MEDICAL POLICY STATEMENT Ohio MyCare Policy Name & Number Date Effective Personal Emergency Response Systems-OH MyCare-MM-1010 04/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin icalguidelines, 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 theMedical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence ofCoverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Polic ies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Personal Emergency Response Systems-OH MyCare-MM-1010Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPersonal Emergency Response System B. BackgroundPersonal Emergency Response Systems (PERS) are devices with an integrated service that can secure help in the event of an emergency. Currently available PERS allow for communication between the user and responders with additional services and alarms incorporated into the device depending on the sophistication of the device. Trained personnel at a remote monitoring station respond to a members alarm signal via the individuals PERS equipment. PERS can provide safety , assist in medication adherence, and allow for independent living when part of the physicians prescribed plan of treatment . C. Definitions Personal Emergency Response System (PERS) Includes telecommunications equipment, a central monitoring station, and a medium for two-way, and hands-free communication between the individual and the station. This does not include remot e video monitoring of the individual in the home or systems that only connect to emergency service personnel. D. PolicyI. The use of a PERS in a members home may be medically necessary when ALL of the following criteria are met: A. Documentation by the members provider of ALL of the following : 1. specific clinical diagnoses and/or physical-functional limitations which serve as an indication for a PERS 2. how t he PERS specifically will improve member safety and facilitate continued residence in the home setting B. The member retains an appropriate mobile or landline phone system that will support the PERS device . C. To be eligible for PERS service, the member is assessed by CareSource Case Management to be: 1. frail and functionally impaired 2. living alone or with another functionally impaired person 3. willing to arrange for private line telephone service , if private line is not currently in place OR willing to sign a form saying that the member has accepted a wireless mobile device as an alternative 4. mentally and physically able to use the equipment appropriately D. CareSource follows OAC waiver guidelines (OAC 5160-44-02 , OAC 5160-58-04, OAC 5160-44-16 , and OAC 5160-46-06 ). E. The PERS does not includ e any of the following: 1. remote video monitoring of the individual in home 2. systems that connect the individual to only emergency service personnel Personal Emergency Response Systems-OH MyCare-MM-1010Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 E. Conditions of CoverageN/A F. Related Polic ies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 09/01/2020Date Revised 03/3 0/202 2 02/01/2023 01/31/2024 12/18/2024No changes; Updated references. No changes; Updated references Annual review: updated background, addition of Section I. E. to the Policy, and updated References. Approved at Committee. Annual review: added OAC rule to policy and updated references. Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. A full guide to personal emergency response systems (PERS). Accessed December 9, 2024. alwaysbestcare.com 2. Bat-Erdene BO, Saver JL. Automatic acute stroke symptom detection and emergency medical systems alerting by mobile health technologies: a review. JStroke Cerebrovasc Disc. 2021;30(7):105826. doi:10.1016/j.jstrokecerebrovasdis.2021.105826 3. Breaux E. 7 Best medical alert systems of 2024: expert tested & reviewed. National Council on Aging. Updated December 1, 2024 . Accessed December 9 , 2024. www.ncoa.org 4. Evidence Review: New Technologies: Epilepsies in Children, Young People and Adults: Diagnosis and Management. National Institute for Health and Care Excellence (NICE); 2022. Accessed December 9, 2024. www.pubmed.ncbi.nlm.nih.gov 5. Falls and fractures in older adults: causes and prevention. National Institute on Aging. Reviewed September 12, 2022. Accessed December 9 , 2024. www.nia.nih.gov 6. Get the facts on falls prevention. National Council on Aging. Updated June 1, 2024 . Accessed December 9 , 2024. www.ncoa.org 7. Golas SB, Nikola-Simons M, Palacholla R, et al. Predictive analytics and tailored interventions improve clinical outcomes in older adults: a randomized controlled trial. NPJ Digit Med . 2021;4(1):97. doi:10.1038/s41746-021-00463-y 8. Goyer A. How to choose a medical alert system. AARP. Updated November 20, 2024 . Accessed December 9 , 2024. www.aarp.org Personal Emergency Response Systems-OH MyCare-MM-1010Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 9. Jehu DA, Davis JC, Falck RS, et al. Risk factors for recurrent falls in older adults: a systematic review with meta-analysis. Maturitas. 2021;144:23-28. doi:10.1016/j.maturitas.2020.10.021 10. Lachal F, Tchalla AE, Cardinaud N, et al. Effectiveness of light paths coupled with personal emergency response systems in preventing functional decline among the elderly. SAGE Open Med . 