MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Trigger Point Injections-MP-MM-1317 04/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………… 2 B. Background ………………………….. ………………………….. ………………………….. ……………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ……………………….. 2 E. State-Specific Information ………………………….. ………………………….. …………………………. 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. .. 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. . 4 I. References ………………………….. ………………………….. ………………………….. ………………… 5 Trigger Point Injections-MP-MM-1317Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectTrigger Point Injections B. BackgroundMyofascial trigger points are self-sustaining hyper-irritative foci in any skeletal muscle, often occurring in response to strain produce d by acute or chronic overload. There is no associated neurologic deficit, and the pain may be aggravated by hyperextension of the spine, standing , and walking. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS) which is responsive to appropriate treatme nt. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor. The purpose of a trigger point injection (TPI) is to treat not only the symptom but also the cause through the injection of a single substance (eg, a local anesthetic) or a mixture of substances (eg, a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Interventional procedures for management of pain should be part of a comprehensive pain management care plan that incorporates an initial trial of conservative treatment utilizing appropriate medications, physical therapy modalities and behavioral support , asneeded.Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers acting within their scope ofpractice who are qualified to deliver these health services.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Physician Supervised Home Exercise Program (HEP) A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to ph ysically perform exercises). Member inconvenience or noncompliance without explanation does not constitute an inability to complete. Subacute Pain Pain that has lasted between 4 weeks and 12 weeks. Trigger P oint A hyper excitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. D. PolicyI. Trigger Point Injections Initial Injections A. Trigger point injections of anesthetic and/or corticosteroid for back pain, neck pain, or myofascial pain syndrome are considered medically necessary when pain has persisted despite appropriate medical management and ALL the following criteria are met : Trigger Point Injections-MP-MM-1317Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 1. Member presents with new (acute or subacute) localized pain, occurring in the last 3 months . 2. Member has been refractory or intolerant of conservative therapies for at least 1 month, including at least 1 of the following : a. bed rest b. active exercise c. ultrasound d. range of motio n e. heating or cooling treatments f. massage 3. TPIs are being given as a part of an overall conservative manage ment (usually short term) plan, including at least 1 of the following: a. physical therapy b. occupational therapy c. physician supervised home exercise program (HEP) d. manipulative therapy 4. Pharmacotherapies are being administered, including at least 1 of the following : a. non-steroidal anti-inf lammatory drugs ( NSAIDS ) b. muscle relaxants c. non-narcotic analgesics d. anti-depressants 5. The member must have a diagnosis for which the trigger point injection is an appropriate treatment; ALL the following information must be documented in the medical record: a. proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point b. reason (s) for select ing this therapeutic option c. affected muscle or muscles d. muscle or muscles injecte d and the number of injections e. frequency of injections required f. name of the m edication used in the injection g. results of any prior treatment h. corroborating evidence that the injection is medically necessary B. Localization techniques to image or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. II. Trigger Point Injections Subsequent InjectionsA. Trigger point injections should be repeated only if doing so is reasonable and medically necessary. No more than 8 dates of service per calendar year per member may be reimbursed . B. Injections may be repeated only with documented positive results to the most recent trigger point injection of the same anatomic si te. Documentation should include at least 50% improvement in pain, functioning , and activity tolerance. Trigger Point Injections-MP-MM-1317Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 III. There is no laboratory or imaging test for establishing the diagnosis of trigger points .Diagnosis is dependent upon a detailed history and a thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis: A. history of onset and its cause (injury, sprain, etc.) B. distribution of pain C. restriction of movement D. mild muscle specific weakness E. focal tenderness of a trigger point F. palpable taut band of muscle in which trigger point is located G. local taut respo nse to snapping palpitation H. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point IV. Payment InformationA. Certain trigger point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. B. Payment may be made for 1 unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a pa rticular date. C. A trigger point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (eg, in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. D. Dry needling is not an acceptable alternative to trigger point injections by an appropriately licensed clinician. E. State-Specific InformationN/A F. Conditions of CoverageN/A G. Related Policies/RulesN/A H. Review/Revision HistoryDATE ACTIONDate Issued 04/27/2022 New policy , replacing individual state policiesDate Revised 03/29/2023 02/28 /2024Annual review: updated references, added definition and payment information. Approved at Committee Annual review: moved state-specific information to section E, updated references, approved at Committee. Trigger Point Injections-MP-MM-1317Effective Dat e: 04/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 02/12/202501/14 /2026 Review: updated references, approved at Committee. Review: updated references. Approved at Committee. Date Effective 04/01/2026 Date Archived I. References1. Appasamy M, Lam C, Alm J, Chadwick AL. Trigger point injections. Phys Med Rehabil Clin NAm . 2022;33(2):307-333. doi:10.1016/j.pmr.2022.01.011 2. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated April 29, 2025 . Accessed December 12 , 2025. www.uptodate.com 3. Debrosse M, Sukhman S, Shah A, et al. Trigger point injection therapies for chronic myofascial neck and back pain: a systematic review. Interventional Pain Medicine . 2022; 1(3):100076. doi.org/10.1016/j.inpm.2022.100076 4. Hammi C, Schroader JD, Yeung B. Trigger point injection. StatPearls . StatPearls Publishing; 2024. Updated July 24, 2023. Accessed December 12 , 2025. www.ncbi.nlm.nih.gov 5. Hamzoian H, Zograbyan V. Trigger point injections versus medical management for acute myofascial pain: a systematic review and meta-analysis. Cureus. 2023;15(8):e43424. doi:10.7759/cureus.43424 6. Isaac Z. Management of non-radicular neck pain in adults. UpToDate . Updated September 30, 2025 . Accessed December 12 , 2025 . www.uptodate.com 7. Khoury AL, Keane H, Varghese F, et al. Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief. NPJ Breast Cancer . 2021;7:123. doi:10.1038/s41523-021-00321-w 8. Meyer GW. Anterior cutaneous nerve entrapment syndrome. UpToDate . Updated February 14, 2025 . Accessed Dec ember 12 , 2025 . www.uptodate.com 9. Moynihan LK, Elkadry E. Myofascial pelvic pain syndrome in females: treatment. UpToDate . Updated January 11, 2023 . Accessed December 12 , 2025. www.uptodate.com 10. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: treatment. UpToDate . Updated September 4, 2025 . Accessed December 12 , 2025. www.uptodate .com Independent Medical Review January 2025
