MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Neonatal Discharge Criteria-OH MCD-MM-1229 06/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Neonatal Discharge Criteria-OH MCD-MM-1229Effective Dat e: 06/01/2025The 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 morbidity 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 Sacroiliac Joint Procedures-OH MCD-MM-0010 05/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology asses sment 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 diagnos is or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services m eet 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 C overage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the 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 a s 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: 05/01/2025The 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 a nd twelve weeks , and chronic when persisting for at least three months. Up to 10% to 25% of patients with persistent low back pain may have a component of pain related to sacroiliac joints (SIJ) . Comprehensive pain management care plans aremost 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 o f pain on a patients daily life, even if the pain cannot be relieved completely. In addition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic treatments, nonsurgical interventions, and surgical interventi ons. 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 med ication 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 a nother 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 follow – 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, incre ased pain, inability to physically perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 05/01/2025The 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 Electrica l 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 stimulat ing the release of endorphins. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy 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 injecti ons 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 injections: CareSource considers up to 2 diagnostic sacroiliac joint 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. pain and tenderness are located in sacroiliac joint region and cause functional disability 3. positive response to at least one SIJ pain provocation test (e g, 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. Therapeu tic i njections : CareSource considers therapeutic sacroiliac joint 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: 05/01/2025The 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 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 tog ether (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 m anagement 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 anesthes ia 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. Radiof requency 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 radiofrequency ablation for SI Jpain per side per rolling 12 months is considere d 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: 05/01/2025The 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 joint-mediated low back pain is considered not medically n ecessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. 3. Pain management literature highlighting controlled studies of SI joint pain management has not demonstrated the effectiveness of RFA as a long-term mana gement 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 U pdate: 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: upd ated references, approved at Co mmittee Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 Date Effective 05/01/2025Date 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. Subacute and chronic low back pain: nonsurgical in terventional treatment. UpToDate. Updated May 15, 202 4. Accessed January 15, 20 25 . 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, an d 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 January 15, 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. Maas ET, Ostelo RWJG, Niemisto L, et al. Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev . 2015(10):CD008572. doi:10.1002/14651858.CD008572.pub2 9. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for face t 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 January 15, 2025 . www.painp hysicianjournal.com 10. 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 11. 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 2016;65:1021-1025. doi:10.15585/mmwr.mm6538a1 12. Szadek K, Cohen SP, de Andres Ares J, et al. Sacroiliac joint pain. Pain Pract. 2023 ;00:1-20. doi:10.1111/papr.13338 13. Wu L, Tafti D, Varacallo M. Sacroiliac joint injection. StatPearls . StatPearls Publishing; 2023. Updated August 4, 2023. Accessed January 15, 2025 . www.ncbi.nlm.nih.g ov Sacroiliac Joint Procedures-OH MCD-MM-0010Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 Independent Medical Review January 2025Approved by ODM 02/20/2025