2016;4 :1-8. doi:10.1177/2050312116665764 11. Nursing Facility-Based Level of Care Home and Community-Based Services Programs: Person-Centered Planning, OHIO ADMIN . CODE 5160-44-02 (2021). 12. Nursing Facility-Based Level of Care Home and Community-Based Services Programs: Personal Emergency Response Systems , OHIO ADMIN . CODE 51 60-44-16 (202 4). 13. MyCare Ohio Waiver: Covered Services and Providers, OHIO ADMIN . CODE 5160-58 – 04 (2019). 14. ODA Provider Certification: Personal Emergency Response System, OHIO ADMIN . CODE 173-39-02.6 (2019). 15. Ohio ho me care waiver program : reimbursement rates and billing procedures , OHIO ADMIN . CODE 5160-46-06 (2024 ). 16. Okuboyejo S, Eyesan O. mHealth: using mobile technology to support healthcare. Online JPublic Health Inform . 2014;5(3):233. doi:10.5210/ojphi.v5i3.4865 17. Stokke R. The personal emergency response system as a technology innovation in primary health care services: an integrative review. JMed Internet Res . 2016;18(7):e187. doi:10.2196/jmir.5727 18. Thorton K, Caprio Y. Community-based care. July 2018. Accessed December 9 , 2024. www.geriatricscareonline.org
MEDICAL POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Peroral Endoscopic Myotomy-OH MyCare-MM-1309 04/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 H. References ………………………….. ………………………….. ………………………….. …………………….. 4 Peroral Endoscopic Myotomy-OH MyCare-MM-1309Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPeroral Endoscopic Myotomy B. BackgroundAchalasia (ie, failure to relax) is a rare esophageal disorder that affects about 1 in every 100,000 people and is usually associated with difficulty swallowing. Most people are diagnosed between the ages of 25 and 60 years. Achalasia occurs when nerves in the esophagus become damaged. As a result, the esophagus becomes paralyzed and dilated over time and eventually loses the ability to squee ze food down into the stomach. Although the condition cannot be cured, the symptoms can usually be controlled with treatment. Treatments for achalasia include oral medica tions, dilation or stretching of the esophagus, surgery (open and laparoscopic), endoscopic surgery, and injection of muscle-relaxing medicines (botulinum toxin) directly into the esophagus. Peroral endoscopic myotomy (POEM) is a procedure developed in Japan that isperformed with the patient under general anesthesia. Studies suggest that POEM can achieve results comparable to or even better than those of pneumatic balloon dilation and laparoscopic Heller myotomy with similar safety. However, POEM is a newer procedure, and long-term outcome data is limited. POEM is a form of natural orifice transluminal endoscopic surgery. The procedure is performed perorally, without any incisions in the chest or abdomen. The advantage of this approach is to reduce procedure-related pain and return patients to regular activi tiessooner than surgeries requiring external incisions.C. Definitions Achalasia A rare disorder making it difficult for food and liquid to pass from the swallowing tube connecting the mouth and stomach. In achalasia, nerve cells in the esophagus degenerate. As a result, the lower end of the esophagus , the lower esophageal sphincter (LES) , fails to open to allow food into the stomach, leading to complications (eg, coughing, choking, aspiration pneumonia, ulceration, and weight loss ). There are three different achalasia types : o Type I Characterized by minimal esophageal pressurization , this type is associated with incomplete relaxation of the LES, a lack of mobility in terms of contraction and relaxation, and a small amount of pressure built up in the esophagus. o Type II Indicated by esophageal compression , this type is more severe with more massive compression in the esophagus, often caused by the failure to relax and the build-up of pressure in the esophagus, typically from food. o Type III With spasms that result in sudden, abnormal squeezing of the esophagus and the LES , this type is the most severe and can also elicit the most serious symptoms (eg, chest pains that may mimic those of a heart attack and spasms that can wake a person from sleep ). Peroral Endoscopic Myotomy-OH MyCare-MM-1309Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Eckardt Symptom Score The grading system most frequently used for the evaluation of symptoms, stages, and efficacy of achalasia treatment. It attributes points (0 to 3 points) for four symptoms of the disease (dysphagia, regurgitation, chest pain, and weight loss), with scores r anging from 0 to 12 . Gastroesophageal Reflux Disease (GERD) A chronic disorder that occurs when stomach bile or acid flows into the esophagus and irritates the lining. Laparoscopic Heller Myotomy (LHM) A minimally invasive, surgical procedure used to treat achalasia. Pneumatic Balloon Dilation (PD) An endoscopic therapy for achalasia. An air – filled cylinder-shaped balloon disrupts the muscle fibers of the lower esophageal sphincter, which is too tight in patients with achalasia. D. PolicyI. CareSource considers the POEM procedure to be medically necessary whe n all the following clinical criteria