MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Breast Reconstruction Surgery-OH MCD-MM-0001 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 H. References ………………………….. ………………………….. ………………………….. …………………….. 4 Breast Reconstruction Surgery-OH MCD-MM-0001Effective Date: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.A. SubjectBreast Reconstruction Surgery B. BackgroundWith an estimated 27 9,000 new cases yearly, breast cancer continues to be the leading cause of new cancer among women in the United States and a leading cause of cancer death. Breast reconstruction is intended to reduce post-mastectomy complications , es tablish symmetry between the surgical breast and the contralateral breast , and improve quality of life following breast cancer surgery . Breast reconstruction procedures may include breast reduction, breast augmentation with FDA-approved breast implants, nipple reconstruction (inc luding surgery, tattooing, or both) , and breast contouring. Reconstruction may be performed immediately following a mastectomy or can be delayed for weeks or years until the member has undergone radiation, chemotherapy, or decides th at reconstruction is want ed . Breast augmentation with an FDA-approved implant can be performed in one stage ,during which the implant is inserted during the same surgical visit as the mastectomy , or in two stages using an implanted tissue expander in the first stage followed by removal of the expander and insertion of the permanent breast implant. Complications may occur from breast implants immediately postoperatively or years later and can include exposure, extrusion, infection, contracture, rupture, and /or pain. Clinically significant complications may require implant removal. Autologous tissue/muscle breast flap reconstruction is a safe and effective alternative to breast implants. Muscle, subcutaneous tissue, and skin can be transposed from the donor site either locally (eg, latissimus dorsi myocutaneous [LD ] flap, pedicledtransverse rectus abdominus myocutaneous [TRAM ] flap) or distally (eg, free TRAMflap, deep inferior epigastric perforator [DIEP ] flap, superficial inferior epigastric artery perforator [SIEP ] flap, inferior or superior gluteal flap, superior gluteal artery perforator flab, Reubens flap, transverse upper gracilis [TUG ] flap). The choice of procedure can be affected by the members age and health, contralateral breast size and shape, personal preference, and expertise of the surgeon. Individuals may also select non-invasive options , such as mastectomy bras and externalbreast prostheses.C. Definitions Breast Conserving Surgery (Lumpectomy, Partial Mastectomy) Surgical removal of tumor and small amount of surrounding breast tissue. Contralateral Breast Unaffected/nonsurgical breast. Cosmetic Procedures Procedures completed to improve appearance and self – esteem and to reshape normal structures of the body. Mastectomy Surgical remov al of one or both breasts. Breast Reconstruction Surgery-OH MCD-MM-0001Effective Date: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.D. PolicyI. Breast reconstruction is not gender specific. II. Surgical OptionsCareSource considers breast reconstruction medically necessary when ANY of the following clinical indications apply: A. following outlined criteria in MCG S-862 Mastectomy, Complete, with Insertion of Breast Prosthesis or Tissue Expander B. following outlined criteria in MCG S-864 Mastectomy, Complete, with Tissue Flap Reconstruction C. congenital deformities affect ing the members physical and psychological well-being D. severe fibrocystic breast disease that limits the members function E. unintentional trauma or injuries F. complications after breast surgery for non-malignant conditions (eg, pain, irritation, bleeding, discharge, complications causing difficulty with lactation) III. CareSource considers treatment of physical complications , including lymphedema ,following breast reconstruction medically necessary. Please see the Womens Health and Cancer Rights Act (WHCRA) at www.cms.gov for more information. IV. Surgical Exclusions:A. CareSource does not cover any breast reconstruction procedures that are considered experimental, investigational, or unproven. B. CareSource does not cover: 1. procedures that are considered cosmetic in nature, including natural changes due to aging and weight loss/gain 2. lipectomy for donor site symmetry 3. suction lipectomy or ultrasonically assisted suction lipectomy (liposuction) for correction of surgically induced donor site asymmetry (eg, trunk or extremity) that results from one or more flap breast reconstruction procedures V. Non-Surgical AlternativesCareSource covers external breast prostheses and mastectomy bras following mastectomy or breast conserving surgery. All other indications are considered not medically necessary. VI. Breast reconstruction with free flap procedures, regardless of technique, applies to CPT code 19364 .E. Conditions of CoverageNA F. Related Policies/RulesNA Breast Reconstruction Surgery-OH MCD-MM-0001Effective Date: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.G. Review/Revision HistoryDATE ACTIONDate Issued 08/23/2004Date Revised 07/01/2009 07/01/2014 04/17/2015 04/18/2019 04/01/2020 02/17/2021 07/01/2021 03/16/2022 11/09/2022 09/27/2023 10/23/202404/09/202502/11 /2026Updated with more specific criteria . Reviewed criteria .No changes to content. Updated reference dates. Approved at PGC. Added section V, updated background and references. Annual review. Approved at committee. Annual review: updated risk reduction mastectomy and reorganized policy section for clarity. Review : elevated post-lumpectomy criteria, updated risk – reducing mastectomy and references . Approved at Committee. Review: revised section D.II to reference MCG for clarity of all indications. Updated references. Approved at Committee. Date Effective 05/01/2026 Date Archived H. References1. Alder L, Zaidi M, Zeidan B, et al. Advanced breast conservation and partial breast reconstruction a review of current available options for oncoplastic breast surgery. Ann RColl Surg Engl . 2022;104(5):319-323. doi:10.1308/rcsann.2021.0169 2. Breast reconstruction surgery. American Cancer Society . Updated September 19 , 2022 . Accessed January 15, 2026 . www.cancer.org 3. Breast cancer statistics. Centers for Disease Control and Prevention. Accessed January 15, 2026 . www.cdc.gov 4. Centers for Medicare and Medicaid Services. Womens Health and Cancer Rights Act (WHCRA) . Accessed January 15, 2026 . www.cms.gov 5. Colwell AS, Taylor EM. Recent advances in implant-based breast reconstruction. Plast Reconstr Surg . 2020;145(2):421e-432e. doi:10.1097/PRS.0000000000006510 6. Costanzo D, Klinger M, Lisa A, et al . The evolution of autologous breast reconstruction. Breast J . 2020;26(11):2223-2225. doi:10.1111/tbj.14025 7. Friedrich M, Kramer S, Friedrich D, et al. Difficulties of breast reconstruction problems that no one likes to face. Anticancer Res . 2021;41(11):5365-5375. doi:10.21873/anticanres.15349 8. Gradishar WJ, Moran MS, Abraham J, et al . NCCN guidelines insights: breast cancer, version 3.2024 . JNatl Compr Canc Netw . 202 4;22(5):332-357 . doi: 10.6004/jnccn.2024.0035 9. Griffin C, Fairhurst K, Stables I, et al. Outcomes of women undergoing mastectomy for unilateral breast cancer who elect to undergo contralateral mastectomy for Breast Reconstruction Surgery-OH MCD-MM-0001Effective Date: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.symmetry: a systematic review. Ann Surg Oncol . 2024;31(1):303-315. doi:10.1245/s10434-023-14294-6 10. Guliyeva G, Torres RA, Avila FR, et al. The impact of implant-based reconstruction on persistent pain after breast cancer surgery: a systematic review. JPlast Reconstr Aesthet Surg . 2022;75(2):519-527. doi:10.1016/j.bjps.2021.09.079 11. Health technology assessment : c omparative effectiveness review of human acellular dermal matrix for breast reconstruction. Hayes; 2019. Reviewed February 28, 2022. Accessed January 15, 2026 . evidence.hayesinc.com 12. Health technology assessment : a utologous fat grafting for breast reconstruction after breast cancer surgery. Hayes ; 2015 . Review ed November 1 3, 202 3. Accessed January 15, 2026 . evidence.hayesinc.com 13. Mastectomy, Complete, with insertion of breast prosthesis or tissue expander : S-862. MCG Health, 29 th ed. Updated June 13, 2025. Accessed January 14, 2026. careweb.careguidelines.com 14. Mastectomy, Complete, with tissue flap reconstruction : S-864. MCG Health, 29 th ed. Updated June 13, 2025. Accessed January 14, 2026. careweb.careguidelines.com 15. Nahabedian M. Options for autologous flap-based breast reconstruction. UpToDate. Updated April 29, 2024 . Accessed January 15, 2026 . www.uptodate.com 16. Nahabedian M. Overview of breast reconstruction. UpToDate. Updated July 10, 2025 . Accessed January 15, 2026 . www.uptodate.com 17. Pappalardo M, Starnoni M, Franceschini G, et al. Breast cancer-related lymphedema: recent updates on diagnosis, severity and available treatments. JPers Med . 2021;11(5):402. doi:10.3390/jpm11050402 18. Sab el MS. Breast conserving therapy. UpToDate. Updated October 30, 2025 . Accessed January 15, 2026 . www.uptodate.com 19. Saldanha IJ, Cao W, Broyles JM, et al. Breast reconstruction after mastectomy: a systematic review and meta-analysis. Comparative effectiveness review No. 245. (Prepared by the Brown Evidence-based Practice Center under Contract No. 75Q80120D00001.) AHRQ Publication No. 21-EHC027. Rockville, MD: Agency for Healthcare Research and Quality; July 2021. doi.org/10.23970/AHRQEPCCER245. 20. Tomita K, Kubo T. Recent advances in surgical techniques for breast reconstruction. Int JClin Oncol . 2023;28(7):841-846. doi:10.1007/s10147-023-02313-1 21. Toyserkani NM, Jorgensen MG, Tabatabaeifar S, Damsgaard T, Sorensen JA. Autologous versus implant-based breast reconstruction: a systematic review and meta-analysis of Breast-Q patient-reported outcomes. JPlast Reconstr Aesthet Surg . 2020;73(2):278-285. doi:10.1016/j.bjps.2019.09.040 22. Zehra S, Doyle F, Barry M, Walsh S, Kell MR. Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis. Breast Cancer . 2020;27(4):534-566. doi:10.1007/s12282-020-01076-1 Approved ODM 2/17/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Trigger Point Injections-OH MCD-MM-0011 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. … 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. .. 4 H. References ………………………….. ………………………….. ………………………….. …………………. 5 Trigger Point Injections-OH MCD-MM-0011Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectTrigger Point Injections B. BackgroundMyofascial trigger points are self-sustaining hyper-irritative foci in any skeletal muscle, often occurring in response to strain produce d by acute or chronic overload. There is no associated neurologic deficit, and the pain may be aggravated by hyperextension of the spine, standing , and walking. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS) which is responsive to appropriate treatme nt. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor. The purpose of a trigger point injection (TPI) is to treat not only the symptom but also the cause through the injection of a single substance (eg, a local anesthetic) or a mixture of substances (eg, a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Interventional procedures for management of pain should be part of a comprehensive pain management care plan that incorporates an initial trial of conservative treatment utilizing appropriate medications, physical therapy modalities , and behavioral support asneeded.Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers acting within their scope ofpractice who are qualified to deliver these health services.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Physician Supervised Home Exercise Program (HEP) A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. Subacute Pain Pain that has lasted between 4 weeks and 12 weeks. Trigger P oint A hyper excitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. D. PolicyI. Trigger Point Injections Initial Injections A. Trigger point injections of anesthetic and/or corticosteroid for back pain, neck pain , or myofascial pai n syndrome is considered medically necessary when pain has persisted despite appropriate medical management and ALL the following criteria are met: Trigger Point Injections-OH MCD-MM-0011Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 1. Patient presents with new (acute or subacute) localized pain, occurring in the last 3 months . 