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295 05/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions a s 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: 05/01/2025The 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 – management and aim to reduce the impact of pain on a patients daily life, even if t he pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. 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 l ow 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 vasculari zed 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 sclerosis. Analysis of Modic lesion s shows that MC I is characterized by high bone turnover, MC II is character ized 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 pathw ay without causing excessive sensory loss, motor dysfunction,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 regio n 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: 05/01/2025The 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 physically perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inab ility 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 c ounter [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 perce ption of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy 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: 05/01/2025The 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 adequat ely 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 abov e criteria. Intraosseous basivertebral nerve ablation isconsidered not medically necessary for all other indications.E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/30/2022 New PolicyDate Revised 03/01/2023 01/31/202401/29 /202 5Annual review: restructured conservative therapy, added HEP and TENS to definitions . Annual review: updated references. Approved at Committee Review: updated references, approved at Committee. Date Effective 05/01/2025 Date Archived Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 H. References1. Becker S, Hadjipavlou A, Heggeness MH. Ablation of the basivertebral nerve for treatment of back pain: a clinical study. Spine J. 2017;17(2):218-223 . doi :10. 1016/j.spinee.2016.08.032 2. Evidence Ba sed Clinical Guidelines for Multidisciplinary Spine Care : Diagnosis and Tr eatment of Low Back Pain . North American Spine Society ; 2020 . Accessed January 2, 2025 . www.spine.org 3. Evolving Evidence Review: Intracept Intraosseous Nerve Ablation System (Relievant Medsystems Inc.) for Treatment of Adults with Low Back Pain. Hayes ; 2023. Reviewed April 17, 2024. Accessed January 2, 202 5. www.evidence.hayesinc.com 4. 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 :10.1 4444/6015 5. 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 6. Lorio M, Clerk-Lamalice O, Rivera M, L ewandrowski K. ISASS policy statement 2022: literature review of intraosseous basivertebral nerve ablation. Int JSpine Surg. 2022;16(6):1084-1094. doi:10.14444/8362 7. McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain-related healthcare ut ilization following intra osseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. Pain Med . 2024;25:20-32. doi:10.1093/pm/pnad114 8. 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 9. 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 10. Sayed D, Naidu RK, Patel KV, et al. Best practice guidelines on the diagnosis and treatment of vertebrogenic pain and basivertebral n erve ablation from the American Society of Pain and Neuroscience. JPain Res . 2022;15:2801-2819. doi:10.2147/JPR.S378544 11. Smuck M, Khalil J, Barrette K, et al. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the t reatment of chronic low back pain: 12-month result. Reg Anesth Pain Med. 2021;46:683-693. doi:10.1136/rapm-2020 – 102259 12. 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 13. U.S. Food and Drug Administration. 510(k) Premarket Notification: Intracept Intraosseous Nerve Ablation System , 510( k) approval K 222281; 2022. Accessed January 2, 202 5. www.accessdata.fda.gov Intraosseous Basivertebral Nerve Ablation-OH MCD-MM-1295Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 14. U.S. Food and Drug Administration. 510(k) Premarket Notification: RelievantMedsystems RF Generator , 510( k) number: K171143; 201 7. Accessed January 2, 202 5. www.accessdata.fda.gov 15. Viswan athan 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 02/ 06/2 025
MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Adaptive Seating for Special Needs-OH MCD-MM-1718 05/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectAdaptive Seating for Special Needs B. BackgroundCerebral palsy, developmental delays, Down syndrome , and other health conditions may compromise an individuals ability to maintain a sitting posture , muscle tone, and movement . Depending on the severity and type of health condition, individuals may require support for the head, trunk, pelvis, and legs limit ing the ability to interact with others, eat, dress, work, and play. In addition, the se individuals may lack the stability and strength for mobility or transfers. Adaptive seating systems (AdSS) may be used by individuals to achieve and hold anupright sitting position , enabl ing individuals to engage with others and conduct activities of daily living. AdSS can be individualized to meet the unique needs of the person with accessories that allow for the seats to tilt, adjust seat height, increase posture support, transfers, and for limited mobility in the local environment . C. Definitions Adaptive Desks Generally considered furniture and used to support physical and educational needs in a school setting. Adaptive Seating Systems (AdSSs) Equipment designed to improve safety, efficiency of movement , and optimize positioning while promoting active participation in daily activities . There are 2 types : o Activity Chairs Seats that o ptimiz e positioning (eg, adaptive chairs, special needs chairs, pediatric positioning chairs, sitters, and therapy chairs ). o High-Low Chairs Height adjustable seats that secure the individual at the midline with adjustable trunk support, shoulder straps, and hip belts. Adaptive Strollers