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Sacroiliac Joint Procedures-MP-MM-1314 03/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectSacroiliac Joint Procedures B. BackgroundNearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent. Persistent pain is categorized as subacute when lasting between four and twelve weeks, and chronic when persisting for at least three months. Up to 10% to 30 % of patients with persistent low back pain may have a component ofpain related to sacroiliac joints (SIJ) . Comprehensive pain management care plans are most effective in managing a patients chronic pain. These plans focus on a person – centered approach and incorporate conservative treatment with other modalities. These multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a pa tients daily life, even if the pain cannot be relieved completely. In add ition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic treatments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative t reatment should be provided only by physicians qualified to deliver these health services. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be effective for diagnostic purposes but provide limited short-term relief from pain resulting from SI Jdysfunction. Long-term use has not be en adequately studied to establish standards of care. Radiofrequency ablation (RFA) is another treatment method, which uses heat to destroy nerves. RFA for the treatment of low back pain has inconsistent results in the peer-reviewed medical literature with l imited 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 multimodal plan of care including both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen supporting muscle groups and target key spinal structures, including physical therapy, occupational therapy, physician supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Inactive Conservative Therapies Passive activit ies by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS use , and/or pharmacotherapy (prescription or over the counter [non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphin s. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Functional Disability Acquired difficulty in performing basic everyday tasks or more complex tasks needed for independent living. Radiofrequency Ablation (RFA) Minimally invasive treatment modality that percutaneously introduces an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. Sacroiliac Joint (SIJ) Injections Corticosteroid and local anesthetic therapeutic injections into the SIJ to treat pain that has not responded to conservative therapies. D. PolicyI. Sacroiliac Joint Injections A. Diagnostic injection s: CareSource considers up to 2 diagnostic SIJ injections for the treatment of chronic low back pain medically necessary when ALL the following criteria are met: 1. somatic or nonradicular low back and/or lower extremity pain experienced for at least 3 months 2. severe pain (ie. at least a 6 out of 10 on pain scale) and tenderness located in the SIJ region that cause functional disability 3. positive response to at least 3 SIJ pain provocation test (eg, distraction, compression, thigh thrust, Gaenslens, Patricks test/FABER test, sacral thrust) 4. failure of conservative therapy, as evidenced by ALL the following: a. documentation in the medical record of at least 6 weeks of active conservative therapy ( as defined above ) within the past 6 months OR inability to complete active conservative therapy due to contraindication, increase d pain, or intolerance b. documentation in the medical record of at least 6 weeks of inactive conservative therapy (as defined above ) within the past 6 months 5. if a second diagnostic injection is requested, at least 1 week has passed since the initial injection B. Therapeutic injections: CareSource considers therapeutic sacroiliac joint injections medically necessary when ALL the following criteria are met: 1. most recent SIJ injection led to at least 75 % pain relief and functional improvement 2. member experiences return of severe pain or deterioration in function Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 3. injection is used in conjunction with conservative therapy (as defined above)4. injection is repeated at a frequency no greater than every 2 months 5. no more than 4 injections total (diagnostic and therapeutic) have been administered at the same site in the last 12 months C. Exclusions/Limitations: 1. Codes 64451 and 27096 may not be billed together (on the same date for the same side of the body). Only one code will be reimbursed . 2. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately. 3. If neural blockade is applied for different regions or different sides, injections are performed at least one week apart. 4. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated injections of the SIJ to be effective as a long-term management modality. Long-term continuation may be subject to medical necessity review. 5. Monitored anesthesia and conscious sedation are not medically necessary. 6. The use of SI Jinjections for the treatment of pain as a result of Herpes Zoster is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. II. Radiofrequency Ablation of the S IJA. Initial radiofrequency ablation of the SIJ 1. Radiofrequency ablation is considered medically necessary when ALL the following have been met in the last 6 months: a. The clinical criteria 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 a reported 75% or greater reduction in pain after injection. B. Repeat radiofrequency ablation of the SIJ 1. Conservative therapy and diagnostic injections are not required if there has been a reduction in pain for at least 12 months or more from the initial RFA within the last 36 months. 2. When there has not been a repeat RFA in the last 36 months, a diagnostic injection is required. 3. A maximum of 1 RFA for SI Jpain per side per 12 months is considered medically necessary. C. Exclusions/Limitations 1. The use of cooled RFA for SI J-mediated low back pain is considered not medically necessary due to insufficient evidence demonstrating efficacy in the peer-reviewed published literature. 2. Pain management literature highlighting controlled studies of SI Jpain management has not demonstrated the effectiveness of RFA as a long-term management modality. Long-term continuation may be subject to medical necessity review. Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 III. Implantable Spinal Cord StimulatorsMember s 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 properl y, an escalation in pain may warrant evaluation and management of the implanted device. E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 04/13/2022 New policyDate Revised 03/01/2023 01/31/202401/29/202512/17 /2025 Annual review: restructured conservative management and clinical criteria , added provocation tests Annual review: updated references and formatting , moved state-specific information to section E, approved at Committee. Review: updated references, approved at Committee. Review: added pain level criteria, increased number of provocation test positives and updated references. Approved at Committee. Date Effective 03/01/2026 Date Archived I. References1. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):493-505. doi:10.7326/M16-2459 2. Chou R , Cohen SP . Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated April 29 , 202 5. Accessed No vember 24 , 2025 . www.uptodate.com 3. Cine HS, Uysal E, Demirkol M, Cetin E. Under what conditions is the intra-articular steroid injection superior to nonsteroidal anti-inflammatory drugs for treating sacroiliac joint pain? Eur Rev Med Pharmacol Sci . 2023;27(21):10539-10546. doi:10.26355/eurrev_202311_34331 Sacroiliac Joint Procedures-MP-MM-1314Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 4. 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 5. Janapala RN, Knezevic E, Knezevic NN, et al. Systematic review and meta-analysis of effectiveness of therapeutic sacroilic joint injections. Pain Physician . 2023;26:E413-E435. Accessed November 24 , 2025 . www.painphysicianjournal.com 6. Lee DW, Pritzlaff S, Jung MJ , et al. Latest evidence-based application for radiofreqneucy 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 7. Liu Y, Suvithayasiri S, Kim JS. Comparative efficacy of clinical interventions for sacroiliac joint pain: systematic review and network meta-analysis with preliminary design of treatment algorithm. Neurospine . 2023 Sep;20(3):997-1010. doi: 10.14245/ns.2346586.293. 8. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint inerventions 2020 guidelines. Pain Physician. 2020;23(3S):S1-S127. Accessed November 24 , 2025 . www.painphysicianjournal.com 9. Sacroiliac Joint Injection: A-1048 (AC). MCG. 29 th ed. Updated June 23, 2025. Accessed December 1, 2025. www.careweb.careguidelines.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. Szadek K, Cohen SP, de Andres Ares, J, et al. Sacroiliac joint pain. Pain Pract. 2023 ;00:1-20 . doi:10.1111/papr.13338 12. Wu L, Tafti D, Varacallo M. Sacroiliac joint injection. StatPearls . StatPearls Publishing; 2023. Updated August 4, 2023. Accessed November 24 , 2025 . www.ncbi.nlm.nih.gov Independent Medical Review January 2025
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Neonatal Discharge Criteria-MP-MM-1411 03/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Neonatal Discharge Criteria-MP-MM-1411Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectNeonatal Discharge Criteria B. BackgroundInfants who require neonatal admission remain at increased risk for morbidity and mortality following discharge. These infants require comprehensive discharge planning to ensure a smooth transition from the neonatal intensive care unit (NICU) and reduce mo rbidity and mortality after discharge. Despite the inability to predict the exact timing of a NICU discharge, discharge planning should begin at NICU admission in an effort to avoid overwhelming parents and hospital staff. This planning will aid in minimizing discharge delays and will promote s afe andhealthy discharges to home.Discharge may be appropriate when the establishment of physiologic competencies, including, but not limited to, thermoregulation, feeding, respiratory control, and stability regardless of weight or corrected gestational age, have been achieved.C. Definitions Acceptable Bilirubin Level Defined per American Academy of Pediatrics (AAP) guidelines. Bilirubin Blood test to measure liver function. Car Seat Test Eligibility An infant tolerance test for sitting usually occurring 36.4 Caxillary while clothed in an open bed/crib. D. PolicyI. CareSource considers neonatal discharge medically appropriate for non-technology dependent infants when ALL of the following clinical criteria are met: A. Thermoregulation Stability 1. Infant demonstrates the ability to maintain normal body temperature while clothed in an open crib. Up to 48 hours of stable body temperature is typically adequate for infants born
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Intraosseous Basivertebral Nerve Ablation-MP-MM-1376 03/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectIntraosseous Basivertebral Nerve Ablation B. BackgroundInterventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self – manag ement and aim to reduce the impact of pain on a patients daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualifie d to deliver these health services. Chronic low back pain (CLBP) is a common disabling condition, estimated to afflict 80%of adults at some point. Degenerative disc disease (DDD) is an important cause of CLBP. While discs are avascular with limited nerve distribution, vertebral endplates have the potential to trigger a c ascade 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 vertebrogenic chronic low back pain, a type of chronic low back pain. Endplate degeneration can be observed on MRI through Modic changes (MC). Histologically, in MC type I (MC I) lesions, the endplate is disrupted as fibrous tissue replaces bone marrow, causing the disc-bone interface to be filled with vascularizedgranulation tissue. MC I represents bone marrow edema and inflammation. In MC type 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 scle rosis. Analysis of Modic lesions shows that MC I is characterized by high bone turnover, MC II is characterized by decreased bone turnover, and MC III are stable. Radiofrequency ablation is a minimally invasive, percutaneous treatment which uses heat to ablate the nerve pathway that conducts the pain signal. The goal of RFA is to interrupt the pain pathway without causing excessive sensory loss, motor dysfunction, o r other complications. Intracept is an RFA system designed to ablate the basivertebral nerve of the vertebral endplate. C. Definitions Chronic Low Back Pain Persistent pain in the lumbar region lasting for more than 12 weeks. Conservative Therapy A multimodality plan of care including both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen muscle groups and target key spinal structures, including physical therapy, occupational therapy, physician supervised home exercise program (HEP), and/or chiropractic care. Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS use, and/or pharmacotherapy (prescription or over the counter [eg, non-steroidal anti-inflammatory drugs, acetaminophen]). Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphin s. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization reques t. 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 has been performed and demonstrates Type I or Ty pe II modic changes at one or more vertebral endplates from level L3 to S1, as demonstrated by: 1. hypointense T1-weighted signal and hyperintense T2-weighted signal (ie, bone marrow edema and inflammation) , or Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 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. member has a 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. current pregnan cy 5. skeletal immaturity 6. implantable pulse generator (eg, pacemaker, defibrillator) or other electronic implant 7. scoliosis 8. spinal instability II. Repeat or additional intraosseous basivertebral nerve ablation is not considered medically necessary, as it has not been adequately studied in the peer-reviewed medical literature. III. Monitored anesthesia and conscious sedation during intraosseous basivertebral nerve ablation are considered not medically necessary and will therefore not be reimbursed.IV. Coverage is limited to the above criteria. Intraosseous basivertebral nerve ablation is considered not medically necessary for all other indications.E. State-Specific Information NA F. Conditions of Coverage NA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 01/04/2023 New policyDate Revised 06/07/2023 01/31/202401/29 /202512/17 /2025 Annual review: reorganized conservative therapy, updated references. Approved at Committee. Annual review: updated references and formatting. Approved at Committee. Review: updated references, approved at Committee. Review: updated references. Approved at Committee. Date Effective 03/01/2026 Date Archived Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 I. References1. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Low Back Pain . North American Spine Society ; 2020. Accessed January 2, 2025. www.spine.org 2. Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: a prospective randomized double-blind sham-controlled multi-center study. Euro Spine J . 2018;27:1146-1156. doi:10.1007/s00586-018-5496-1 3. Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 2-year results from a prospective randomized double-blind sham-controlled multicenter study. Int JSpine Surg . 2019;13(2):110-119. doi:10.14444/6015 4. Fischgrund JS, Rhyne A, Macadaeg K, et al. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham – controlled multi-cent er study. Eur Spine J. 2020;29:1925-1934. doi:10.1007/s00586 – 020-06448-x 5. Health Technology Assessment: Intracept Intraosseous Nerve Ablation System (Relievant Medsystems Inc.) for Treatment of Adults with Low Back Pain. Hayes ; 2025. Reviewed November 20, 2025. Accessed December 2, 2025. www.evidence.hayesinc.com 6. Khalil JG, Smuck M, Koreckij T, et al. A prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J. 2019:1620-1632. doi:10.1016/j.spinee.2019.05.598 7. Lorio M, Clerk-Lamalice O, Beall DP, Julien T. ISASS guideline : intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain. Int JSpine Surg . 2020;14(1):18-25. doi:10.14444/7002 8. Lorio M, Clerk-Lamalice O, Rivera M, Lewandrowski K. ISASS policy statement 2022: literature review of intraosseous basivertebral nerve ablation. Int JSpine Surg. 2022;16(6):1084-1094. doi:10.14444/8362 9. McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain-related healthcare utilization following intrasosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. Pain Med . 2024;25:20-32. doi:10.1093/pm/pnad114 10. Nwosu M, Agyeman WY, Bisht A, et al. The effectiveness of intraosseous basivertebral nerve ablation in the treatment of nonradiating vertebrogenic pain: a systematic review. Cureus . 2023;15(4):e37114. doi:7759/cureus.37114 11. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3728-3832. doi:10.2147/JPR.S386879 12. Sayed D, Naidu RK, Patel KV, et al. Best practice guidelines on the diagnosis and treatment of vertebrogenic pain and basivertebral nerve ablation from the American Society of Pain and Neuroscience. JPain Res . 2022;15:2801-2819. doi:10.2147/JPR.S378544 13. Smuck M, Khalil J, Barrette K, et al. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: Intraosseous Basivertebral Nerve Ablation-MP-MM-1376Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 12-month result. Reg Anesth Pain Med. 2021;46:683-693. doi:10.1136/rapm-2020-102259 14. Smuck M, McCormick ZL, Gilligan C, et al. A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J . 2024;S1529-9430(24)01040-4. doi:10.1016/j.spinee.2024.09.016 15. U.S. Food and Drug Administration. 510(k) Premarket Notification: Intracept Intraosseous Nerve Ablation System , 510( k) approval K 222281; 2022. Accessed December 2, 2025. www.accessdata.fda.gov 16. U.S. Food and Drug Administration. 510(k) Premarket Notification: Relievant Medsystems RF Generator , 510( k) number: K171143; 201 7. Accessed December 2, 2025. www.accessdata.fda.gov 17. Viswanathan VK, Shetty AP, Rajasekaran S. Modic changes : an evidence-based, narrative review on its pathophysiology, clinical significance and role in chronic low back pain. JClin Orthop Trauma . 2020;11(5):761-769. doi:10.1016/j.jcot.2020.06.025 Independent med ical review 2022
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Epidural Steroid Injections-MP-MM-1359 03/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………. 2 B. Background ………………………….. ………………………….. ………………………….. ………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………… 3 E. State-Specific Information ………………………….. ………………………….. …………………………. 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. … 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. .. 6 I. References ………………………….. ………………………….. ………………………….. …………………. 6 Epidural Steroid Injections-MP-MM-1359Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectEpidural Steroid Injections B. BackgroundNearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are persistent. Persistent pain is categorized as subacute when lasting between 4 and 12 weeks and chronic when persisting for at least 3 months. Comprehensive pain management care plans are most effective in managing patients chronic pain. These plans focus on a person-centered approach and incorporateconservative treatment with other modalities. These multidisciplinary treatments include promoti ng patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. In addition to conservative therapy, additional treatment options may include nonpharmacologic or pharmacologic treat ments, nonsurgical interventions, and surgical interventions. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. Epidural steroid injections (ESIs) are a nonsurgical, minimally invasive intervention for chronic back pain. ESIs may be administered through the translaminar approach (via the interlaminar space in the spine), the transforaminal approach (through the neuroforamen dorsal to the nerve root), or the caudal approach (through the sacral hiatus at the sacra l canal). There is conflicting evidence on the efficacy of ESIs and a lack of consensus on frequency and number of epidural steroid injections from professional organizations. However, clinical experience suggests that some patients obtain more significant relief, making it reasonable to offer a trial of steroid injections when conservative management has failed. Imaging studies of the symptomatic region may be performed to evaluate suspected specific causes of spinal pain (eg, herniated disc, spinal stenosis, degenerative vertebral disease, rule out fracture or tumor). However, evidence does not support the routin e useof imaging or other diagnostic tests in patients with nonspecific back pain. Diagnostic imaging and testing are only recommended when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination. C. Definitions Conservative Therapy A multimodality plan of care includ ing both active and inactive conservative therapies. o Active Conservative Therapies Actions or activities that strengthen muscle groups and target key spinal structures, including physical therapy, occupational therapy, a physician supervised home exercise program (HEP), and/or chiropractic care. Epidural Steroid Injections-MP-MM-1359Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 HEP A 6-week program requiring an exercise prescription and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete the HEP due to a stated physical reason (ie, increased pain, inability to physical ly perform exercises). Patient inconvenience or noncompliance without explanation does not constitute an inability to complete. o Inactive Conservative Therapies Passive activities by the patient that aid in treating symptoms associated with pain, including rest, ice, heat, medical devices, TENS u se , and/or pharmacotherapy (prescription or over the counter [eg, non-steroidal