2. Patient has been refractory or intolerant of conservative therapies for at least 1 month, including at least 1 of the following: a. bed rest b. active exercise c. ultrasound d. range of motion e. heating or cooling treatments f. massage 3. TPIs are being given as a part of an overall conservative management (usually short term) plan, including at least 1 of the following: a. physical therapy b. occupational therapy c. physician supervised home exercise plan (HEP) d. manipulative therapy 4. Pharmacotherapies are being administered, including at least 1 of the following : a. non-steroidal anti-inf lammatory drugs ( NSAIDS ) b. muscle relaxants c. non-narcotic analgesics d. anti-depressants 5. The patient must have a diagnosis for which the trigger point injection is an appropriate treatment . ALL the following information must be documented in the patient’s medical record: a. proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point b. reason (s) for select ing this therapeutic option c. affected muscle or muscles d. muscle or muscles injecte d and the number of injections e. frequency of injections required f. name of the m edication used in the injection g. results of any prior treatment h. corroborating evidence that the injection is medic ally necessary B. Localization techniques to image or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. II. Trigger Point Injections Subsequent InjectionsA. Trigger point injections should be repeated only if doing so is reasonable and medically necessary. No more than 8 dates of service per calendar year per member may be reimbursed . B. Injections may be repeated only with documented positive results to the most recent trigger point injection of the same anatomic site. Documentation should Trigger Point Injections-OH MCD-MM-0011Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 indicate a decrease in pain, improvement in function, and/or increase in activity tolerance .III. There is no laboratory or imaging test for establishing the diagnosis of trigger points .Diagnosis is dependent upon a detailed history and a thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis: A. history of onset and its cause (injury, sprain, etc.) B. distribution of pain C. restriction of movement D. mild muscle specific weakness E. focal tenderness of a trigger point F. palpable taut band of muscle in which trigger point is located G. local taut respo nse to snapping palpitation H. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point IV. Payment InformationA. Certain trigger point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. B. Payment may be made for 1 unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a particular date. C. A trigger point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (eg, in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. D. Dry needling is not an acceptable alternative to trigger point injections by an appropriately licensed clinician. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/10/2015Date Revised 03/06/2019 06/10/2020 Annual Update: No changesAnnual Update: Prior authorization is now required; removal of payment information defer policy PY-1100. Trigger Point Injections-OH MCD-MM-0011Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 09/01/202105/26/202104/12 /202203/29/202302/28/202402/12/202501 /14 /2026Revisions include: such as was changed to ONE of the following : I. B. 2. and 3. Annual Update: Removed PA language. Annual Review; updated references, formatting, separated criteria into initial and subsequent injections, added active conservative therapy options Annual review: updated references, added definition and payment information. Approved at Committee Annual review: editorial changes, updated references, approved at Committee Review: updated references, approved at Committee. Review: updated references. App roved at Committee. Date Effective 05/01/2026 Date Archived H. References1. Appasamy M, Lam C, Alm J, et al . Trigger point injections. Phys Med Rehabil Clin N Am . 2022;33(2):307-333. doi:10.1016/j.pmr.2022.01.011 2. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate . Updated April 29 , 202 5. Accessed December 12 , 202 5. www.uptodate.com 3. Hammi C, Schroader JD, Yeung B. Trigger point injection. StatPearls . StatPearls Publishing; 2024. Updated July 24, 2023. Accessed December 12 , 202 5. www.ncbi.nlm.nih.gov 4. Hamzoian H, Zograbyan V. Trigger point injections versus medical management for acute myofascial pain: a systematic review and meta-analysis. Cureus. 2023;15(8):e43424. doi:10.7759/cureus.43424 5. Immunizations, Injections and Infusions ( Including Trigger-Point Injections), Skin Substitutes, and Provider-Administered Pharmaceuticals , OHIO ADMIN CODE 5160-4- 12 (2022). 6. Isaac Z. Management of non-radicular neck pain in adults. UpToDate . Updated Deptember 30, 2025 . Accessed December 12 , 202 5. www.uptodate.com 7. Khoury AL, Keane H, Varghese F, et al. Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief. NPJ Breast Cancer . 2021;7:123. doi:10.1038/s41523-021-00321-w 8. Meyer GW. Anterior cutaneous nerve entrapment syndrome. UpToDate . Updated February 14, 2025 . Accessed December 12 , 202 5. www.uptodate.com 9. Moynihan LK, Elkadry E. Myofascial pelvic pain syndrome in females: treatment. UpToDate. Updated January 11, 2023 . Accessed December 12 , 202 5. www.uptodate.com 10. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate . Updated September 4, 2025 . Accessed December 12 , 202 5. www.uptodate .com Independent Medical Review January 2025ODM Approved 02 /11/2026
MEDICAL POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 5 H. References ………………………….. ………………………….. ………………………….. …………………….. 5 Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPeripheral Nerve Blocks for Treatment of Pain B. BackgroundPeripheral n erve blocks are injection s of medication into a specific area of the body where nerves cause pain to a specific organ or body region . Nerve block s cause the temporary interruption of impulse conduction in peripheral nerves or nerve trunks and may or may not contain a steroid , which can be used to treat pain. Various areas of pain require different types of nerve blocks that can be administered in numerous parts of the body , with some of the most common blocks being sympathetic, peripheral , and occipital. Sacroiliac and facet j oint interventions , epidural steroid injections , and trigger pointinjections are addressed in other policies.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Ambulatory Surgery Surgery performed in a hospital-based or freestanding ambulatory surgery center (ASC) with patient discharge the same day . Chronic Pain Pain lasting more than 3 months, which is considered beyond normal healing time. Conservative Therapy A multimodality plan of care including both active and inactive conservative therapies . o Active Conservative Therapies Action or activit ies that strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational therapy, a physician-supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion , or documentation of the inability to complete HEP due to a stated physical reason (ie , increased pain, inability to physically perform exercise). Patient inconvenience and/or noncompliance without explanation does not constitute an inability to complete . o Inactive Conservative Therapies Passive activities that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, acupuncture, a TENS device, and/or pharmacotherapy (prescription or over the counter [non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins . Its u se, frequency, duration, and start dates must be documented in the medical record. Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Emergent Medically necessary care, which is immediately needed to preserve life,prevent serious impairment to bodily functions, organs, or parts, or prevent placing the physical or mental health of a patient in serious jeopardy. Low-Risk Procedure Procedures associated with minimal physiologic effect and excludes any intrathoracic, intra-abdominal, vascular, or orthopedic procedures. Sub-Acute Pain Pain lasting between 4 to 12 weeks. D. PolicyI. CareS ource considers p eripheral nerve blocks (PNB) , single injection , medically necessary when appropriate documentation for the treatment of acute pain or chronic pain are included , only as part of an active component of a comprehensive pain management program . CareSource uses MCG Health guidelines to address criteria for specific nerve blocks. Documentation must include indications that ALL the following criteria are met: A. PNB is performed as an a mbulatory or outpatient procedure that (1) is not treating an emergent condition, (2) is a low risk procedure , and (3) requires no inpatient care for a preoperative disease or condition (eg, altered mental status , hypotension, hypoxemia, tachycardia) . B. Acute, sub-acute or c hronic, neuropathic or radicular pain, as indicated by ONE or more of the following: 1. cancer-related pain 2. Complex regional pain syndrome (CRPS) 3. peripheral neuropathy with pain that limits activit ies of daily living , e xcluding diabetic neuropathy 4. peripheral vascular disease with rest pain 5. acute herpes zoster of face or neck and prevention of postherpetic neuralgia 6. pancreatic pain, pelvic pain, or abdominal pain related to malignancy 7. chronic, relapsing pancreatitis C. Symptoms poorly controlled by maximum medical therapy or intolerable side effects to such therapy D. Failure of non-invasive treatment (s) (eg, non-steroidal anti-inflammatory drugs (NSAIDs), exercise, physical therapy, spinal manipulation therapy) E. No coagulopathy or thrombocytopenia F. No infection at or underlying the injection site II. Acute or Sub-Acute PainPNB may provide means of analgesia for acute pain in the following (not an all – inclusive list): A. Patients at risk of respiratory depression related to systemic or neuraxial opioids (eg, obstructive sleep apnea, severe obesity, underlying pulmonary disease, advanced age) . B. Patients with another indication to minimize opioid use (eg, chronic opioid use, intolerance to opioids) . C. Patients with acute, severe pain poorly managed with systemic medication . Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 D. Patients who cannot tolerate chiropractic or other physical and/or manipulative therapies . III. Chronic PainCareSource considers PNB , single injection, medically necessary when appropriate documentation for the treatment of chronic pain is included, only as part of an active component of a comprehensive pain management program when the re has been a failure of conservative therapy, as evidenced by ALL the following: A. Documentation in the medical record of at least 6 weeks of active conservative therapy within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance. B. Documentation in the medical record of at least 6 weeks inactive conservative therapy within the past 6 months. Insufficient evidence support s the following use s of PNB for chronic pain and is notconsidered medically necessary:A. Genicular nerve or branches for chronic knee pain. B. Cluneal nerve injections or blocks for chronic low back pain or pelvic pain. C. Pudendal blocks for chronic pelvic pain conditions. IV. Radiofrequency Ablation (RFA) or NeurotomyRadiofrequency ablation and/or neurotomy are considered experimental and investigational , or unproven for any indication, including but not limited to the treatment of acute or chronic pain due to insufficient evidence of efficacy in the peer reviewed literature. V. Limitations and ExclusionsA. A member can receive a maximum of 6 injections in a rolling 12 month period .B. Up to 2 anatomic sites (eg, specific nerve, plexus, or branch as defined by CPT code descripti on) can be injected at any one session . C. Nerve blocks used as part of a surgical procedure or other medical procedure are not separately reimbursable but an inclusive component of that procedure . These injections will not be compensated separately or unbundled for coverage. D. Any procedure submitted for payment with an incorrect CPT code or description will be denied. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provide d. If requesting a block to a specific part of the body, coding to the highest level of specificity should be used. E. Exclusions 1. Treatment of peripheral neuropathy due to diabetes. 2. Use of nerve blocks with or without use of electrostimulation for treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases. Medical management using systemic medications is clinically indicated for the treatment of these conditions. Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 E. Conditions of Coverage Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers within their scope of practice who are qualified to deliver these health services . F. Related Policies/RulesEpidural Steroid Injections Experimental or Investigational Item or Service Facet Joint Interventions Sacroiliac Joint Procedures Trigger Point Injections G. Review/Revision HistoryDATE ACTIONDate Issued 10/01/2022Date Revised 02/15/2023 02/28/202402/26/202501/28/2026 Annual review. Changed conservative therapy from 6 months in past 12 months to 6 weeks in past 6 months. Annual review-editorial changes ; Approved at Committee Annual review-references updated. Approved at Committee. Annual review, approved at Committee. Date Effective 05/01/2026 Date Archived H. References1. Ailani J, Burch RC, Robbins MS; American Headache Society. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache . 2021;61(7):1021-1039. doi:10.1111/head.14153 2. Allen SM, Mookadam F, Cha SS, et al. Greater occipital nerve block for acute treatment of migraine headache: a large retrospective cohort study. JAm Board Fam Med . 2018;31(2):211-218. doi:10.3122/jabfm.2018.02.170188 3. American Headache Society. AHS consensus statement: The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache . 2019;59(1):1-18. doi:10.1111/head.13456 4. Antolak S, Antolak C, Lendway L. Measuring the quality of pudendal nerve perineural injections. Pain Physician . 2016;19:299-306. Accessed January 13, 2026 . www.pubmed.ncbi.nlm.nih.gov 5. Caponnetto V, Ornello R, Frattale I, et al. Efficacy and safety of greater occipital nerve block for the treatment of cervicogenic headache: a systematic review. Expert Rev Neurotherapeutics . 2021; 21(5):591-597. doi:10.1080/14737175.2021.1903320 6. Chang A, Dua A, Singh K, et al . Peripheral nerve blocks. StatPearls . StatPearls Publishing; 202 5. Accessed January 13, 2026 . www.ncbi.nlm.nih.gov Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 7. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated April 29, 2025 . Accessed January 12, 2026 . www.uptodate.com8. Dowell D, Ragan KR, Jones CM, et al . CDC clinical practice guideline for prescribing opioids for pain. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1 9. Evidence Analysis Research Brief: Genitofemoral Nerve Block or Ablation for Treatment of Groin Pain. Hayes; 2024. Accessed January 13, 2026 . www.evidence.hayesinc.com 10. Evidence Analysis Research Brief: Local Injection Therapy for Cervicogenic Headache and Occipital Neuralgia. Hayes; 2023. Accessed January 13, 2026 , 2025. www.evidence.hayesinc.com 11. Evidence Analysis Research Brief: Peripheral Nerve Stimulation for the Treatment of Superior Cluneal Neuralgia. Hayes; 2024. Accessed January 13, 2026 . www.evidence.hayesinc.com 12. Evidence Analysis Research Brief: Radiofrequency Ablation of Cluneal Nerve for Treatment of Chronic Low Back Pain. Hayes; 2023. Accessed January 13, 2026 . 13. Evolving Evidence Review: Middle Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2022. Reviewed February 7, 2025. Accessed January 13, 2026 . www.evidence.hayesinc.com 14. Evolving Evidence Review: Percutaneous Conventional Radiofrequency Ablation of Medial Branch Nerve(s) for Treatment of Thoracic Spinal Pain. Hayes; 2025. Accessed January 13, 2026. www.evidence.hayesinc.com 15. Evolving Evidence Review: Pulsed Radiofrequency for the Treatment of Pudendal Neuralgia. Hayes; 2024. Reviewed November 13, 2025. Accessed January 13, 2026. www.evidence.hayesinc.com 16. Evolving Evidence Review: Superior Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2021. Reviewed December 18, 2024. Accessed January 13, 2026 . www.evidence.hayesinc.com 17. Frank FT, Sawsan A. Chronic pelvic pain in adult females: treatment. UpToDate. Updated August 16, 2024. Accessed January 13, 2026 . www.uptodate.com 18. Garza I. Occipital neuralgia. UpToDate. Updated March 3, 2025 . Accessed January 13, 2026 . www.uptodate.com 19. Garza I, Schwedt TJ. Chronic migraine. UpToDate. Updated October 3, 2024. Accessed January 13, 2026 . www.uptodate.com 20. Gautam S, Gupta N, Khuba S, et al. Evaluation of the efficacy of superior cluneal nerve block in low back pain: a prospective observational study. JBodyw Mov Ther . 2022;30:221-225. doi:10.1016/j.jbmt.2022.03.001 21. Headaches in Over 12s: Diagnosis and Management . National Institute for Excellence; 20 21 . NICE Guideline No 150 . Updated June 3, 2025. Accessed January 13, 2026 . www.nice.org 22. Health Technology Assessment: Cooled or Pulsed Radiofrequency for Chronic Low Back Pain Arising From the Sacroiliac Joint. Hayes; 2022. Reviewed December 10, 2024. Accessed January 13, 2026. www.evidence.hayesinc.com Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 23. Health Technology Assessment: Genicular Nerve Block for the Treatment of KneeOsteoarthritis. Hayes; 2023. Reviewed December 4, 2025 . Accessed January 13, 2026 . www.evidence.hayesinc.com 24. Health Technology Assessment: Greater Occipital Nerve Blocks for Treatment of Migraine. Hayes; 2019. Reviewed October 10, 2022. Accessed January 13, 2026 . www.evidence.hayesinc.com 25. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain. Hayes; 2021. Reviewed April 17, 2024. Accessed January 13, 2026 . www.evidence.hayesinc.com 26. Health Technology Assessment: Pulsed Radiofrequency for Treatment of Chronic Shoulder Pain. Hayes; 2022. Reviewed September 16, 2025. Accessed January 13, 2026. www.evidence.hayesinc.com 27. Health Technology Assessment: Radiofrequency Nerve Ablation for the Management of Osteoarthritis of the Knee. Hayes; 2020. Reviewed December 28, 2023. Accessed January 13, 2026. www.evidence.hayesinc.com 28. Hui J, Seko K, Shrikhande G, et al. A novel, nonopiod-based treatment approach to men with urologic chronic pelvic pain syndrome using ultrasound-guided nerve hydrodissection and pelvic floor musculature trigger point injections. Neurourol Urodyn . 2020;39(2):658-664. doi:10.1002/nau.24242 29. Inan L, Inan N, Unal-Artik H, et al. Greater occipital nerve block in migraine prophylaxis: narrative review. Cephalalgia . 2019;39:908-920. doi:10.1177/0333102418821669 30. Isu T, Kim K, Morimoto D, et al . Superior and middle cluneal nerve entrapment as a cause of low back pain. Neurospine . 2018;15(1):25-32. doi:10.14245/ns.1836024.012 31. Jeng C, Rosenblatt M. Overview of peripheral nerve blocks. UpToDate. Updated July 30, 2025 . Accessed January 13, 2026 . www.uptodate.com 32. Matsumoto J, Isu T, Kim K, et al. Middle cluneal nerve entrapment mimics sacroiliac joint pain. Acta Neurochir (Wien) . 2019;161(4):657-661. doi:10.1007/s00701-019 – 03861-0 33. Mustafa A, Brooks B, Leishear K, et al. A novel treatment approach for women with chronic pelvic pain syndrome leading to increased pelvic functionality. JWomens Health Gyn . 2020;7:1-10. doi:10.17303/jwhg.2020.7.402 34. Nielsen TD, Moriggl B, Barckman J, et al. Randomized trial of ultrasound-guided superior cluneal nerve block. Reg Anesth Pain Med . 2019;44:772-780. doi:10.1136/rapm-2018-100174 35. Ornello R, Lambru G, Caponnetto V, et al. Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic review and meta – analysis. Expert Rev Neurotherapeutics . 2020;20(11):1157-1167. doi:10.1080/14737175.2020.1809379 36. Plavnik K, Tenaglia A, Hill C, et al. A novel, non-opioid treatment for chronic pelvic pain in women with previously treated endometriosis utilizing pelvic-floor musculature trigger-point injections and peripheral nerve hydrodissection. PM R . 2020;12(7):655 – 662. doi:10.1002/pmrj.12258 Peripheral Nerve Blocks for Treatment of Pain-OH MCD-MM-1230Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 37. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on chronic pain management and theAmerican Society of Regional Anesthesia and Pain Medicine. Anesthesiology . 2010;112(4):810-833. doi:10.1097/ALN.0b013e3181c43103 38. Shauly O, Gould DJ, Sahai-Srivastava S, et al. Greater occipital nerve block for the treatment of chronic migraine headaches: a systematic review and meta-analysis. Plast Reconstr Surg . 2019;144(4):943-952. doi:10.1097/PRS.0000006059 39. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: evaluation. UpToDate. Updated September 11, 2025 . Accessed January 13, 2026 . www.uptodate.com 40. Watson JC. Cervicogenic headache. UpToDate. Updated September 9, 2025 . Accessed January 13, 2026 . www.uptodate.com 41. Wray JK, Dixon B, Przkora R. Radiofrequency ablation. StatPearls . StatPearls Publishing; 2025. Accessed January 13, 2026 . www.ncbi.nlm.nih.gov Approved by ODM 02/04/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Sacroiliac Joint Procedures-OH MCD-MM-0010 04/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Polices/Rules ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectSacroiliac Joint Procedures B. BackgroundNearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent. Persistent pain is categorized as subacute when lasting between four and twelve weeks , and chronic when persisting for at least three months. Up to 10% to 30 % of patients with persistent low back pain may have a component ofpain related to sacroiliac joints (SIJ) . Comprehensive pain management care plans are most effective in managing a patients chronic pain. These plans focus on a person – centered approach and incorporate conservative treatment with other modalities. These multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a pat ients daily life, even if the pain cannot be relieved completely. In addition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic tre atments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be effective for diagnostic purposes but provide limited short-term relief from pain resulting from SI Jdysfunction. Long-term use has not be en adequately studied to establish standards of care. Radiofrequency ablation (RFA) is another treatment method, which uses heat to destroy nerves. RFA for the treatment of low back pain has inconsistent results in the peer-reviewed medical literature with limited fol low – up. However, clinical experience suggests that some patients obtain more significant relief from these procedures, making it reasonable to offer SIJ injections and/or RFA when conservative management has failed. C. Definitions Conservative Therapy A multimodality plan of care includ ing both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational therapy, physician supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Inactive Conservative Therapies Passive activities that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS unit, and/or pharmacotherapy (prescription or over the counter [non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphin s. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. Sacroiliac Joint (SIJ) Injections Corticosteroid and local anesthetic therapeutic injections into the SIJ to treat pain that hasnt responded to conservative therapies. Functional Disability Acquired difficulty in performing basic everyday tasks or more complex tasks needed for independent living. D. PolicyI. Sacroiliac Joint Injections A. Diagnostic i njections: CareSource considers up to 2 diagnostic SIJ injection s for the treatment of chronic low back pain medically necessary when ALL the following criteria are met: 1. somatic or nonradicular low back and lower extremity pain experienced for at least 3 months 2. severe pain (ie. at least a 6 out of 10 on pain scale) and tenderness are located in SIJ region and cause functional disability 3. positive response to at least 3 SIJ pain provocation test (eg, distraction, compression, thigh thrust, Gaenslens, Patricks test/FABER test, sacral thrust) 4. failure of conservative therapy, as evidenced by ALL the following: a. documentation in the medical record of a t least 6 weeks of active conservative therapy (as defined above ) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance b. documentation in the medical record of a t least 6 weeks of inactive conservative therapy ( as defined above ) within the past 6 months 5. If a second diagnostic injection is requested, at least 1 week has passed since the initial injection. B. Therapeutic i njections : CareSource considers therapeutic SIJ injections medically necessary when ALL the following criteria are met: 1. previous SIJ injection led to significant functional pain relief as measured by a decrease in pain level (demonstrated on a qualitative pain scale), decrease in pain medications, and/or increase in physical function Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 2. member experiences return of severe pain or deterioration in function3. injection is used in conjunction with conservative therapy (as defined above) 4. injections should not be repeated more frequently than every 2 months 5. no more than 4 injections total ( diagnostic and therapeutic ) have been administered at the same site the last 12 months C. Exclusions/Limitations: 1. Codes 64451 and 27096 may not be billed together (on the same date for the same side of the body). Only one code will be reimbursed . 2. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately. 3. If neural blockade is applied for different regions or different sides, injections are performed at least one week apart. 4. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated injections of the SI Jto be effective as a long-term management modality. Long-term continuation may be subject to medical necessity review. 5. Monitored anesthesia and conscious sedation are not medically necessary. 6. The use of SI Jinjections for the treatment of pain as a result of Herpes Zoster is not indicated due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. II. Radiofrequency Ablation of the SIJA. Initial radiofrequency ablation of the SI J 1. Radiofrequency ablation is considered medically necessary when ALL the foll owing have been met in the last 6 month s: a. The clinical criter ia above for failed conservative therapy (I.A. 4.a. and I.A.4. b.) has been met . b. One diagnostic injection per joint to evaluate pain and attain therapeutic effect has been performed , with significant functional pain relief as measured by a decrease in pain level (demonstrated on a qualitative pain scale), decrease in pain medications, and/or increase in physical function . B. Repeat radiofrequency ablation of the SI J 1. Conservative therapy and diagnostic injections are not required if there has been a reduction in pain for at least 12 months or more from the initial RFA within the last 36 months. 2. When there has not been a repeat RFA in the last 36 months, a diagnostic injection is required. 