Strollers with increased seating and positioning options than a basic stroller . D. PolicyI. Adaptive Seating Systems (AdSS) and Accessories A. Adaptive Seating Systems A review of medical necessity must occur prior to purchase/delivery of the item. CareSource considers AdSS medically necessary when ALL the following clinical criteria are met: 1. A prescription valid for 1 year is written by any of the following providers with an established relationship with the member and appropriate certifications or training after document ing a completed face-to-face encounter : a. physician b. advanced practice registered nurse c. physician assistant Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 2. Documentation that the member cannot safely sit in conventional seating due to a medical condition, modifications to the members current seating equipment cannot meet their needs, and at least 1 of the following criteria: a. significant head and/or trunk instability or weakness with decreased motor control b. requires external support to maintain an upright position and proper body alignment c. has no functional protective or righting reaction d. must be in an upright su pported position for safe and effective feeding and would otherwise have to be held by the caregiver for feeding e. severe seizure activity f. orthopedic condition resulting in significant bony fragility or significant fracture 3. A physical therap ist (PT) or occupational therapist (OT) experienced in an appropriate specialty and independent from the equipment vendor completed an evaluation and documented that the member can benefit from and safely use the item requested. 4. An y person-centered service plans for the member, when applicable, must list use of AdSS. 5. A complete description of the item requested, including: a. manufacturer b. model of style c. size d. all bundled components e. any accessories or not-included components f. any itemization of all charges B. Accessories 1. Accessorie s are considered medically necessary when they provide additional functional support than is offered by a chair alone and any of the following criteria are met : a. cannot maintain head control in an upright position b. unable to perform a functional weight shift requiring relief to prevent pressure injuries c. needs additional trunk support that is not provided by the chair alone d. changes in muscle tone affecting body tilt or needs additional support for proper digestion or avoidance of severe gastro esophageal reflux e. needed for independent movement in and out of the chair or repositioning the chair to complete daily activities II. Exclusions and LimitationsA. AdSS does not include ANY of the following: 1. adaptive desks 2. adaptive strollers 3. any items not meeting the medical necessity criteria in this policy Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 B. Duplicative equipment is excluded. Equipment with the same function as an existing AdSS will not be reviewed for medical necessity. C. AdSS must be the lowest cost alternative that addresses the members health condition. D. AdSS is for the benefit of the member and not for any caregiver, family member, or provider convenience. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 12/04/2024 New policy. Approved at Committee.Date Revised Date Effective 05/01/2025 Date Archived H. References1. Angsupaisal M, Maathuis CGB, Hadders-Algra M. Adaptive seating systems in children with severe cerebral palsy across International Classification of Functioning, Disability, and Health for children and youth version domains: a systematic review. Dev Med Child Neurol . 2015;57(10):919-930. doi:10.1111/dmcn.12762 2. Barkoudah E, Whitaker A. Cerebral palsy: treatment of spasticity, dystonia, and associated orthopedic issues. UpToDate. Updated Nov 17, 2023. Accessed January 3, 2025 . www.uptodate.com 3. Hale LW, Martin C. Autism spectrum disorder in children and adolescents: behavioral and educational interventions. UpToDate. Updated October 22, 2024. Accessed January 3, 2025 . www.uptodate.com 4. Inthachom R, Prasertsukdee S, Ryan SE, et al. Evaluation of the multidimensional effects of adaptive seating interventions for young children with non-ambulatory cerebral palsy. Disabil Rehabil Assist Technol . 2021;16(7):780-788. doi:10.1080/17483107.2020.1731613 5. Khan I, Leventhal BL. Developmental Delay . StatPearls Publishing; 2023. Accessed January 3, 2025 . www.ncbi.nlm.nih.gov 6. Lyman J. Complex rehabilitation fact sheet. Cerebral Palsy Foundation. Published August 16, 2022. Accessed January 3, 2025 . cpresource.org 7. Paleg G, Livingstone R, Rodby-Bousquet E, et al. Care Pathways central hypotonia. American Academy of Cerebral Palsy and Developmental Medicine. Accessed January 3, 2025 , 2024. www.aacpdm.org Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 8. Provider recommendations for FY 2024 budget medical care advisory committee meeting June 2022. National Council for Assistive & Rehab Technology. Accessed January 3, 2025 , 2024. www.ncart.us9. Ryan SE. Lessons learned from studying the functional impact of adaptive seating interventions for children with cerebral palsy. Dev Med Child Neurol . 2016;58 (Suppl 4):78-82. doi:10.1111/dmcn.13046 10. Saihinoglu D, Coskun G, Bek N. Effects of different seating equipment on postural cont rol and upper extremity function in children with cerebral palsy. Prosthet Orthot Int . 2017;41(1):85-94. doi:10.1177/0309364616637490 Independent medical review December 2024ODM approved 1/23/2025
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