anti-inflammatory drugs, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator (TENS) A device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphin s. Its use, frequency, duration, and start dates must be documented in the medical record to be considered part of conservative therapy during the period of prior authorization request. Epidural Steroid Injection Administration of steroids via a needle inserted in the space between the ligamentum flavum and the dura and administered by translaminar, transforaminal, or caudal approach es . Injections are intended to cause a short-term reduction in pain in the affected region. D. PolicyI. Epidural steroid injections for labor and delivery in childbirth or post-surgical pain do not require medical necessity review . II. Initial (Diagnostic) InjectionCareSource considers an initial (diagnostic) epidural steroid injection (maximum of 2injections) medically necessary for the management of chronic back pain when ALL the following clinical criteria are met: A. Pain is located in either the cervical, thoracic, or lumbar spine and is predominantly radiating or shooting in nature . B. Pain is causing functional disability (at least a 6 on a scale of 0 to 10) . C. Signs or symptoms are consistent with radiculopathy, as indicated by at least 1 of the following: 1. diminished or absent deep tendon reflexes 2. paresthesia, numbness, sensory change, or weakness in dermatomal distribution 3. positive femoral nerve stretch test 4. positive Spurling test 5. positive straight leg raising test D. Conservative therapy has failed to alleviate symptoms , as evidenced by ALL the following: 1. documentation in the medical record of at least 6 weeks of active conservative therapy (see definition above) within the past 6 months OR Epidural Steroid Injections-MP-MM-1359Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 inability to complete active conservative therapy due to contraindication, increased pain, or intolerance2. documentation in the medical record of at least 6 weeks of inactive conservative therapy (see definition above) within the past 6 months E. Imaging (eg, x-ray, CT, MRI) , if performed, demonstrates that there are no conditions present that would preclude the safety of the performance of the procedure. III. Subsequent (Therapeutic) InjectionsCareSource considers therapeutic epidural steroid injections medically necessary when ALL the following criteria are met: A. The diagnostic or last therapeutic injection for current episode of pain provided significant functional pain relief of at least 50% as measured by a significant decrease in pain level, decrease in pain medications, and/or increase in physical function . B. The member continues to have ongoing pain or documented functional disability (at least a 6 on a scale of 0 to 10) . C. At least 3 weeks have passed since the prior injection in order to reach pharmacodynamic effect . D. No more than 3 procedures in a 12-week period of time per region are considered medically necessary. E. The member continues to engage in conservative therapy (see definition above) . IV. Limitations and ExclusionsA. The maximum number of all epidural injections a member can receive in 12 months is 6, regardless of the number of levels involved.B. For interlaminar or caudal epidural injections, no more than 1 epidural injection per treatment date should be performed . C. For transforaminal epidurals or selective nerve root blocks (SNRBs), no more than 2 vertebral levels per treatment date, whether unilateral or bilateral, should be performed . D. Real-time image guidance and any injection of contrast are inclusive components of epidural injections and are not compensated for separately or unbundled for coverage. E. Conscious sedation, if required for co-morbidities or patient/physician preference, may be provided without a medical necessity review but services will be considered part of the procedure and are not eligible for additional reimbursement if administered b y a second provider. F. Monitored anesthesia is considered not medically necessary. G. Patients with indwelling implanted spinal cord stimulators or pain pumps must have a device interrogation report and an interpretation submitted with medical records and included in the prior authorization request for proposed interventional pain injection s. If a device is not functioning properly, an escalation in pain may warrant evaluation and management of the implanted device. Epidural Steroid Injections-MP-MM-1359Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 H. Clinical evaluations and care of candidate patients for epidural injections should also address, at the discretion of the physician and according to prevailing standards of medical care:1. no acute spinal cord compression 2. selected body imaging evaluations to evaluate the area of pain, particularly for acute pain, or to evaluate escalations in chronic baseline pain 3. appropriate imaging to rule out red flag conditions may be indicated if potential issues of trauma, osteomyelitis or malignancy , or other diagnoses are a concern I. Contraindications include any of the following: 1. pain related to cancer etiology 2. local or systemic infection 3. cauda equina syndrome 4. spinal trauma (eg, hematoma, hemorrhage, mass, ischemia) 5. coagulopathy V. Inconclusive or Non-Supportive EvidenceA. Evidence reported in the medical literature is inconclusive as to the use of epidural injections for long term relief or treatment of chronic pain. Long-term continuation (epidural injections beyond 1 year) may be subject to medical necessity review. B. For both cervical and lumbar transforaminal (TF) ESIs, using particulate steroid is associated with a rare risk of catastrophic neurovascular complications such as stroke or death. Cervical transforaminal injections are risky because arterial supply may be densely concentrated in and around the intervertebral foramen. TF ESIs can be performed without contrast in patients with documented contraindication to its use. In these circumstances , particulate steroids are contraindicated and only the preservative fr ee, particulate free steroids which are available should be used. C. Cervical transforaminal ESIs have sparse literature for cervical radicular pain, and, if performed, should be performed by injecting contrast medium under real – time fluoroscopy and/or digital subtraction angiography (DSA) in a frontal plane, before injecti ng any substance potentially hazardous to the patient. Particulate steroids should not be used for cervical TF injections as per the contraindication established by the FDA warning. E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesNA Epidural Steroid Injections-MP-MM-1359Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 H. Review/Revision HistoryDATE ACTIONDate Issued 12/14 /2022 New policyDate Revised 03/15 /2023 01/31/202401/15 /202512/03/ 2025Annual review : reorganized criteria, simplified conservative therapy, added provocation tests, added pain scale to diagnostic injection criteria . Approved at Committee . Annual review: updated references, approved at Committee. Review: removed US limitation, updated references, approved at Committee. Review: updated references, approved at Committee. Date Effective 03/01/2026 Date Archived I. References1. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate . Updated April 29, 2025 . Accessed November 18, 2025 . www.uptodate.com 2. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med . 2017;166(7):493-505. doi:10.7326/M16-2459. 3. Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med . 2015;163(5):373-381. doi:10.7326/M15-0934 4. Conger A, Cushman DM, Speckman RA, et al. The effectiveness of fluroscopically guided cervical transforaminal epidural steroid injection for the treatment of radicular pain; a systematic review and meta-analysis. Pain Med. 2020;21(1):41-54. doi:410.1093/pm/pnz127 5. Dydyk AM, Hu Y, Stretanski MF, et al. Cervical Epidural Injection. In: StatPearls [Internet]. Updated June 2, 2025. Accessed November 18, 2025. www.ncbi.nlm.nih.gov 6. Fromm MK, Liu SH, Carr C, et al. Factors associated with improved outcomes after lumbar transforaminal epidural steroid injections for radicular pain: a systematic review. NASSJ . 2025;21:100592. doi:10.1016/j.xnsj.2025.100592 7. Goel A, Singh S, Shukla NK, Yadav A. Efficacy of caudal epidural steroid injections in chronic low backache patients. JPharm Bioallied Sci. 2023;15(Supple 1):S669 – S672. doi:10.4103/jpbs.jpbs_89_23 8. Helm S, Harmon PC, Noe C, et al. Transforaminal epidural steroid injections: a systematic review and meta-analysis of efficacy and safety. Pain Phys ician . 2021;24:S209-S232. Accessed December 18, 2024 . www.painphysicianjournal.com 9. Manchikanti L, Benyamin RM, Falco FJ, et al. Do epidural injections provide short – and long-term relief for lumbar disc herniation? A systematic review. Clin Orthop Relat Res. 2015;473(6):1940-1956. doi:10.1007/s11999-014-3490-4 10. Manchikanti L, Knezevic NN, Boswell MV, et al. Epidural injections for lumbar radiculopathy and spinal stenosis: a comparative systematic review and meta – Epidural Steroid Injections-MP-MM-1359Effective Dat e: 03/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 analysis. Pain Physician. 2016;19(3):E365-410. Accessed November 18, 2025 .www.painphysicianjournal.com 11. Manchikanti L, Knezevic NN, Navani A, et al. Epidural interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) comprehensive evidence-based guidelines. Pain Physician. 2021;24(S1): S27-S208. Accessed November 18, 2025 . www.painphysicianjournal.com 12. Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020;4(4):CD013577. doi: 10.1002/14651858.CD013577 13. Qassem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med . 2017 ;166(7):514-530 . doi:10.7326/M16-2367 14. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guidelines of interventional treatments for low back pain. JPain Res . 2022;15:3729-3832. doi:10.2147/JPR.S386879 15. Taskaynatan MA, Tezel K, Yavuz F, et al. The effectiveness of transforaminal epidural steroid injection in patients with radicular low back pain due to lumbar disc herniation two years after treatment. JBack Musculoskelet Rehabil. 2015;28(3):447 – 451. doi:10.3233/BMR-140539 16. Verheijen EJA, Bonke CA, Amorij EMJ, Vleggeert-Lankamp CLA . Epidural steroid compared to placebo injection for sciatica: a systematic review and meta-analysis. Euro Spine J . 2021;30:3255-3264. doi:10.1007/s00586-021-06854-9 17. Woo JH, Park HS. Cervical transforaminal epidural block using low-dose local anesthetic: a prospective, randomized, double-blind study. Pain Med. 2015;16(1):61 – 67. doi:10.1111/pme.12582 18. Yang S, Kim W, Kong HH, et al. Epidural steroid injection versus conservative treatment for patients with lumbosacral radicular pain: a meta-analysis of randomized controlled trials. Med. 2020;99(30):e21283. doi:10/1097/MD. 0000000000021283
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Inhaled Nitric Oxide-MP-MM-1321 02/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 7 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 7 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 8 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 8 G. Related Polic ies/Rules ………………………….. ………………………….. ………………………….. …….. 9 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 9 I. References ………………………….. ………………………….. ………………………….. ……………………. 9 Inhaled Nitric Oxide-MP-MM-1321Effective Dat e: 02/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectInhaled Nitric Oxide (iNO) B. BackgroundInhaled Nitric oxide (iNO) is a lipophilic gas that is naturally produced in numerous cells in the body and is readily absorbed across pulmonary membranes in the ventilated lung after inhalation. In the body, nitric oxide is involved in oxygen transport to the tissues, the transmission of nerve impulses, and other physiological activities. When administered via inhalation, it is a potent endogenous vasodilator that induces relaxation of vascular and bronchial smooth muscle, vasodilation of blood vessels, and can increase the partial pressure of arterial oxygen. iNO was initially approved by the U .S. Food and Drug Administration (FDA) in 1999. A complete nitric oxide delivery system is comprised of a nitric oxide administration apparatus, a nitric oxide gas analyzer, and a nitrogen dioxide gas analyzer. Additional warnings and precautions were adde d in 2013, including rebound hypertension following abrupt discontinuation, hypoxia from methemoglobinemia, and airway injury from nitrous dioxide. Dilation of pulmonary vessels in well-ventilated lung areas redistributes blood flow awayfrom lung areas where ventilation/perfusion ratios are poor. iNO has been used in conjunction with ventilator support as a treatment of hypoxic respiratory failure associated with persistent pulmonary hypertension of the newborn (PPHN), in infants who are at term or near-term (greater than 34 weeks gestation) to improve oxygenation,and to decrease the need for extracorporeal membrane oxygenation (ECMO). Respiratory failure is a clinical state that is defined either by the inability to rid the bodyof carbon dioxide or establish an adequate blood oxygen level. Acute respiratory failure is the most common clinical problem seen in term, near-term (born at 34 or more weeks of gestation), and pre-term (less than 34 weeks of gestation) infants admitted to neonatal intensive care units. Acute respiratory failure is frequently associated with meconium aspiration syndrome, sepsis, pulmonary hypoplasia, and/or primary pulmonary hypertension of the newborn. Management of infants with respiratory failure includes administration of high concentrations of oxygen, hyperventilation, high-frequency ventilation, neuromuscularblockade, antenatal steroids for the prevention of respiratory distress syndrome, use of po st-natal steroids to decrease inflammation, as well as iNO therapy.Clinical studies have shown that iNO is a selective pulmonary vasodilator without significant effects on the systemic circulation. There is scientific evidence that iNO therapy improves oxygenation and ventilation, reduces the need for extracorporealmembrane oxygenation (ECMO), and lowers the incidences of chronic lung disease and death among infants with respiratory failure. Moreover, the literature indicates that iNO does not appear to increase the incidence of adverse neurodevelopmental, behavioral, or medical sequelae in these high-risk neonates. Infants with congenital diaphragmatic hernia (CDH) have not been shown to benefit from iNO therapy. Clark, et al (2000) Inhaled Nitric Oxide-MP-MM-1321Effective Dat e: 02/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 concluded iNO does not lead to reduced ECMO use and Putnam, et al (2016) concluded iNO use in CDH may be associated with increased mortality.In preterm infants, the most common cause of acute respiratory failure is respiratory distress syndrome as a result of surfactant deficiency. According to the available literature, treatment of preterm infants usually entails exogenous surfactant administr ation. A