3. A maximum of 1 RFA for SI Jpain per side per rolling 12 months is considered medically necessary. C. Exclusions/Limitations 1. Codes 64451 and 27096 are considered the same procedure and may not be billed together. Only one code will be reimbursed. Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 2. The use of cooled RFA for SI J-mediated low back pain is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. 3. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated the effectiveness of RFA as a long-term management modality. Long-term continuation may be subject to medical necessity review. III. Implantable Spinal Cord StimulatorsPatients with indwelling implanted spinal cord stimulators or pain pumps should have a device interrogation report submitted with medical records for a prior authorization request for proposed interventional pain injections. If a device is not functioning properly, an escalation in pain may warrant evaluation and management of the implanted device. E. Conditions of CoverageNA F. Related Polices/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/10/2015 New PolicyDate Revised 07/28/2015 07/26/2016 02/08/2018 03/06/2019 10/8/201905/13/202004/28/202103/29/202203/01 /202301/31 /202401/29/2025Removed Herpes CriteriaAnnual Update: Removed start and end dates. Addition of PA clarification and documentation requirements. Revision of injection frequency. Removed joint fusion denial language. This service will be addressed in the Sacroiliac Joint Fusion policy. Annual Update: Added clinical criteria for coverage of radiofrequency ablation of the SI Joint. Added coding information. Annual Update: Removed PA language. Annual Review: Updated background and references, re – organized criteria into initial and subsequent procedures, type of procedure. Annual Review: restructured conservative management and clinical criteria, added provocation tests Annual review: updated formatting and references, approved at Committee. Review: updated references, approved at Committee Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 12/17 /2025 Review: added pain level criteria, increased number of positive provocation test positives and updated references . Approved at Committee. Date Effective 04/01/2026 Date Archived H. References1. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med . 2017;166(7):493-505. doi:10.7326/M16-2459 2. Chou R, Cohen SP. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated April 29 , 202 5. Accessed November 24 , 2025 . www.uptodate.com 3. Cine HS, Uysal E, Demirkol M, Cetin E. Under what conditions is the intra-articular steroid injection superior to nonsteroidal anti-inflammatory drugs for treating sacroiliac joint pain? Eur Rev Med Pharmacol Sci . 2023;27(21):10539-10546. doi:10.26355/eurrev_202311_34331 4. Immunizations, injections and infusions ( including trigger-point injections), skin substitutes, and provider-administered pharmaceuticals , OHIO ADMIN . CODE 5160-4- 12 (2022 ). 5. Jamjoom AM, Saeedi RJ, Jamjoom AB. Placebo effect of sham spine procedures in chronic low back pain: a systematic review. JPain Res . 2021;14:3057-3065. doi:10.2147/JPR.S317697 6. Janapala RN, Knezevic E, Knezevic NN, et al. Systematic review and meta-analysis of effectiveness of therapeutic sacroilic joint injections. Pain Phys ician . 2023;26:E413-E435. Accessed November 24 , 2025 . www.painphysicianjournal.com 7. Lee DW, Pritzlaff S, Jung MJ, et al. Latest evidence-based application for radiofreq uen cy neurotomy (LEARN): best practice guidelines from the American Society of Pain and Neuroscience (ASPN). JPain Res . 2021;14:2807-2831. doi:10.2147/JPR.S235665 8. Liu Y, Suvithayasiri S, Kim JS. Comparative efficacy of clinical interventions for sacroiliac joint pain: systematic review and network meta-analysis with preliminary design of treatment algorithm. Neurospine . 2023 Sep;20(3):997-1010. doi: 10.14245/ns.2346586.293. 9. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint inerventions 2020 guidelines. Pain Phys ician . 2020;23(3S):S1-S127. Accessed November 24 , 2025 . www.painphysicianjournal.com 10. Sacroiliac Joint Injection: A-1048 (AC). MCG. 29 th ed. Updated June 23, 2025. Accessed December 1, 2025. www.careweb.careguidelines.com 11. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 12. Stevens AC, Carroll DD, Courtney-Long EA, et al. Adults with one or more functional disabilisties United States, 2011-2014. MMWR Morb Mortal Wkly Rep Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 2016;65:1021-1025. doi:10.15585/mmwr.mm6538a113. Szadek K, Cohen SP, de Andres Ares J, et al. Sacroiliac joint pain. Pain Pract. 2023 ;00:1-20. doi:10.1111/papr.13338 14. Wu L, Tafti D, Varacallo M. Sacroiliac joint injection. StatPearls . StatPearls Publishing; 2023. Updated August 4, 2023. Accessed November 24, 2025 . Independent Medical Review January 2025Approved by ODM 01/08/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Neonatal Discharge Criteria-OH MCD-MM-1229 04/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Neonatal Discharge Criteria-OH MCD-MM-1229Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNeonatal Discharge Criteria B. BackgroundInfants who require neonatal admission remain at increased risk for morbidity and mortality following discharge. These infants require comprehensive discharge planning to ensure a smooth transition from the neonatal intensive care unit (NICU) and reduce mo rbidity and mortality after discharge. Despite the inability to predict the exact timing of a NICU discharge, discharge planning should begin at NICU admission in an effort to avoid overwhelming parents and hospital staff. This planning will aid in minimizing discharge delays and will promote s afe andhealthy discharges to home.Discharge may be appropriate when the establishment of physiologic competencies, including, but not limited to, thermoregulation, feeding, respiratory control, and stability regardless of weight or corrected gestational age, have been achieved.C. Definitions Acceptable Bilirubin Level Defined per American Academy of Pediatrics (AAP) guidelines. Bilirubin Blood test to measure liver function. Car Seat Test Eligibility An infant tolerance test for sitting usually occurring 36.4 Caxillary while clothed in an open bed/crib. D. PolicyI. CareSource considers neonatal discharge medically appropriate for non-technology dependent infants when ALL of the following clinical criteria are met: A. Thermoregulation Stability 1. Infant demonstrates the ability to maintain normal body temperature while clothed in an open crib. Up to 48 hours of stable body temperature is typically adequate for infants born
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295 04/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectIntraosseous Basivertebral Nerve Ablation B. BackgroundInterventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self – manag ement and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualifie d to deliver these health services. Chronic low back pain (CLBP) is a common disabling condition, estimated to afflict 80%of adults at some point. Degenerative disc disease (DDD) is an important cause ofCLBP. While discs are avascular with limited nerve distribution, vertebral endplates have the potential to trigger a cascade of degenerative events if there is a loss of integrity. Vertebral endplates are a thin interface between bone marrow and discs and contain neural elements. Breakdown of the endplate is believed to cause v ertebrogenic chronic low back pain , a type of chronic low back pain . Endplate degeneration can be observed on MRI through Modic changes (MC). Histologically in MC type I (MC I) lesions, the endplate is disrupted as fibrous tissuereplaces bone marrow causing the disc-bone interface to be filled with vascularized granulation tissue. MC I represents bone marrow edema and inflammation. In MC t ype II (MC II) lesions, there is demonstration of fatty marrow replacement in addition to MC type I findings. MC II represents conversion of hematopoietic marrow into fatty, yellow bone marrow. MC type III (MC III) lesions are related to subchondral bone sclero sis. Analysis of Modic lesion s shows that MC I is characterized by high bone turnover, MC II is characterized by decreased bone turnover, and MC III are stable. Radiofrequency ablation (RFA) is a minimally invasive, percutaneous treatment which uses heat to ablate the nerve pathway that conducts the pain signal. The goal of RFA is to interrupt the pain pathway without causing excessive sensory loss, motor dysfunct ion,or other complications. Intracept is an RFA system designed to ablate the basivertebral nerve of the vertebral endplate. C. Definitions Chronic Low Back Pain Persistent pain in the lumbar region lasting for more than 12 weeks. Conservative Therapy A multimodality plan of care including both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen muscle groups and target key spinal structures, including physical therapy, occupational Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 therapy, physician supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS u se , acupuncture, and/or pharmacotherapy (prescription or over the counter [eg, non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorph ins. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Modic Changes Vertebral bone marrow signal intensity changes that are observable on MRI and are commonly associated with degenerative disc disease. o Modic Change Type I Characterized by hypo-and hyper-intense signal intensities on T1-and T2-weighted spin-echo (T1W1 and T2W1), respectively. o Modic Change Type II Characterized by hyper-intense signal intensities on both T1W1 and T2W1. o Modic Change Type III Characterized by hypo-intense signal intensities on both T1W1 and T2W1. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial or lateral branches of the dorsal spinal nerves. D. PolicyI. CareSource considers intraosseous basivertebral nerve ablation medically necessary when ALL the following clinical criteria are met: A. Member has a diagnosis and documentation of chronic low back pain of at least 6 months duration . B. Failure of conservative therapy, as evidenced by ALL the following: 1. documentation in the medical record of at least 6 weeks of active conservative therapy (see definition above) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance 2. documentation in the medical record of at least 6 weeks of inactive conservative therapy (see definition above) within the past 6 months C. MRI demonstrates Type I or Type II mo dic changes at one or more vertebra l endplates from level L3 to S1 , as demonstrated by Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 1. hypointense T1-weighted signal and hyperintense T2-weighted signal (ie,bone marrow edema and inflammation) , or 2. hyperintense T1-weighted signal and hyperintense T2-weighted signal (ie, bone marrow ischemia) D. Device is FDA-approved (eg, Intracept System) . E. Member does not have any of the following contraindications: 1. severe cardiac or pulmonary compromise 2. targeted ablation zone less than 10mm from a sensitive structure not intended to be ablated (including vertebral foramen) 3. active systemic infection or localized infection in the area to be treated 4. member is currently pregnant 5. skeletal immaturity 6. implantable pulse generator (eg, pacemaker, defibrillator) or other electronic implant 7. scoliosis 8. spinal instability II. Repeat or additional intraosseous basivertebral nerve ablation is not considered medically necessary, as it has not been adequately studied in the peer-reviewed medical literature. III. Monitored anesthesia and conscious sedation during intraosseous basivertebral nerve ablation are considered not medically necessary and will therefore not be reimbursed.IV. Coverage is limited to the above criteria. Intraosseous basivertebral nerve ablation is considered not medically necessary for all other indications.E. Conditions of Coverage NA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/30/2022 New PolicyDate Revised 03/01/2023 01/31/202401/29 /202512/17 /2025 Annual review: restructured conservative therapy, added HEP and TENS to definitions . Annual review: updated references. Approved at Committee Review: updated references, approved at Committee. Review: updated references. Approved at Committee. Date Effective 04/01/2026 Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 Date ArchivedH. References1. Evidence Ba sed Clinical Guidelines for Multidisciplinary Spine Care : Diagnosis and Tr eatment of Low Back Pain . North American Spine Society ; 2020 . Accessed December 2, 2025. www.spine.org 2. Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: a prospective randomized double-blind sham-controlled multi-center study. Euro Spine J. 2018;27:1146-1156. doi:10.1007/s00586-018-5496-1 3. Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 2-year results from a prospective randomized double-blind sham-controlled multicenter study. Int JSpine Surg. 2019;13(2):110-119 . doi:10.14444/6015 4. Fischgrund JS, Rhyne A, Macadaeg K, et al. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham – controlled multi-cent er study. Eur Spine J. 2020;29:1925-1934. doi:10.1007/s00586 – 020-06448-x 5. Health Technology Assessment: Intracept Intraosseous Nerve Ablation System (Relievant Medsystems Inc.) for Treatment of Adults with Low Back Pain. Hayes; 2025. Reviewed November 20, 2025. Accessed December 2, 2025. www.evidence.hayesinc.com 6. Khalil JG, Smuck M, Koreckij T, et al. A prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J. 2019:1620-1632. doi:10.1016/j.spinee.2019.05.598 7. Lorio M, Clerk-Lamalice O, Beall DP, Julien T. ISASS guideline : intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain. Int JSpine Surg . 2020;14(1):18-25. doi:10.14444/7002 8. Lorio M, Clerk-Lamalice O, Rivera M, Lewandrowski K. ISASS policy statement 2022: literature review of intraosseous basivertebral nerve ablation. Int JSpine Surg. 2022;16(6):1084-1094. doi:10.14444/8362 9. McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain-related healthcare utilization following intraosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. Pain Med . 2024;25:20-32. doi:10.1093/pm/pnad114 10. Nwosu M, Agyeman WY, Bisht A, et al. The effectiveness of intraosseous basivertebral nerve ablation in the treatment of nonradiating vertebrogenic pain: a systematic review. Cureus . 2023;15(4):e37114. doi:7759/cureus.37114 11. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 12. Sayed D, Naidu RK, Patel KV, et al. Best practice guidelines on the diagnosis and treatment of vertebrogenic pain and basivertebral nerve ablation from the American Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 Society of Pain and Neuroscience. JPain Res . 2022;15:2801-2819. doi:10.2147/JPR.S378544 13. Smuck M, Khalil J, Barrette K, et al. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month result. Reg Anesth Pain Med. 2021;46:683-693. doi:10.1136/rapm-2020 – 102259 14. Smuck M, McCormick ZL, Gilligan C, et al. A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J . 2024;S1529-9430(24)01040-4. doi:10.1016/j.spinee.2024.09.016 15. U.S. Food and Drug Administration. 510(k) Premarket Notification: Intracept Intraosseous Nerve Ablation System , 510( k) approval K 222281; 2022. Accessed December 2, 202 5. www.accessdata.fda.gov 16. U.S. Food and Drug Administration. 510(k) Premarket Notification: Relievant Medsystems RF Generator , 510( k) number: K171143; 201 7. Accessed December 2, 202 5. www.accessdata.fda.gov 17. Viswanathan VK, Shetty AP, Rajasekaran S. Modic changes an evidence-based, narrative review on its pathophysiology, clinical significance and role in chronic low back pain. JClin Orthop Trauma . 2020;11(5):761-769. doi:10.1016/j.jcot.2020.06.025 Independent med ical review March 2022 Approved by ODM 01/07/ 2026
MEDICAL POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Medical Interventions for Gender Dysphoria-OH MCD-MM-0034 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject …………………………………………………………………………………………………………….. 2 B. Background………………………………………………………………………………………………………. 2 C. Definitions ………………………………………………………………………………………………………… 2 D. Policy ………………………………………………………………………………………………………………. 3 E. Conditions Of Coverage ……………………………………………………………………………………… 4 F. Related Policies/Rules ……………………………………………………………………………………….. 4 G. Review/Revision History …………………………………………………………………………………….. 4 H. References ………………………………………………………………………………………………………. 4 02/07/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 2 Medical Interventions for Gender Dysphoria-OH MCD-MM-0034 Effective Date: 02/07/2026A.SubjectMedical Interventions for Gender DysphoriaB.BackgroundState Medicaid programs have a responsibility to ensure that payments are consistent with efficiency, economy, and quality of care under Section 1902(a)(30)(A) of the Social Security Act. Section 1902(a)(19) requires that states provide such safeguards as may be necessary to ensure that covered care and services are provided in a manner consistent with the best interests of recipients. Agencies have a basic obligation to ensure the quality of Medicaid-covered care and that such care is provided in a manner consistent with the best interest of beneficiaries.Federal matching funds may not be claimed for any sterilization procedure performed on an individual under age 21, 42 C.F.R 441.253(a). Specifically, federal financial participation is unavailable for any procedure, treatment or operation done for the purpose of permanently rendering an individual incapable of reproducing, 42 C.F.R. 441.251. Additionally, 42 C.F.R. 441.255(a) prohibits financial federal participation for any hysterectomy performed solely for sterilization. All sterilization procedures must also meet the consent and waiting-period requirements set forth in 42 C.F.R. 441.252.254.C.Definitions Cross-Sex Hormone Testosterone, estrogen, or progesterone given to a minor individual in an amount greater than would normally be produced endogenously in a healthy individual of the minor individual’s age and sex. Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program A comprehensive preventive health program for individuals under age 21 that requires coverage of any service necessary to correct or ameliorate defects, physical and mental illnesses and conditions discovered by screening. 42 C.F.R. 441.50 et seq. Gender Dysphoria Affective and/or cognitive discontent accompanying incongruence between experienced or expressed gender and assigned gender, lasting at least 6 months and meeting diagnostic criteria listed in the DSM-5-TR. Gender Reassignment Surgery Any surgery performed for the purpose of assisting an individual with gender transition that seeks to surgically alter or remove healthy physical or anatomical characteristics or features that are typical for the individual’s biological sex, in order to instill or create physiological or anatomical characteristics that resemble a sex different from the individual’s birth sex, including genital or non-genital gender reassignment surgery. Gender-Related Condition Any condition where an individual feels an incongruence between the individual’s gender identity and biological sex, including gender dysphoria. Gender Transition Services Any medical or surgical service (including physician services, inpatient and outpatient hospital services, or prescription drugs or hormones) provided for the purpose of assisting an individual with gender transition The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 3 that seeks to alter or remove physical or anatomical characteristics or features that are typical for the individuals biological sex, or to instill or create physiological or anatomical characteristics that resemble a sex different from the individuals birth sex, including medical services that provide puberty blocking drugs, cross-sex hormones, or other mechanisms to promote the development of feminizing or masculinizing features in the opposite sex, or genital or non-genital gender reassignment surgery. Minor Any member under the age of 18. Puberty-Blocking Drugs Gonadotropin-releasing hormone analogs or other synthetic drugs used to stop luteinizing hormone and follicle stimulating hormone secretion, synthetic antiandrogen drugs used to block the androgen receptor or any drug to delay or suppress normal puberty. D. Policy I. CareSource complies with state and federal regulations for the coverage of medically necessary services. Medically necessary services are health care services needed to diagnose or treat that meet the accepted standards of medicine. 42 C.F.R. 440.230. All requests are reviewed on a case-by-case basis, including any applicable requests under the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. II. For any member under the age of 18, Ohio Revised Code 3129.06 prohibits coverage of gender transition services, subject to certain exceptions as follows: A. mental health services provided for a gender-related condition B. treatment, including surgery or prescribing drugs or hormones, to a minor who 1. was born with a medically verifiable disorder of sex development 2. received a diagnosis of a disorder of sexual development 3. needs treatment for any infection, injury, disease, or disorder that has been caused or exacerbated by the performance of gender transition services III. Any member 18 to 20 years of age, as per 42 CFR 441.56 and 42 U.S.C. 1396d(r), will be reviewed for medical necessity as required by the EPSDT program (ie, Ohio Healthchek). CareSource will cover medically necessary care if deemed essential by a healthcare provider, including gender-related care. IV. For any member 21 years of age or older, Ohio Administrative Code 5160-2-03 establishes that gender transformation services are not covered services (eg, clitoroplasty, intersex surgery, vaginectomy, penectomy, mastectomy, breast augmentation). V. All behavioral health services for gender dysphoria will be subject to the same utilization management and cost-sharing requirements as other behavioral and medical benefits in compliance with Mental Health Parity and Addiction Equity Act. 42 U.S.C. 300gg-26; 45 C.F.R. Part 146. Medical Interventions for Gender Dysphoria-OH MCD-MM-0034 Effective Date: 02/07/2026 The MEDICAL Policy Statement detailed above has received due consideration as defined in the MEDICAL Policy Statement Policy and is approved. 4 Dates Action Date Issued 05/18/2017 Date Revised 05/29/2019 09/02/2020 07/07/2021 05/19/2022 06/21/2023 07/17/2024 07/02/2025 Updated evidence, changed policy # (MM-0080), removed pharmacy info, added addtl requirements for surgery, specifics on hair removal, items not covered & types of surgery for medical necessary review. Updated definitions, removed research & codes, added references, changed letter recommendation requirement, changed title. Removed endocrinologist rule, added psych NP & safety info. Annual review. Updated definitions. Added PCP to hormone therapy requirement. Removed conception counseling for genital surgery. Removed breast augmentation from the exclusion list. Annual review. Updated background, definitions, reference list. Approved at Committee. Annual review. Top changed to chest, bottom to genital. Updated background & definitions. Combined letter info. Updated references. Approved at Committee. Rewrote background to comply with 2025 CMS letter. Revised all sections re: compliance with regulations. Approved at Committee. Date Effective Date Archived H. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revised (DSM-5-TR). Arlington, VA; 2022. 2. Conditions and Limitations. OHIO ADMIN. CODE 5160-2-03 (2022). 3. Definitions. 42 U.S.C. 1396d(r) (2024). 4. Gender Transition Services for Minors. OHIO REV. CODE Chapter 3129 (2024). 5. Healthchek: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Covered Services. OHIO ADMIN. CODE 5160-1-14 (2017). 6. Medicaid Medical Necessity: Definitions and Principles. OHIO ADMIN. CODE 5160-1-01 (2022). 7. Puberty Blockers, Cross-sex Hormones, and Surgery Related to Gender Dysphoria. Centers for Medicare and Medicaid Services; April 11, 2025. Accessed June 11, 2025. www.cms.gov. 8. Required Activities. 42 C.F.R. 441.56 (1984). Approved by Ohio Department of Medicaid 10/24/2025. Medical Interventions for Gender Dysphoria-OH MCD-MM-0034 Effective Date: 02/07/2026E.Conditions Of CoverageNAF.Related Policies/RulesMedical Necessity DeterminationsG.Review/Revision History02/07/2026
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Epidural Steroid Injections-OH MCD-MM-0007 03/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………… 2 B. Background ………………………….. ………………………….. ………………………….. …….. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………….. 3 E. Conditions of Coverage ………………………….. ………………………….. …………………. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………….. 5 G. Review/Revision History ………………………….. ………………………….. ……………….. 6 H. References ………………………….. ………………………….. ………………………….. ……… 6 Epidural Steroid Injections-OH MCD-MM-0007Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectEpidural Steroid Injections B. BackgroundNearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent . Persistent p ain is categorized as subacute when lasting between 4 and 12 weeks and chronic when persisting for at least 3 months. Comprehensive pain management care plan s are most effective in managing a patientschronic pain. These plans focus on a person-centered approach and incorporate conservative treatment with other modalities . These m ultidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. In addition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic tre atments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. Epidural steroid injections (ESIs) are a nonsurgical, minimally-invasive intervention for chronic back pain. ESIs may be administered through the translaminar approach (via the interlaminar space in the spine), the transforaminal approach (through the neuroforamen dorsal to the nerve root), or the caudal approach (through the sacral hiatus at the sacr al canal ). There is conflicting evidence on the efficacy of ESIs and a lack of consensus on frequency and number of epidural steroid injections from professional organizations. However, clinical experience suggests that some patients obtain more significan t relief, making it reasonable to offer a trial of steroid injections when conservative management has failed. Imaging studies of the symptomatic region may be performed to evaluate suspected specific causes of spinal pain (eg, herniated disc, spinal stenosis, degenerative vertebral disease, rule out fracture or tumor). However, evidence does not support the routin e useof imaging or other diagnostic tests in patients with nonspecific back pain. Diagnostic imaging and testing are only recommended when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination. C. Definitions Conservative Therapy A multimoda l plan of care including both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen muscle groups and target key spinal structures, including physical therapy, occupational therapy, a physician supervised home exercise program (HEP), and/or chiropractic care. Epidural Steroid Injections-OH MCD-MM-0007Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly per form exercises). Patient inconvenience or noncompliance without explanation does not consistute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, acupuncture, TENS u se , and/or pharmacotherapy (prescription or over the counter [eg, non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphi ns. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Epidural Steroid I njection Administration of steroids via a needle inserted in the space between the ligamentum flavum and the dura and adm inistered by translaminar, tranforaminal , or caudal approach es . Injections are intended to cause a short-term reduction in pain in the affected region. D. PolicyI. Epidural steroid injections for labor and delivery in childbirth or post-surgical pain do not require medical necessity review . II. Initial (Diagnostic) InjectionCareSource considers an initial (diagnostic) epidural steroid injection (maximum of 2injections) medically necessary for the management of chronic back pain when ALL the following clinical criteria are met: A. Pain is located in either the cervical, thoracic, or lumbar spine and is predominantly radiating or shooting in nature . B. Pain is causing functional disability . C. Signs or symptoms are consistent with radiculopathy, as indicated by at least 1 of the following: 1. diminished or absent deep tendon reflexes 2. paresthesia, numbness, sensory change, or weakness in dermatomal distribution 3. positive femoral nerve stretch test 4. positive Spurling test 5. positive straight leg raising test D. Conservative therapy has failed to alleviate symptoms, as evidenced by ALL the following: 1. documentation in the medical record of at least 6 weeks of active conservative therapy ( see definition above ) within the past 6 months OR Epidural Steroid Injections-OH MCD-MM-0007Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 inability to complete active conservative therapy due to contraindication, increased pain, or intolerance2. documen tation in the medical record of at least 6 weeks of inactive conservative therapy ( see definition above ) within the past 6 months E. Imaging (eg, x-ray, CT, MRI), if performed, demonstrates that there are no conditions present that would preclude the safety of the performance of the procedure. III. Subsequent (Therapeutic) InjectionsCareSource considers therapeutic epidural steroid injections medically necessary when ALL the following criteria are met: A. The diagnostic or last therapeutic injection for current episode of pain provided significant functional pain relief as measured by a significant decrease in pain level (as demonstrated on a qualitative pain scale) , decrease in pain medications, and/or increase in physical function . B. The member continues to have ongoing pain or documented functional disability . C. At least 3 weeks have passed since the prior injection in order to reach pharmacodynamic effect . D. No more than 3 procedures in a 12-week period of time per region are considered medically necessary. E. The member continues to engage in conservative therapy (see definition above). IV. Limitations and ExclusionsA. In general, most individuals should not require more than 6 total epidural injections in 12 months. Additional injections may be considered on a case by case basis when the individual has multiple treatment sites.B. For interlaminar or caudal epidural injections , no more than 1 epidural injection per treatment date should be performed . C. For t ransforaminal epidurals or selective nerve root blocks (SNRBs) , no more than 2 vertebral levels per treatment date, whether unilateral or bilateral, should be performed . D. Real-time image guidance and any injection of contrast are inclusive components of epidural injections and are not compensated for separately or unbu ndled for coverage. E. Conscious sedation, if required for co-morbidities or patient/physician preference, may be provided without a medical necessity review but services will be considered part of the procedure and are not eligible for additional reimbursement if administered by a second provider. F. Monitored anesthesia is considered not medically necessary . G. Patients with indwelling implanted spinal cord stimulators or pain pumps must have a device interrogation report and an interpretation submitted with medical records, and included in the prior authorization request for p ropos ed interventional pain injections. If a device is not functioning properly, an escalation in pain may warrant evaluation and management of the implanted device. Epidural Steroid Injections-OH MCD-MM-0007Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 H. Clinical evaluations and care of candidate patients for epidural injections should also address, at t he discretion of the physician and according to prevailing standards of medical care: 1. no acute spinal cord compression 2. selected body imaging evaluation s to evaluate the area of pain, particularly for acute pain, or to evaluate escal ations in chronic baseline pain 3. appropriate imaging to rule out red flag conditions may be indicated if potential issues of trauma, osteomyelitis or malignancy , or other diagnoses are a concern I. Contraindications include any of the following: 1. pain related to cancer etiology 2. local or systemic infection 3. cauda equina syndrome 4. spinal trauma (eg, hematoma, hemorrhage, mass, ischemia) 5. coagulopathy V. Inconclusive or Non-Supportive EvidenceA. Evidence reported in the medical literature is inconclusive as to the use of epidural injections for long term relief or treatment of chronic pain. Long-term continuation (epidural injections beyond 1 year) may be subject to medical necessity review. B. For both cervical and lumbar transforaminal (TF) ESIs, using particulate steroid is associated with a rare risk of catastrophic neurovascular complications such as stroke or death. Cervical transforaminal injections are risky because arterial supply may be densely concentrated in and around the interver tebral foramen. TF ESIs can be performed without contrast in patients with documented contraindication to its use. In these circumstances , particulate steroids are contraindicated and only the preservative fr ee, particulate fre e steroids which are available should be used. C. Cervical transforaminal ESIs have sparse literature for cervical radicular pain, and , if performed , should be performed by injecting contrast medium under real – time fluoroscopy and/or digital subtraction angiography (DSA) in a frontal plane, before injecting any substance potentially hazardous to the patient. Particulate steroids should not be used for cervical TF injections as per the contraindication established by the FDA warning. E. Conditions of CoverageNA F. Related Policies/RulesNA Epidural Steroid Injections-OH MCD-MM-0007Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 G. Review/Revision HistoryDATES ACTIONDate Issued 01/27/2015 New PolicyDate Revised 03/06/2019 05/13/202004/28/202103/ 16 /2022 11/03/202203/15 /202301/31/202401/15/202512/03 /2025Annual Update: Removed start and end dates. Addition of PA clarification and documentation requirements.Annual Update : Updated language around benefit limits. Annual Update: Removed PA language. Annual Review. Updated formatting and references, consolidated background and evidence , separated indic ations into initial and subsequent injections, frequency restrictions, and limitations/exclusions, added contraindications. Removed anti-platelet therapy contraindication Annual review: reorganized criteria, simplified conservative therapy, added provocation tests . Approved at Committee. Annual review: updated references and formatting. Approved at Committee. Review: removed US limitation, updated references, approved at Committee. Review: Updated references. Approved at Committee . Date Effective 03/01/2026 Date Archived H. References1. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate . Updated April 29 , 202 5. Accessed November 18, 202 5. www.uptodate.com 2. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med . 2017;166(7):493-505. doi:10.7326/M16-2459 3. Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med . 2015;163(5):373-381. doi:10.7326/M15-0934 4. Conger A, Cushman DM, Speckman RA, et al. The effectiveness of fluroscopically guided cervical transforaminal epidural steroid injection for the treatment of radicular pain; a systematic review and meta-analysis. Pain Med. 2020;21(1):41-54. doi:410.1093/pm/pnz127 5. Dydyk AM, Hu Y, Stretanski MF, et al. Cervical Epidural Injection. In: StatPearls [Internet]. Updated June 2, 2025. Accessed November 18, 2025. www.ncbi.nlm.nih.gov 6. Fromm MK, Liu SH, Carr C, et al. Factors associated with improved outcomes after lumbar transforaminal epidural steroid injections for radicular pain: a systematic review. NASSJ . 2025; 21:100592 . doi :10.1016/j.xnsj.2025.100592 Epidural Steroid Injections-OH MCD-MM-0007Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 7. Goel A, Singh S, Shukla NK, et al . Efficacy of caudal epidural steroid injections in chronic low backache patients. JPharm Bioallied Sci. 2023;15(Suppl 1):S669-S672. doi:10.4103/jpbs.jpbs_89_23 8. Helm S, Harmon PC, Noe C, et al. Transforaminal epidural steroid injections: a systematic review and meta-analysis of efficacy and safety. Pain Phys ician . 2021;24:S209-S232. Accessed November 18 , 202 5. www.painphysicianjournal.com 9. Manchikanti L, Benyamin RM, Falco FJ, et al. Do epidural injections provide short – and long-term relief for lumbar disc herniation? A systematic review. Clin Orthop Relat Res. 2015;473(6):1940-1956. doi:10.1007/s11999-014-3490-4 10. Manchikanti L, Knezevic NN, Boswell MV, et al. Epidural injections for lumbar radiculopathy and spinal stenosis: a comparative systematic review and meta – analysis. Pain Physician. 2016;19(3):E365-410. Accessed November 18 , 202 5. www.painphysicianjournal.com 11. Manchikanti L, Knezevic NN, Navani A, et al. Epidural interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) comprehensive evidence-based guidelines. Pain Physician. 2021;24(S1): S27-S208. Accessed November 18 , 202 5. www.painphysicianjournal.com 12. Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020;4(4):CD013577. doi: 10.1002/14651858.CD013577 13. Qassem A, Wilt TJ, McLean RM et al. Noninvasive treatments for acute, subacute and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Inter n Med . 2017 ;166(7):514-530 . doi:10.7326/M16-2367 14. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3729-3832. doi:10.2147/JPR.S386879 15. Taskaynatan MA, Tezel K, Yavuz F, et al. The effectiveness of transforaminal epidural steroid injection in patients with radicular low back pain due to lumbar disc herniation two years after treatment. JBack Musculoskelet Rehabil. 2015;28(3):447 – 451. doi:10.3233/BMR-140539 16. Verheijen EJA, Bonke CA, Amorij EMJ, et al . Epidural steroid compared to placebo injection for sciatica: a systematic review and meta-analysis. Euro Spine J . 2021;30:3255-3264. doi:10.1007/s00586-021-06854-9 17. Woo JH, Park HS. Cervical transforaminal epidural block using low-dose local anesthetic: a prospective, randomized, double-blind study. Pain Med. 2015;16(1):61 – 67. doi:10.1111/pme.12582 18. Yang S, Kim W, Kong HH, et al. Epidural steroid injection versus conservative treatment for patients with lumbosacral radicular pain: a meta-analysis of randomized controlled trials. Med. 2020;99(30):e21283. doi:10/1097/MD. 0000000000021283 Approved by ODM 12/10 /2025