is met: A. The member has a diagnosis of primary achalasia, types I, II, or III . B. POEM is being proposed after the patient has tried and failed conventional therapy, including pneumatic dilation or is not a surgical candidate for Heller myotomy . C. Eckardt symptom score is greater than or equal to 3. D. There is no history of previous open surgery of the stomach or esophagus. II. Members 18 or younger should be reviewed for medical necessity.III. POEM for any other indication is considered experimental, investigational , and unproven. IV. Contraindications for this procedure are as follows :A. severe erosive esophagitis B. significant coagulation disorders C. liver cirrhosis with portal hypertension D. severe pulmonary disease E. esophageal malignancy F. prior therapy that may compromise the integrity of the esophageal mucosa or lead to submucosal fibrosis, including recent esophageal surgery, radiation, endoscopic mucosal resection, or radiofrequency ablation V. Previous therapies for achalasia (eg, PD, botulinum toxin injection, LHM ) are not contraindications to POEM. VI. Members receiving POEM should be made aware there is a high risk in develop ingGERD and will need to be advised of management considerations prior to undergoing the procedure. Peroral Endoscopic Myotomy-OH MyCare-MM-1309Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 E. Conditions of CoverageN/A F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 02/15/2023 New policyDate Revised 02/14/2024 12/18/2024Annual review: title has been altered to remove the acronym, editorial changes to policy document language, deleted POEM definition, lowered Eckardt symptom score criteria to 3 to match LCD, changed reflux esophagitis in Section D.V. to GERD to match LCD , and updated references. Approved at Committee. Annual review: updated age requirement and references. Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. Aiolfi A, Bona D, Riva CG, et al. Systematic review and bayesian network meta – analysis comparing laparoscopic Heller myotomy, pneumatic dilatation, and peroral endoscopic myotomy for esophageal achalasia. JLaparoendosc Adv Surg Tech A . 2020;30(2):147-155. doi:10.1089/lap.2019.0432 2. Familiari P, de Andreis FB, Landi R, et al. Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomized controlled trial. Gut . 2023;72(8):1442-1450. doi:10.1136/gutjnl-2021-325579 3. Health technology assessment: peroral endoscopic myotomy for treatment of esophageal achalasia. Hayes; 2019. Reviewed March 7, 2023. Accessed December 5, 2024. www.evidence.hayes.inc.com 4. Khashab MA, Vela MF, Thosani N, et al . ASGE guideline on the management of achalasia. Gastrointest Endosc . 2020;91(2):213-227 . doi:10.1016/j.gie.2019.04.231 5. Khashab MA, Kumbhari V, Tieu AH, et al. Peroral endoscopic myotomy achieves similar clinical response but incurs lesser charges compared to robotic Heller myotomy. Saudi JGastroenterol . 2017;23(2):91-96. doi:10.4103/1319-3767.203360 6. Kohn GP, Dirks RC, Ansari MT, et al. SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia. Surg Endosc . 2021;35(5):1931-1948. doi:10.1007/s00464-020-08282-0 7. Meng F, Li P, Wang Y, et al . Peroral endoscopic myotomy compared with pneumatic dilation for newly diagnosed achalasia. Surg Endosc . 2017;31(11):4665-46 72 . doi:10.1007/s00464-017-5530-0 Peroral Endoscopic Myotomy-OH MyCare-MM-1309Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 8. Patel DA, Lappas BM, Vaezi MF . An overview of achalasia and its subtypes.Gastroenterol Hepatol . 2017 ;13(7): 411-421. Accessed December 5 , 2024. www.ncbi.nlm.nih.gov 9. Schneider AM, Louie BE, Warren HF, et al . A matched comparison of per oral endoscopic myotomy to laparoscopic Heller myotomy in the treatment of achalasia. J Gastrointest Surg . 2016;20(11):1789-17 96 . doi:10.1007/s11605-016-3232-x 10. Spechler SJ. Achalasia: pathogenesis, clinical manifestations, and diagnosis . UpToDate. Updated July 3, 2024. Accessed December 5 , 2024. www.uptodate.com 11. Tan S, Zhong C, Ren Y, et al. Efficacy and safety of peroral endoscopic myotomy in achalasia patients with failed previous intervention: a systematic review and meta – analysis. Gut Liver . 2021;15(2):153-167. doi:10.5009/gnl19234 12. Vaezi MF, Pandolfino JE, Yadlapati RH, et al. ACG clinical guidelines: diagnosis and management of achalasia: diagnosis and management. Am JGastroenterol . 2020;115(9):1393-1411. doi:10.14309/ajg.0000000000000731 13. Vespa E, Pellegatta G, Chandrasekar VT, et al. Long-term outcomes of peroral endoscopic myotomy for achalasia: a systematic review and meta-analysis. Endoscopy . 2023;55(2):167-175. doi:10.1055/a-1894-0147 Independent med ical review March 2022