systematic review of the evidence (Barrington and Finer, 2003)concluded: “The currently published evidence from randomized trials does not support the use of inhaled nitric oxide in preterm infants with hypoxic respiratory failure.” Carey, et al (2018) also concluded, Off-label prescription of iNO is not associated with reduced in-hospital mortality among premature infants with respiratory distress syndrome (RDS). In an Agency for Healthcare Research and Qualitys assessment on Inhaled Nitric Oxidein Preterm Infants , Allen, et al (2010) systematically reviewed the evidence on the use of iNO in preterm infants born at or before 34 weeks gestation age who receive respiratory support. They searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Studies (CENTRAL) and PsycInfo in June 2010. They also searched the proceedings o f the 2009 and 2010 Pediatric Academic Societies Meeting and ClinicalTrials.gov. T hey identified additional studies from reference lists of eligible articles and relevant reviews, as well as from technical experts. Questions were developed in collaboration with technical experts, including the chair of the upcoming National Institutes o f Health Office of Medical Applications of Research Consensus Development Conference. These researchers limited their review to randomized controlled trials (RCTs) for the question of survival or occurrence of bronchopulmonary dysplasia (BPD), and for the question on short-term risks. All study designs were considered for long-term pulmonary or neurodevelopmental outcomes, and for questions about whether outcomes varied by subpopulation or by intervention characteristics. Two investigators independently screened search results and abstracted data from eligible articles. These investigators identified a total of 14 RCTs, reported in 23 articles, and 8 observational studies. Chronic Lung Disease (CLD) or BPD studies have shown that there is insufficient evidence to support iNO for the treatment of CLD or BPD. Mortality rates in the neonatal intensive care unit (NICU) did not differ for infants treatedwith iNO versus those not treated with iNO (RR 0.97 (95 % CI: 0.82 to 1.15)). Broncho-pulmonary dysplasia at 36 weeks for iNO and control groups also did not differ (RR 0.93 (0.86, 1.003) for survivors). A small difference was found between iNO and control infants in the composite outcome of death or BPD (RR 0.93 (0.87, 0.99)). There was inconsistent evidence about the risk of brain injury from individual RCTs, bu t meta – analyses showed no difference between iNO and control groups. These researchers found no evidence of differences in other short-term risks. There was no evidence to suggest a difference in the incidence of cerebral palsy (RR 1.36 (0.88, 2.10)), neu rodevelopmental impairment (RR 0.91 (0.77, 1.12)), or cognitive impairment (RR 0.72 (0.35, 1.45)). Evidence was limited on whether the effect of iNO varies by subpopulation or by characteristics of the therapy (timing, dose and duration, mode of delivery, or concurrent therapies). The authors concluded that there was a 7% reduction in the risk of the composite outcome of death or BPD at 36 weeks PMA for infants Inhaled Nitric Oxide-MP-MM-1321Effective Dat e: 02/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 treated with iNO compared to controls, but no reduction in death or BPD alone. They stated that further studies are needed to explore subgroups of infants and to assess long-term outcomes including function in childhood. There is currently no evidence to support the use of iNO in preterm infants with respiratory failure outside the context of rigorously conducted RCTs. To provide health care professionals, families, and the general public with a responsible assessment of currently available data regarding the benefits and risks of iNO in premature infants, the Eunice Kennedy Shriver National Institute of Child Health andHuman Development, the National Heart, Lung, and Blood Institute, and the Office of Medical Applications of Research of the National Institutes of Health (Cole, et al, 2011) convened a consensus-development conference. Findings from a substantial body of experimental work in developing animals and other model systems suggest that iNO may enhance lung growth and reduce lung inflammation independently of its effects on blood vessel resistance. Although this work demonstrates biological plausibility and the results of RCTs in term and near-term infants were positive, combined evidence from the 14 RCTs of iNO treatment in premature infants of gestation of 34 weeks or less shows equivocal effects on pulmonary outcomes, survival, and neurodevelopmental outcomes. A National Institutes of Health Consensus Development Conference for inhaled nitricoxygen in premature infants (Cole, et al, 2010) recommended the following:1. Taken as a whole, the available evidence does not support use of iNO in early routine, early rescue, or later rescue regimens in the care of premature infants
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Durable Medical Equipment Repairs-MP-MM-1582 02/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Durable Medical Equipment Repairs-MP-MM-1582Effective Dat e: 02/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectDurable Medical Equipment Repairs B. BackgroundDurable medical equipment (DME) is equipment that serves a medical purpose, helps complete activities of daily living (ADLS), can withstand repeated use and is primarily used in the home . DME includes items, such as wheelchairs, hospital beds, continuous positive airway pressure (CPAP), walkers, oxygen tanks, etc. DME is dispensed when medical necessity is established to meet the needs of the member s medical condition. DME is likely to last 3 years or more but may require maintenance, service, or repairperiodically. When service is required, the DME provider may request authorization to perform the required maintenance, service, or repair to restore the DME item to working order. C. Definitions Durable Medical Equipment (DME) Equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, is not useful to a person in the absence of illness or injury, is appropriate for use in the home . Healthcare Common Procedure Coding System (HCPCS) A numeric and alphanumeric code set maintained and distributed by The Centers for Medicare and Medicaid Services (CMS) for the uniform designation of certain medical procedures and related services. Repair The repairs, including replacement of essential accessories (eg, hoses, tubes, mouth pieces ) are covered when necessary to make th e item/device serviceable. Replacement Equipment beyond its reasonable or useful life span , irreparable , and includes the same or similar type of equipment . D. PolicyI. A review of medical necessity is required for all DME repairs. If the DME item was not originally approved by CareSource, medical necessity must be established before any repair is authorized. II. Providers must include the following:A. specification of the item, including manufacturer, model, and serial number , if applicable B. date on which the item was originally purchased or dispensed or, if the date is not known, the approximate age of the item C. any warranty period and the type of warranty (manufacturer or dealer) D. a full description of the wear, damage, or malfunction E. a full description of the repair F. a description, with dates, of previous repairs (both major and minor) G. a complete itemization of parts Durable Medical Equipment Repairs-MP-MM-1582Effective Dat e: 02/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 