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Home Health Services-OH MCD-MM-1243 03/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 4 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 8 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 8 Home Health Services-OH MCD-MM-1243Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectHome Health Services B. BackgroundHome health services are skilled and supportive care services provided in the members home to meet skilled care needs and associated activities of daily living (ADLs) to allow the member to safely stay in the home. Home health services incorporate a wide variety of skilled healthcare and supportive services provided by licensed and unlicensed professionals. These services are designed to meet the needs of members with acute, chronic, and terminal illnesses or disabilities, who without this support might ot herwise require services in an acute care or residential facility. These guidelines identify clinical information that CareSource uses to determine medicalnecessity for home health services. These guidelines are based on generally accepted standards of practice, review of medical literature, as well as federal and state policies and laws applicable to Medicaid programs.Providers should consult Chapter 5160-12 of the Ohio Administrative Code for detailsabout 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 twenty years and 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 the 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 health aide services, which means any of the following services provided by an employee of a home health agency: hands-on bathing or assistance with a tub bath or shower assistance with dressing, ambulation, and toileting catheter care but not insertion meal preparation and feeding Home Health Aide Services Services that use the skills of and are performed by a home health aide employed or contracted by the Medicare Certified Home Health Home Health Services-OH MCD-MM-1243Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Agency (MCHHA) providing the service. Home health aide services include, but are not limited to, the following:o bathing, dressing, grooming, hygiene, including shaving, skin care, foot care, ear care, hair, nail and oral care, that are needed to facilitate care or prevent deterioration of the individual’s health, and including changing bed linens of an incontinent or immobile individual o feeding, assistance with elimination including administering enemas (unless the skills of a home health nurse are required), routine catheter care, routine colostomy care, assistance with ambulation, changing position in bed, and assistance with transfers o assisting with activities such as routine maintenance exercises and passive range of motion as specified in the plan of care. These activities are directly supportive of skilled therapy services but do not require the skills of a therapist to be safely and effectively performed. The plan of care is developed by either a licensed therapist or a licensed registered nurse within their scope of practice o performing routine care of prosthetic and orthotic devices Home Health Nursing Services Services that require the skills of and are performed by a registered nurse or a licensed practical nurse at the direction of a registered nurse. The nurse performing the home health service must possess a current, valid, and unrestricted license with the Ohio Board of Nursing and must be employed or contracted by an MCHHA that has an active Medicaid provider agreement. A service is not considered a nursing service merely because it is performed by a licensed nurse. o Home health nursing services include, but are not limited to, the following: IV insertion, removal, or discontinuation IV medication administration programming of a pump to deliver medications including, but not limited to, epidural, subcutaneous IV (except routine doses of insulin through a programmed pump) insertion or initiation of infusion therapies central line dressing changes blood product administration o Home health nursing services do not include a visit when the sole purpose is for the supervision of the home health aide. Medical Necessity Must meet ALL of the following conditions: o meets generally accepted standards of medical practice o clinically appropriate in its type, frequency, extent, duration, and delivery setting o appropriate 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 it is used for diagnostic purposes o not provided primarily for the economic benefit of the provider nor for the convenience of the provider or anyone else other than the recipient Home Health Services-OH MCD-MM-1243Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 Skilled Therapies A collective term encompassing physical therapy, occupational therapy, speech-language pathology, and audiology. D. PolicyI. Home health services, including home health aide and home health nursing, are provided to any CareSource Ohio Medicaid member when considered medically necessary. II. Duplicative services are not covered.A. There must be documentation of all other therapies/services the member is receiving, when relevant to home health services. B. If the member is receiving other assistance (eg, meal delivery program, family caregiver, additional supportive services), this information and the hours involved must be provided to adequately evaluate medical necessity of home health services. C. The care provided must be appropriate to the member. Guidelines are provided (see Table below) to assist in determining the amount of care a member requires. III. Home Health Services for Individuals Age d 21 Years and OlderA. Routine home health services are considered medically necessary for individuals age d 21 years and older when ALL the following criteria are met: 1. There has been a face-to-face encounter between the individual and a qualifying treating physician, advanced practice registered nurse, or physician assistant . 2. The face-to-face encounter occurred within 90 days prior to the start of home health services or within 30 days following the start of home health services . 3. There is a written plan of treatment, as evidenced by one of the following: the Ohio Department of Medicaid (ODM) 07137 Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services OR the individual’s plan of care if all of the data elements specified for home health services on the ODM 07137 are included . 4. At the time of billing, the plan of care /treatment plan contains the signature, credentials , and the date of the signature of the qualifying treating physician, advanced practice registered nurse , or physician assistant . 5. The home health services will be provided by a MCHHA . 6. The services are provided on a part-time or intermittent basis as follows: a. Total Hours Per Visit: 4 hours (individuals who require more than 4 hours of care per visit may qualify for private duty nursing (PDN) , which is outside the scope of this policy) b. Total Hours Per Day: 8 hours combined per day of home health nursing, home health aide, and skilled therapies c. Total Hours Per Week: 14 hours combined per week of home health nursing and home health aide services Home Health Services-OH MCD-MM-1243Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 NOTE: additional hours of care may be considered based upon medical necessity . B. Following discharge from an inpatient hospital stay, home health services are considered medically necessary for individuals age 21 years and older when ALL the following criteria are met: 1. There has been a face-to-face encounter between the individual and a qualifying treating physician, advanced practice registered nurse, or physician assistant . 2. The face-to-face encounter occurred within 90 days prior to the start of home health services, or within 30 days following the start of home health services . 3. There is a written plan of treatment as evidenced by the ODM 07137 Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services . 4. The individual is discharged from a covered inpatient hospital stay of at least 3 days, with the discharge date recorded on form ODM 07137 . 5. The individual has a comparable level of care as evidenced by either: enrollment in a home and community-based services (HCBS) waiver OR a medical condition that temporarily meets the criteria for an institutional level of care . 6. The individual requires home health nursing, or a combination of PDN , home health nursing, or waiver nursing and/or skilled therapy services at least 1 per week . 7. The home health services will be provided by a MCHHA . 8. The services are provided on a part-time or intermittent basis as follows: a. Total Hours Per Visit: 4 hours (individuals who require more than 4 hours of care per visit may qualify for PDN , which is outside the scope of this policy) b. Total Hours Per Day: 8 hours combined per day of home health nursing, home health aide, and skilled therapies c. Total Hours Per Week: 28 hours combined per week of home health nursing and home health aide services for up to 60 consecutive days from the date of discharge from an inpatient hospital stay Note: additional hours of care may be considered based upon medical necessity. IV. Routine Home Health Services for Individuals Under Age 21 YearsA. Routine home health services are considered medically necessary for individuals under age 21 years when ALL of the following criteria are met: 1. There has been a face-to-face encounter between the individual and a qualifying treating physician, advanced practice registered nurse, or physician assistant . 2. The face-to-face encounter occurred within 90 days prior to the start of home health services, or within 30 days following the start of home health services . 3. There is a written plan of treatment, as evidenced by one of the following: the ODM 07137 Certificate of Medical Necessity for Home Health Services and Home Health Services-OH MCD-MM-1243Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 Private Duty Nursing Services OR the individual s plan of care if all of the data elements specified for home health services on the ODM 07137 are included . 4. At the time of billing, the plan of care contains the signature, credentials , and the date of the signature of the qualifying treating physician, advanced practice registered nurse or physician assistant . 5. The home health services will be provided by a MCHHA . 6. The services are provided on a part-time or intermittent basis as follows: a. Total Hours Per Visit: 4 hours (individuals who require more than 4 hours of care per visit may qualify for PDN , which is outside the scope of this policy) b. Total Hours Per Day: 8 hours combined per day of home health nursing, home health aide, and skilled therapies c. Total Hours Per Week: 14 hours combined per week of home health nursing and home health aide services d. A member may qualify for increased home health services when ALL the following criteria are met: 01. The services are required for treatment in accordance with the Healthchek program (EPSDT) . 02. The member has a comparable level of care as evidenced by either enrollment in a HCBS waiver or a level of care evaluated initially and annually by ODM or its designee for an individual not enrolled in an HCBS waiver . 03. The member needs home health nursing or a combination of PDN, home health nursing, waiver nursing, and skilled therapies at least once per week . 04. The member needs more than, as ordered by the treating clinician, 8 hours per day of any home health service, or a combined total of 14 hours per week of home health aide and home health nursing. B. Following discharge from an inpatient hospital stay, home health services are considered medically necessary for individuals under age 21 years when ALL the following criteria are met: 1. There has been a face-to-face encounter between the individual and a qualifying treating physician, advanced practice registered nurse, or physician assistant . 2. The face-to-face encounter occurred within 90 days prior to the start of home health services, or within 30 days following the start of home health services . 3. There is a written plan of treatment as evidenced by the ODM 07137 Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services . 4. The home health services will be provided by a MCHHA . 5. The individual is discharged from a covered inpatient hospital stay of at least 3 days , with the discharge date recorded on form ODM 07137 . 6. The services are provided on a part-time or intermittent basis as follows: Home Health Services-OH MCD-MM-1243Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 a. Total Hours Per Visit: 4 hours (individuals who require more than 4hours of care per visit may qualify for PDN , which is outside the scope of this policy) b. Total Hours Per Day: 8 hours combined per day of home health nursing, home health aide, and skilled therapies c. Total Hours Per Week: 28 hours combined per week of home health nursing and home health aide services for up to 60 consecutive days from the date of discharge from an inpatient hospital stay d. A member may qualify for increased home health services when ALL the following criteria are met: 01. The services are required for treatment in accordance with the Healthchek program (EPSDT) . 02. The individual has a comparable level of care as evidenced by either: enrollment in a HCBS waiver OR a medical condition that temporarily meets the criteria for an institutional level of care . 03. The individual requires home health nursing, or a combination of PDN , home health nursing, or waiver nursing and/or skilled therapy services at least 1 per week . 