MEDICAL POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Non-Emergency Facility to Facility Transfers-OH MyCare-MM-1489 04/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider 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 Medica l Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Non-Emergency Facility to Facility Transfers-OH MyCare-MM-1489 Effective Dat e: 04/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNon-Emergency Facility to Facility Transfers B. BackgroundThis policy addresses the necessity of transferring a patient to a second acute care facility (receiving facility) when the individual requires care not available at the original facility. The goal of any transfer is to maintain the optimal health of the patient. This is accomplished by transferring the patient to the nearest facility that provides the highest specialized care needed. Inter-hospital patient transfer is an important aspect of patient care, most often toimprove patient management. During such transfers, there must be continuity of medical care. Key elements include the decision to transfer and communication, pre-transfer stabilization and preparation, choosing the appropriate mode of transfer, personnel accompanying the patient, equipment and monitoring required during the transfer, and documentation and handover of the patient at the receiving facility. Transfer, admission , and subsequent care to the receiving facility is not medicallynecessary when the needed care is available at the originating facility.C. Definitions Non-Emergency A situation for which immediate response is not needed for the provision of medical treatment. Inter-Facility Transfer The transfer of patients between two healthcare facilities. Intra-Facility Transfer The transfer of patients within the same facility. Originating Facility The current facility to which an individual has been admitted for care and from which a transfer is planned. Participating (In-Network) Facility Facility that is contracted with CareSource. Non-Participating (Out-of-Network) Facility Facility that is not contracted with CareSource. Receiving Facility The facility to which a transfer is planned. D. PolicyI. The following non-emergency transfers require a prior authorization : A. A non-emergency transfer from a participating inpatient facility to a participating inpatient facility that is not within the same healthcare system. B. A non-emergency transfer from a non-participating facility to a participating facility. C. A non-emergency transfer from a non-participating facility to a non-participating facility. II. For non-emergency transfers that require a prior authorization , the receiving facility submits the prior authorization request to CareSource. Non-Emergency Facility to Facility Transfers-OH MyCare-MM-1489 Effective Dat e: 04/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 III. Requests for transfers that require a prior authorization must meet the following criteria: A. Member must be medically stable for transfer AND 1. Member requires transfer to a level of care which is not available at the originating facility . 2. Member requires transfer for a medically necessary diagnostic or therapeutic service which is not available at the originating facility . 3. Member requires transfer for services of a specialist to evaluate, diagnose , or treat their condition when that specialist is not available at the originating facility . 4. Member requires transfer because member has received care at a specific prior institution for a condition not normally managed at the originating facility and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue . 5. Member requires transfer to improve the health and welfare of the member (ie, parental bonding) . 6. Transfer to allow a parent who gave birth to remain with the neonate is considered medically necessary when the neonate transfer meets the medically necessary criteria listed above and the parent who gave birth requires continued hospitalization due to birth complications or other medically necessary conditions . IV. The following non-emergency transfers do not require a prior authorization :A. Inter-facility transfers within the same healthcare system . B. Intra-facility transfers within the same facility . V. Non-emergency (elective) transfers are not a covered service for the following:A. The criteria above have not been met . B. The transfer is for the convenience of the member , the members family, the physician, or the originating facility . E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/15/2023 New policy. Approved at Committee.Date Revised 02/14/2024 01/15/2025Annual review No changes to content. Updated references. Approved at Committee.Annual review. Updated prior authorization language to review of medical necessity and references. Approved at Committee. Non-Emergency Facility to Facility Transfers-OH MyCare-MM-1489 Effective Dat e: 04/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 Date Effective 04/01/2025Date Archived H. References1. Appropriate interhospital patient transfer. American College of Emergency Physicians. January 2022. Accessed December 16, 2024. www.acep.org 2. Discharges and Transfers, 42 C.F.R. 412.4 (202 4). 3. Heaton JK. EMS Inter-Facility Transport. StatPearls . StatPearls Publishing; 2022. 4. Obstetric Care Consensus Number 9. Levels of Maternal Care. American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM); 2019. Accessed December 16, 2024. www.acep.org Independent med ical review 02/21/2023
