ; clarified provider requirements ; added ASD diagnosis, home school /IEP, doc requirements, type of ASD treatment program with PA ; revised continuation of A BA therapy requirements . Added AFLS, ESDM and PEAK-DT assessments & section on ABA transition to school , revised discontinuation criteria & exclusions; removed PA checklist. Clarified telehealt h, moved doc requirements to Medical Records Doc for Practitioners ; re moved transition to school section ; updated school section & RBT supervision ; u pdated definitions & ABA criteria. Removed PA language. III.B.1. Primary diagnosis by a qualified practitioner. Added to section 5. F.02: Removed old section M. to sec. DIII 5.g. added ABA services must include parent/family training . Edited Sec. V. Removed VII. A E-voted ODM changes Sec. B. 1 and 2 Consolidated information into Sec. IV. Initial ABA Treatment Plan. Added Sec. V.J. Pare nt/Caregiver Involvement. Updated references. Reorganized policy & updated definitions. Removed 1:1 telehealth ABA exclusion. Removed I under Exclusions . Annual review. Added VII-X. Merged AD policy info to Cond of Coverage section. Updated H. Approved at Committee. Out of cycle review. Adde d backgroun d, D.I.D, IX.E., E.IV. Updated references. Approved at Committee . Out of cycle review. Removed parent signature as requirement per ODM. Approved at Committee. Removed VII. A.3. and B.7. Approved at Committee. Date Effective 07/01/2025 Date Archived H. References1. 2024 Q2 NCCI MUE Edits-Practitioner Services . Centers for Medicare and Medicaid Services. Accessed September 16 , 2024. www.cms.gov 2. Additional Medicaid Waiver Components for Home and Community-Based Services, OHIO REV . CODE 5166.20 (2016). 3. Anglim M, Conway EV, Barry M, et al. An initial examination of the psychometric properties of the Diagnostic Instrument for Social and Communication Disorders (DISCO-11) in a clinical sample of children with a diagnosis of autism spectrum disorder. Ir JPsychol Med . 2022;39(3):251-260. doi:10.1017/ipm.2020.100 4. Applied Behavior Analysis: B-806-T. MCG. 2 8th ed. Updated March 14 , 202 4. Accessed September 16 , 2024. www.careweb.careguidelines.com 5. Augustyn M. Autism spectrum disorder in children an d adolescents: evaluation and diagnosis. Up ToDate. Updated May 16, 2022. Accessed September 16, 2024 . www.uptodate.com Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.16 6. Augustyn M. Autism spectrum disorder (ASD) in children and adolescents: terminology, epidemiology, and pathogenesis. Up ToDate. Updated January 24,2024. Accessed September 16, 2024 . www.uptodate.com 7. Augustyn M, Von Hahn E. Autism spectrum disorder in children and and adolescents: clinical features. Up ToDate. Updated May 17, 2023. Accessed September 16, 2024 . www.uptodate.com 8. Autism spectrum disorder. American Academy of Pediatrics . Updated April 5, 2023. Accessed September 16, 2024 . www.aap.org 9. Autism spectrum disorder in young children: screening. U.S. Preventive Services Task Force; 2016. Accessed September 16 , 2024. www.uspreventiveservicestaskforce.org 10. Autism Spectrum Disorders: M-7075. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 11. Autism Spectrum Disorders: B-012-HC. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 12. Autism Spectrum Disorders, Adult, Inpatient Care: B-012-IP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 13. Autism Spectrum Disorders, Child or Adolescent: B-019-IP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 14. Autism Spectrum Disorders, Intensive Outpatient Program: B-012-IOP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 15. Autism Spectrum Disorders, Outpatient Care: B-012-AOP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 16. Autism Spectrum Disorders, Partial Hospitalization Program: B-012-PHP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 17. Autism Spectrum Disorders, Residential Care: B-012-RES. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 18. BACB Newsletter . Behavior Analyst Certfication Board; September 2023. Accessed September 16, 2024 . www.bacb.com 19. BACB Newsletter: Introducing the 2026 RBT Examination and Certification Requirements . Behavior Analyst Certification Board; December 2023. Accessed September 16, 2024 . www.bacb.com 20. Bak M, Plavnick J, Dueas A, et al. The use of automated data collection in applied behavior analytic research: a systematic review. Behavior Analysis: Res Practice. 2021;21(4), 376 405. https://doi.org/10.1037/bar0000228 21. Board Certified Behavior Analyst Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed September 16 , 2024. www.bacb.com 22. Board Certified Assistant Behavior Analyst Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed September 16 , 2024. www.bacb.com 23. Buckley A, Hirtz D, Oskoui M, et al; Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Practice guideline: treatment for insomnia an d disrupted sleep behavior in children and Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.17 adolescents with autism spectrum disorder. Neurology . 2020;94(9):392-404. doi:10.1212/WNL0000000000009033 24. Certified Ohio behavior analyst supervision. State of Ohio Board of Psychology. Accessed September 16, 2024 . www.psychology.ohio.gov 25. Chun T, Mace S, Katz E; American Academy of Pediatrics; Committee on Pediatric Emergency Medicine and American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Evaluation and management of children and adolescents with acute mental health or behavioral health problems , I: common clinical challenges of patients with mental health or behavioral emergencies. Pediatr. 