04. The member needs more than, as ordered by the treating clinician, a combined total of 28 hours per week of home health nursing and home health aide for up to 60 days. V. Incidental services may be included during a home health visit, as long as the services do not substantially extend the time of the visit. A. Incidental services are necessary household tasks that must be performed by someone to maintain a home and can include light chores, laundry, light house cleaning, preparation of meals, and taking out the trash. B. The main purpose of a home health aide visit cannot be solely to provide these incidental services since the services are not health related services. C. Incidental services are to be performed only for the individual and not for other people in the individuals place of residence. VI. Home health services do NOT include any of the following :A. a visit when the sole purpose is for the supervision of the home health aide B. patient assessment services C. patient consultation services D. transporting the member to grocery stores, pharmacies, banks, etc. E. homemaker services (eg, shopping, laundry, cleaning, meal preparation) F. chores (eg, running errands, picking up prescriptions) G. sitter or companion services (eg, activity planning, escorting member to events) H. respite care VII. General guidelines for care based on the Aide Norms ToolTask Type General Guideline Home Health Services-OH MCD-MM-1243Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 Mobility (bed, transfer, locomotion)5min/ADL inside and 15min outside. Positioning Q2 hr Bathing 30 min/day includes prep/clean up; transfers Grooming 15 min/day includes all hair care, oral care, nails general hygiene care Medication 5 min/dose time regardless of number of medications Toileting Bladder : 10 min/2 hr awake; 2x/night; add 5 min if incontinent. Bowel: 10 min/BM, add 10 min if incontinent Dressing 15 min/day; plus 5 min/device (prosthetic) Eating 30 min/meal with 3 meals and 2 snacks per day Linen Changes 30 min/week E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 1/19/2022 New policy.Date Revised 06/16/2022 02/01/202301/17 /202401/15 /202512/03 /2025Out-of-cycle update: split criteria III.A.3 and IV.A.3 so latter states at time of billing. Annual review: updated references, clarified hours of care based on medical necessity . Annual review: updated references and formatting. Approved at Committee. Review: updated references. Approved at Committee. Review: updated acronyms and references. Approved at Committee. Date Effective 03/01/2026 Date Archived H. References1. Administrative procedures for comprehensive health care for children in placement, OHIO ADMIN . CODE 51 80:2-42-66 (20 24 ). 2. Definitions, OHIO ADMIN . CODE 3701-19-01 (2020). 3. Definitions, OHIO ADMIN . CODE 3701-60-01 (20 23 ). 4. Home Health and Private Duty Nursing: visit policy, OHIO ADMIN . CODE 5160-12-04 (2021). 5. Home Health Services: provision requirements, coverage and service specification, OHIO ADMIN . CODE 5160-12-01 (2021). Home Health Services-OH MCD-MM-1243Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.9 6. Managed Care: covered services, OHIO ADMIN . CODE 5160-26-03 (2022).7. Medicare Certified Home Health Agencies: qualification and requirements, OHIO ADMIN . CODE 5160-12-03 (2015). 8. Payment For Home Health Nursing Services and Home Health Aide Services , OHIO ADMIN . CODE 4123-6-38 (2022). 9. Payment For Nursing and Caregiver Services Provided by Persons Other Than Home Health Agency Employees, OHIO ADMIN . CODE 4123-6-38.1 (2022). 10. Reimbursement: exceptions, OHIO ADMIN . CODE 5160-12-07 (2015). 11. Reimbursement: home health services, OHIO ADMIN . CODE 5160-12-05 (202 4). Approved by ODM on 12/10 /202 5
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Tumor Treatment Field Device Therapy-OH MCD-MM-1224 02/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Tumor Treatment Field Device Therapy-OH MCD-MM-1224Effective Date: 02/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectTumor Treatment Field Device Therapy B. BackgroundGlioblastoma multiforme is the most common central nervous system malignancy of the brain accounting for 47.7% of all cases. Median age of diagnosis is 64 years, and it is more common in men as compared to women. Management of the disease follows a combined-modality approach, including adjuvant postoperative radiation therapy and adjuvant chemotherapy following initial surgery. Surgery remains the mainstay of treatment in order to remove as much tumor as possible while preserving surrounding brain tissue required for normal brain function. Despite tumor debulking measures, glioblastoma tumors infiltrate surrounding tissues creating little success for removal of the entire tumor (AANS, 2020). Glioblastoma has a high rate of recurrence and poor overall survival rate even with optimum therapy treatments, with approximately 40% survival in the first year post diagnosis and 17% in the second year. Lung cancer is the leading cause of cancer-related mortality in the United States. The 5-year relative survival rate from 2014 to 2020 for patients with lung cancer was 27%. The 5-year relative survival rate varies markedly for patients diagnosed at local stage (64%), regional stage (36%), or distant stage (9%). Non-Small Cell Lung Cancer (NSCLC) is any type of epithelial lung cancer other than small cell lung cancer (SCLC). The most common types of NSCLC are squamous cell carcinoma, large cell carcinoma, and adenocarcinoma, but there are several other types that occur less frequently, and all types can occur in unusual histological variants. Although NSCLCs are associated with cigarette smoke, adenocarcinomas may be found in patients who never smoked. Tumor treating field devices (TTF) are a novel method of cancer treatment involving emitting alternating electric fields to disrupt the rapid cell division exhibited by cancer cells. This treatment first became available in 2011 to treat recurrent glioblastoma. TTF is considered safe with no systemic toxicity observed and only mild to moderate side effects (reported in 1-2% of patients) involving the skin beneath transducer arrays. Patients are required to wear the device at least 18 hours a day for effectiveness and minimum treatment duration is 4 weeks. Randomized clinical trial results suggest the device improves overall survival when combined with monthly temozolomide in patients with newly diagnosed glioblastoma in the post radiation setting. C. Definitions Glioblastoma Multiforme (GBM) Also referred to as a grade IV astrocytoma, is a fast-growing and aggressive brain tumor. It invades the nearby brain tissue but generally does not spread to distant organs. Karnofsky Performance Status (KPS) An index that classifies the functional impairment of patients. This can be used to compare the effectiveness of different therapies and to assess the prognosis in individual patients. The lower the Karnofsky score, the worse the survival for most serious illnesses. Tumor Treatment Field Device Therapy-OH MCD-MM-1224Effective Date: 02/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Medically Necessary Services which are necessary for the diagnosis or treatment of disease, illness, and injury, and meet accepted guidelines of medical practice. A medically necessary service must be related to the illness or injury for which it is performed regarding type, intensity, and duration of service and setting of treatment. Non-Small Cell Lung Cancer (NSCLC) A group of lung cancers named for the kinds of cells found in the cancer and how the cells look under a microscope. The three main types of non-small cell lung cancer are adenocarcinoma (most common), squamous cell carcinoma, and large cell carcinoma. Response Assessment in Neuro-Oncology (RANO) A working group established to improve the assessment of tumor response and selection of end points, specifically in the context of clinical trials. Tumor Treatment Fields (TTF) Mild electrical fields that vibrate through the skin of the scalp and disturb cancer cells ability to divide, possibly slowing tumor growth and spread. D. Policy I. Tumor treatment field devices are considered medically necessary for the following: A. Glioblastoma multiforme 1. Initial treatment is considered medically necessary when ALL of the following criteria have been met: a. The member has a new diagnosis of GBM (grade IV astrocytoma). b. The member is age 22 years or older. c. The member has received initial treatment with surgery when reasonable. d. TTF therapy is initiated within 7 weeks from the last dose of chemotherapy or radiotherapy. e. The member has a Karnofsky Performance Scale (KPS) index of at least 60. f. TTF treatment will be used for an average of 18 hours per day. 2. Continued coverage (beyond first 3 months of therapy) for newly diagnosed GBM and documentation of clinical benefit demonstrates ALL of the following: a. in-person clinical re-evaluation by treating practitioner b. objective evidence of adherence to therapy, reviewed by treating practitioner c. maintain KPS of at least 60 d. if KPS is unavailable, then no evidence of progression by Response Assessment in Neuro-Oncology (RANO) criteria B. Non-Small Cell Lung Cancer (NSCLC) Treatment is considered medically necessary when ALL of the following criteria have been met: 1. NSCLC metastatic disease with progression on or after platinum-based therapy Tumor Treatment Field Device Therapy-OH MCD-MM-1224Effective Date: 02/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 2. TTF therapy is administered in combination with atezolizumab, nivolumab,pembrolizumab, or docetaxel II. The following is a list of contraindications for TTF treatment (not all inclusive):A. cardiac pacemaker or implantable defibrillator B. deep brain, spinal cord, or vagus nerve stimulator C. major skull defect (eg, missing section of calvarium) D. metal within brain (eg, aneurysm clip, bullet fragment) E. programmable ventriculoperitoneal shunt F. pregnancy G. known sensitivity to conductive hydrogels (eg, gels used on electrocardiogram) H. ECG stickers or transcutaneous electrical nerve stimulation (TENS) electrodes III. CareSource considers TTF therapy for GBM and NSCLC only. Treatment of any other tumors is not medically necessary and experimental/investigational. IV. The use of enhanced treatment planning software (Novotal) is non-covered becauseCareSource considers it to be experimental/investigational for ALL indications. E. Conditions of CoverageN/A F. Related Policies/Rules N/A G. Review/Revision History DATE ACTIONDate Issued 09/29/2021 New Policy.Date Revised 07/06/2022 11/8//2023 11/06/2024 11/05/2025 Updated references. No changes. Archived Jan.2023. Added Section II (Continued coverage) . Approved at Committee. Removed PA language from policy. Updated references. Approved at Committee. Changed title to Tumor Treatment Field Device Therapy. Added background on non-small cell lung cancer and definition. Added Sec. I.B. to describe medical necessity criteria for NSCLC. Added NSCLC to sec. III. Updated references. Approved at Committee. Date Effective 02/01/2026 Date Archived H. References1. Alternating Electric Field Therapy ACG: A-0930 (AC). 2025. Accessed September26, 2025. www.careweb.careguidelines.com Tumor Treatment Field Device Therapy-OH MCD-MM-1224Effective Date: 02/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 2. Batchelor T. Initial treatment and prognosis of IDH-wildtype glioblastoma in adults.UpToDate. Updated August 7, 2024. Accessed September 30, 2025. www.uptodate.com 3. Burri SH, Gondi V, Brown PD, Mehta MP. The evolving role of tumor treating fields in managing glioblastoma: guide for oncologists. Am JClin Oncol . 2018;41(2):191-196. doi:10.1097/COC.0000000000000395 4. Chukwueke UN, Wen PY. Use of the Response Assessment in Neuro-Oncology (RANO) criteria in clinical trials and clinical practice. CNS Oncol . 2019;8(1):CNS28. doi:10.2217/cns-2018-0007 5. Fernandes C, Costa A, Osrio L, et al. Current standards of care in glioblastoma therapy. In: De Vleeschouwer S, ed. Glioblastoma . Codon Publications; 2017. Accessed September 26, 2025. www.ncbi.nih.gov 6. Glioblastoma multiforme. American Association of Neurological Surgeons. Accessed September 26, 2025. www.aans.org 7. Health Technology Assessment: Tumor Treatment Fields (Optune) for Treatment of Glioblastoma. Hayes; 2019. Reviewed January 5, 2023. Accessed September 26, 2025. www.evidence.hayesinc.com 8. Kanderi T, Gupta V. Glioblastoma Multiforme. In: StatPearls . Treasure Island (FL): StatPearls Publishing; 2022. Accessed September 30, 2025. 9. Karnofsky Performance Status Scale definitions rating criteria. National Palliative Care Research Center. Accessed September 30, 2025. www.npcrc.org 10. Katiyar V, De Jesus O. Tumor Treatment Fields in Oncology. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 23, 2023. Accessed September 30, 2025 11. Leal T, et al. Tumor Treating Fields therapy with standard systemic therapy versus standard systemic therapy alone in metastatic non-small-cell lung cancer following progression on or after platinum-based therapy (LUNAR): a randomised, open-label, pivotal phase 3 study. Lancet Oncology 2023;24(9):1002-1017. DOI: 10.1016/S1470-2045(23)00344-3. 12. Non-Small Cell Lung Cancer. NIH, National Cancer Institute. Accessed September 30, 2025. www.cancer.org 13. OPTUNE (NovoTTF-100A System) Patient Information and Operation Manual . Food and Drug Administration. Document QSD-QR-33 Accessed September 30, 2025. www.accessdata.fda.gov 14. Wen PY, Chang SM, Van den Bent MJ, et al Response assessment in neuro- oncology clinical trials. JClin Oncol . 2017;35(21):2439-2449. doi:10.1200/JCO.2017.72.7511 ODM Approved 11/12/2025 Independent medical review November 2020
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