MEDICAL POLICY STATEMENTOhio MyCare Policy Name & Number Date Effective Home Health Services-OH MyCare-MM-1271 04/01/2025 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 t echnology 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, dysfunctio n 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 an y 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 servic es. 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 Cove rage), 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 behavior al 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/R ules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 Home Health Services-OH MyCare-MM-1271Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDI CAL 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 reside 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 otherwise require services in an acute care or residential facility. These guidelines for medical necessity determination identify clinical information thatCareSource uses to determine medical necessity 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.MyCare providers must utilize State plan services before accessing waiver nursing or aide services. C. Definitions 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 a s 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 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 Home Health Services-OH MyCare-MM-1271Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDI CAL Policy Statement Policy and is approved.3 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 t he 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 agreeme nt. A service is not considered a nursing service merely because it is performed by a licensed nurse. 1. Home Health Nursing Services include, but are not limited to, the following: a. IV insertion, removal, or discontinuation b. IV medication administration c. programming of a pump to deliver medications including, but not limited to , epidural, subcutaneous IV (except routine doses of insulin through a programmed pump) d. insertion or initiation of infusion therapies e. central line dressing changes f. blood product administration 2. Home health nursing services do not include a visit when the sole purpose is for the supervision of the home health aide. Homemaker Services Service s enabling individuals to achieve and maintain clean, safe, and healthy environments, assisting individuals to manage their personal appointments and day-to-day household activities, and ensuring individuals maintain their current living arrangements. The s ervice consists of general household activities, such as meal preparation and routine household care when persons regularly responsible for these activities are temporarily absent or unable to manage the home. Homemaker staff may act as travel attendants f or individuals. Medical Necessity Must meet ALL 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 medica l problem o provides unique, essential, and appropriate information if it is used for diag nosti c Home Health Services-OH MyCare-MM-1271Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDI CAL Policy Statement Policy and is approved.4 purposes o not provided primarily for the economic benefit of the provider nor for th e convenience of the provider or anyone else other than the recipient Skilled Therapies A collective term encompassing physical therapy, occupationa l therapy, speech-language pathology, and audiology. Waiver Personal Care Services Services provided pursuant to the person – centered services plan that assist the individual with activities of daily living (ADL) and instrumental activities of daily living (IADL) needs. If the individual’s person – centered services plan states that the serv ice provided is to be personal care aide services, the service shall never be billed as a nursing service. If the provider cannot perform IADLs, the provider shall notify ODM or its designee, in writing, of the service limitations before inclusion on the i ndividual’s person-centered services plan. D. PolicyI. Home health services , including home health aide and home health nursing , are provided to any CareSource Ohio MyCare member when they are considered medically necessary. II. Duplicative services are not covered.A. There must be documentation of all other therapies/services the member i s receiving, when relevant to home health services. B. If the member is receiving other assistance (eg, meal delivery program, family caregiver, and additional supportive services), this information and the hours involved must be provided to adequately evaluate medical necessity of home health services. C. The aid e 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:A. Routine home health services are considered medically necessary for MyCare members when ALL the following criteria are met: 1. There has been a face-to-face encounter betwe en 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 the most recent written plan of treatment by the agency , 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 Se rvices OR the individual’s current 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 qualifying treating physician, advanced practice registered nurse or physician assistant . Home Health Services-OH MyCare-MM-1271Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDI CAL Policy Statement Policy and is approved.5 5. The home health services will be provided by a Medicare Certified HomeHealth Agency (MCHHA) . 