2016;138(3):e20161570. doi:10.1542/peds.2016-1570 26. Chun T, Mace S, Katz E; American Academy of Pediatrics; Committee on Pediatric Emergency Medicine and American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Evaluation and management of children and adolescents with acute mental health or behavioral health problems , II: recognition of clinically challenging mental health related conditions presenting with medical or uncertain symptoms. Pediatr. 2016;138(3):e20161573. doi:10.1542/peds.2016-1573 27. Coverage for Autism Spectrum Disorder, OHIO REV . CODE 1751.84 (2021). 28. Crockett, JL, Fleming RK, Doepke K, et al. Parent training: acquisition and gene ralization of discrete trials teaching skills with parents of children with autism. Res Dev Disabilities . 2007; 28 (1):23-36. doi :10.1016/j.ridd.2005.10.003 29. Ethics Code for Behavior Analysts . Behavior Analyst Certification Board; 2020. Updated January 1, 2023. Accessed September 16 , 2024. www.bacb.com 30. Evidence Analysis Research Brief: Applied Behavior Analysis Training Via Telehealth for Caregivers of Children with Autism Spectrum Disorder . Hayes; 2022. Accessed September 16 , 2024. www.evidence.hayesinc.com 31. Evidence Analysis Research Brief: Direct-To-Patient Applied Behavior Analysis Telehealth for Children with Autism Spectrum Disorder . Hayes; 2022. Accessed September 16 , 2024. www.evidence.hayesinc.com 32. Gonzlez MC, Vsquez M, Hernndez-Chvez M. Autism spectrum disorder: clinical diagnosis and ADOS Test. Rev Chil Pediatr . 2019;90(5):485-491. doi:10.32641/rchped.v90i5.872 33. Health Technology Assessment: Comparative Effectiveness Review of Intensive Behavioral Intervention for Treatment of Autism Spectrum Disorder . Hayes; 2019. Updated February 10, 2022. Accessed September 16 , 2024. www.evidence.hayesinc.com 34. Hyman S, Levy S, Myers S ; Council on Children with Disabilities. Developmental and behavioral pediatrics : identification, evaluation, and management of children with autism spectrum disorder . Pediatr . 2020 ;145(1) :e20193447 . d oi:10.1542/peds.2019 – 3447 35. Information on autism spectrum disorder for healthcare providers. Centers for Disease Control and Prevention (CDC). Updated December 6, 2022. Accessed September 16 , 2024. www.cdc.gov 36. Lebersfeld JB, Swanson M, Clesi CD, et al. Systematic review and meta-analysis of the clinical utility of the ADOS-2 and the ADI-R in diagnosing autism spectrum Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.18 disorders in children. JAutism Dev Disord . 2021;51(11):4101-4114. doi:10.1007/s10803-020-04839-z 37. Lefort-Besnard J, Vogeley K, Schilbach L, et al. Patterns of autism symptoms: hidden structure in the ADOS and ADI-R instruments. Transl Psychiatry . 2020;10(1):257. doi:10.1038/s41398-020-00946-8 38. Lim N, Russell-George A. Home-based early behavioral interventions for young children with autism spectrum disorder. Clin Psycho l. 2022;29(4):415-416. doi:10.1037/cps0000117 39. Registered Behavior Technician Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed September 16 , 2024. www.bacb.com 40. Medicare Claims Processing Manual. Centers for Medicare and Medicaid Services; 2024. Publication # 100-04 . Accessed September 16 , 2024. www.cms.gov 41. Sneed L, Little S, Akin-Little A. Evaluating the effectiveness of two models of applied behavior analysis in a community-based setting for children with autism spectrum disorder. Behav Anal: Res Pract . 2023;23(4):238-253. doi:10.1037/bar0000277 42. Society guideline links: autism spectrum disorder. Up ToDate. Accessed September 16 , 2024. www.uptodate.com 43. Standards for Telehealth Services, OHIO REV . CODE 4743.09 (2023). 44. State Board of Psychology-Certified Ohio Behavior Analysts, OHIO ADMIN . CODE 4783-1 to 11 (2023). 45. Volkmar F, Siegel M, Woodbury-Smith M, et al.; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. JAm Acad Child Adolesc Psychiatry . 2014;53(2):237-57. doi:10.1016/j.jaac.2013.10.013 46. Weissman L. Autism spectrum disorders in children and adolescents: behavioral and educational interventions . Up ToDate. Updated December 4, 2023. Access ed September 16 , 2024. www.uptodate.com 47. Weissman L. Autism spectrum disorder in children and adolescents: overview of management. Up ToDate. Updated September 8, 2023. Accessed September 16 , 2024. www.uptodate.com 48. Weissman L. Autism spectrum disorder in children and adolescents: pharmacologic interventions. Up ToDate. Updated May 30, 2024 . Accessed September 16 , 2024. www.uptodate.com 49. Weissman L. Autism spectrum disorder in children and adolescents: screening tools. Up ToDate. Updated January 24, 2024. Accessed September 16 , 2024. www.uptodate.com 50. Weissman L. Autism spectrum disorder in children and adolescents: surveillance and screening in primary care. Up ToDate. Updated May 5, 2022. Accessed September 16 , 2024. www.uptodate.com 51. Weissman L, Harris H. Autism spectrum disorder in children and adolescents: complementary and alternative therapies. Up ToDate. Updated June 20, 2022. Accessed September 16 , 2024. www.uptodate.com 52. Wergeland J, Posserud M, Fjermestad K, et al. Early behavioral interventions for children and adolescents with autism spectrum disorder in routine clinical care: a Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.19 systematic review and metaanalysis. Clin Psycho l. 2022;29(4):400-414. doi:10.1037/cps0000106 53. Witwer A, Walton K, Held M. Taking an evidence-based child-and family-centered perspective on early autism intervention. Clin Psychol . 2022;29(4):420-422. doi:10.1037/cps0000122 Approved by Ohio Department of Medicaid 04/01/2025

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