6. The services are provided on a part-time or intermittent basis as follows: a. Total Hours Per Visit: four hours (individuals who require more than four hours of care per visit may qualify for private duty nursing, which is outside the scope of this policy) b. Total Hours Per Day: eight hours combined per day of home health nursing, home health aide, and skilled therapies c. Total Hours Per Week: fourteen hours combined per week of home health nursing and home health aide servi ces 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 when ALL the following criteria are met: 1. There has been a face-to-face encounter between the individual and a qualifying t reating physician, advanced practice registered nurse, or physicia n 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 the most recent written plan of treatment by the agency 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 three 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 institutiona l level of care . 6. The individual requires home health nursing, or a combination of private dut y nursing, home health nursing, or waiver nursing and/or skilled therapy services at least one per week . 7. The home health services will be provided by a Medicare Certified Home Health Agency (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 four hours of care pe r visit may qualify for private duty nursing, 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. Home Health Services-OH MyCare-MM-1271Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDI CAL Policy Statement Policy and is approved.6 IV. Home health services do NOT include respite care.V. Members that have CareSource for their Medicare and Medicaid coverage are considered opt-in members. The following information pertains to these members only: A. The Medicare benefit should be explored based on me mbers skilled service needs prior to use of Medicaid services. B. Process for approval of state plan services The care manager (CM) will complete members initial assessment and determine member s needs utilizing the Aide Norms Tool or similar. 1. State plan se rvices must be implemented as appropriate before waiver services are considered. 2. State plan home health services are covered only if provided on a part-time or intermittent basis as outlined in section III, above. 3. State plan home health services can only b e provided by a Medicare certified agency. 4. State plan home health aide services may include incidental services as long as they do not substantially extend the time of the visit. Incidental services are necessary household tasks that must be performed by s omeone to maintain a home and can include light chores, laundry, light house cleaning, preparation of meals, and taking out the trash. The main purpose of a home health aide visit cannot be solely to provide these incidental services since they are not hea lth related services. Incidental services are to be performed only for the individual and not for other people in the individual’s place of residence . 5. State plan home health services must be provided in the members home . 6. State plan home health services must be prior authorized by CareSource Utilization Management . 7. No state plan home health service is authorized on the service plan. If the assessment indicates member has needs greater than the allowable coverage under state plan home health services, the CM will authorize services under the Waiver benefit. C. Home maker services are not determined through a PA through UM and are inst ead determined by a CM (0903.01 homemaker services for MyCare waiver members procedure) . 1. The CM will determine if a member is a legacy waiver or non-legacy waiver member. Verification can be determined through the Area Agency on the Aging (AAA) by utiliz ation of the PIMS system, verification in Ohio Benefits or MITS. 2. Care Manager will complete the appropriate assessment tools to determine the members needs, for example, the Aide Norms Tool. 3. The CM will determine what hours are appropriate to assign to the personal care code (T1019UA) and what hours are appropriate to assign to the homemaker code (S5130). 4. Application of the homemaking code only applies to legacy Passport Home Health Services-OH MyCare-MM-1271Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDI CAL Policy Statement Policy and is approved.7 members and non-legacy waiver members in the event the personal care code of T1019U A is utilized by the provider. 5. Homemaking services do not include providing personal care services and should be assigned only when the member has no personal care needs. CM must document the times of service for personal care and for homemaking on the se rvice plan within the appropriate authorization. CM should specify how services will be provided on the Aide Norms Tool and in the service plan authorization, including days and times of service. 6. If the member transitions from a legacy waiver with an inco rrect billing code CareSource will not continue with an incorrect billing code/rate. CareSource must ensure the service level remains unchanged but is able to correct the billing code/rate in accordance with OAC. 7. Only ODA certified providers can provide the homemaker service. To determine provider certification and the appropriate rule to follow the CM should reach out to the CareSource team lead or manager. D. Group billing (0902.01 group billing for MyCare waiver members procedure) 1. The CM will determine if a member is a legacy waiver member or non-legacy waiver member. Verification can be determined through the Area Agency on the Aging (AAA) by utilization of the PIMS system or verification in Ohio Benefits or MITS. 2. The CM will as sess the needs of member(s) residing at the same address and determine if the group billing should be applied. 3. CM will complete the appropriate assessment tools to determine each members needs , including the Aide Norms Tool and the Private Duty Nursing Tool. 4. The CM will authorize the appropriate personal care code based on whether the member is a legacy waiver or is a non-legacy waiver member. When utilizing group billing for personal care services, the HQ modifier will be applied based on the determinat ion of whether the member originated from the leg acy waiver or is a non-legacy waiver member. 5. If the member(s) is a legacy waiver member who transitioned to MyCare from Passport, the authorization will be T1019UA. Group billing will be applied when the me mbers receive simultaneous or consecutive personal care visits. The first member to receive services will be coded as T1019UA and payment will be at 100% of the statutory or contracted rate. The second and/or subsequent member(s) to receive services will b e coded as T1019UAHQ and will receive payment at 75% of the statutory or contracted rate in accordance with OAC rule 173-39-02. 6. If the member(s) is a legacy waiver member who transitioned to MyCare from Ohio Home Care Waiver the authorization will be T101 9. Group billing will be applied when the members receive services simultaneously. All members receiving care should be coded as T1019HQ and payment will be made at 75% of the statutory or contracted rate in accordance with the OAC rule 5160-58-04. 7. If the member transitioned from a legacy waiver with an incorrect billing code. Home Health Services-OH MyCare-MM-1271Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDI CAL Policy Statement Policy and is approved.8 CareSource is not obligated to continue with an incorrect billing code/rate. The service level must remain unchanged, but CareSource is able to correct the billing code/rate in accor dance with the OAC. 8. When a member did not transition from a legacy waiver, the group billing requirements of the entity that certified/approved the provider will apply. If the provider is both ODM and ODA certified CareSource may apply either ODMs or ODAs rule on group billing. To determine provider certification and the appropriate rule to follow, the CM should reach out to the CareSource team lead or manager. 9. Waiver nursing services are group billed when nursing services are provided at the same time regardless of legacy waiver. Services would be coded T1002 HQ or T1003 HQ for both memb ers. 10. The application of group billing applies to all types of personal care and nursing providers, including independent providers. VI. General guidelines for care based on the Aide Norms Tool:Task Type General Guideline Mobility (bed, transfer, locomotion) 5 min/ADL inside and 15 min 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 numb er 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 10 min/week E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/16/2022 New policy.Date Revised 06/16/2022 02/01 /202301/17/2024Out-of-cycle update: split criteria III.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 , adjusted Medicare benefit language in D.V.A . Approved at Committee. Home Health Services-OH MyCare-MM-1271Effective Dat e: 04/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDI CAL Policy Statement Policy and is approved.9 01/ 15 /2025 Review: updated references, approv ed at Committee.Date Effective 04/01/2025 Date Archived H. References1. Administrative Procedures for Comprehensive Health Care for Children in Placement, OHIO ADMIN . CODE 5101:2-42-66 (2019). 2. Definitions, OHIO ADMIN . CODE 3701-19-01 (2020). 3. Definitions, OHIO ADMIN . CODE 3701-60-01 (2023). 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). 6. Managed Care: Covered Services, OHIO ADMIN . CODE 5160-26-03 (2022). 7. Home health services. Medicare Benefit Policy Manual . Centers for Medi care and Medicaid Services; 2003. Reviewed December 21, 2023 . Accessed January 15, 202 5. www.cms.gov 8. Medicare Certified Home Health Agencies: Qualification and Requirements, OHIO ADMIN . CODE 5160-12-03 (2015). 9. Payment For Home Health Nursing Services and Home Health Aide Services, OHIO ADMIN . CODE 4123-6-38 (2022). 10. Payment For Nursing and Caregiver Servic es Provided by Persons Other Than Home Health Agency Employees, OHIO ADMIN . CODE 4123-6-38.1 (2022). 11. Reimbursement: Exceptions, OHIO ADMIN . CODE 5160-12-07 (2015). 12. Reimbursement: Home Health Services, OHIO ADMIN . CODE 5160-12-05 (202 4).
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