H. an estimate of labor time needed (Labor should be billed with K0739 for 15-minute increments, 4 units = 60 minutes of labor .) III. During the medical necessity reviewA. Providers should advise CareSource when, in the professional opinion, replacement of an item would be more cost-effective than repair. B. CareSource may consider whether the purchase of a new piece of equipment may be more cost-effective than continued repair. C. Multiple repairs requested within a short time span may suggest deliberate or malicious damage or destruction. In these cases, repair may be denied. IV. No separate payment will be made for the following items or services:A. temporary replacement (“loaner”) equipment provided while an individual’s own equipment is being repaired B. repair of an item if within the preceding 12 months Medicaid payment has been made for the repair of a duplicate or conflicting item currently in the individual’s possession C. repair of an item that is no longer deemed to be medically necessary D. maintenance and repair of DME during a rental period V. CareSource considers a replacement part as a new equipment purchase , and modifier NU should be used instead of modifier RB. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/14/2024 New policy. Approved at Committee.Date Revised 01/15/2025 11 /05 /2025Annual review. Updated references and medical necessity language . Approved at Committee.Periodic review. Updated references. Approved at Committee. Date Effective 02/01/2026 Date Archived H. References1. Definitions, 42 U.S.C. 1395x (202 5). 2. Repairs, maintenance, replacement, and delivery. Medicare Benefit Policy Manual, XV: Covered Medical and Other Health Services . Centers for Medicare and Medicaid Services; 202 5:110.2. Accessed October 27, 2025 . www.cms.gov
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Non-Emergency Facility to Facility Transfers-MP-MM-1448 02/01 /2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry 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.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia 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-MP-MM-1448Effective Dat e: 02/01/2026The 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 Inter-Facility Transfer The transfer of patients between two healthcare facilities. Intra-Facility Transfer The transfer of patients within the same facility. Non-Emergency A situation for which immediate response is not needed for the provision of medical treatment. Non-Participating (Out-of-Network) Facility Facility that is not contracted with CareSource. 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. Receiving Facility The facility to which a transfer is planned. D. PolicyI. The following non-emergency transfers require a medical necessity review : 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 medical necessity review , the receiving facility submits the medical necessity review request to CareSource. Non-Emergency Facility to Facility Transfers-MP-MM-1448Effective Dat e: 02/01/2026The 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 medical necessity review must meet the following criteria: A. Member must be medically stable for transfer AND one or more of the following situations. 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 medical necessity review :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 01/15/202511/05/2025Annual review. No changes. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Annual review. Replaced prior authorization with Non-Emergency Facility to Facility Transfers-MP-MM-1448Effective Dat e: 02/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 medical necessity review. Updated D. III. and references. Approved at Committee. Date Effective 02/01/2026 Date Archived H. References1. Appropriate interhospital patient transfer. American College of Emergency Physicians. January 2022. Accessed October 27, 2025. www.acep.org 2. Discharges and Transfers,42 C.F.R. 412.4 (2025). 3. Heaton JK. EMS Inter-Facility Transport. In: StatPearls. StatPearls Publishing; 2025. 4. Kulshrestha A, Singh J. Inter-hospital and intra-hospital patient transfer: recent concepts. Indian JAnaesth. 2016;60(7):451-457. doi:10.4103/0019-5049.186012 5. Obstetric Care Consensus Number 9. Levels of Maternal Care. American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM); 2025. Accessed October 27, 2025. www.acog.org Independent med ical review 02/21/2023
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Special Needs Car Seats-MP-MM-1439 01/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Special Needs Car Seats-MP-MM-1439Effective Dat e: 01/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectSpecial Needs Car Seats B. BackgroundThe American Academy of Pediatrics (AAP) states that all children should have access to proper resources for safe transportation, including children with specific functional needs. Safe transportation includes not only the proper restraints, but also the c orrect positioning to secure the child in the vehicle. The AAP notes that a standard car seat provides the best protection for most travel needs. However, additional research is needed for the biomechanics of test dummies representative of children with ce rtain functional needs in crash testing so that such test dummies can be utilized by the National Highway Traffic Safety Administration (NHTSF). Currently, the Federal Motor Vehicle Safety Standard (FMVSS) Number 213 regulates the design and performance of child restraint systems for children weighing up to 80 pounds. However, children greater than 80 pounds may require car seat restraint , andseveral manufacturers have tested car seats beyond an 80-pound maximum. Once a child has outgrown a standard 5-point harness car seat, options include car seats specially designed for full support of a childs head, neck, and back supporting up to 115 pounds. Conventional travel vests or specialized medical seating can be used for children who require additional trunk support but have stable neck control. Some older children with certain functional needs, including poor trunk control, can be transported in a special needs belt-positioning booster seat or a c onventional belt-positioning booster with trunk support. Data has shown that rear-facing car seats offer greater protection for the head and neckthan a front-facing car seat, by reducing neck loading in vehicular crashes with a frontal component. Therefore, the AAP encourages use of a rear facing car seat for a s long as possible for all children, but especially for children diagnosed with a neurological condition (s), as a forward-facing car seat increases the risk of injury in a crash . Recommendations by the AAP specify that car seats should be placed in the rear seat of the vehicle. However, it is noted that a child with certain functional needs requiring frequent monitoring may need to be placed in the front seat when no adult is avail able tosit in the rear seat with the child. If the child is placed in the front seat, the automatic air bag should be disabled.If the person using the car seat is more than 50 pounds and has significant abnormal tone, contractures, or has significant behaviors, transfer s in and out of the vehicle can bevery difficult. Car seats come with different weight limits and support systems. In addition, cars have different standard restraint systems, seat dimensions, and configurations that can accommodate specific types of cars seats. Not all vehicles come with the standard hardware necessary to secure car seats, especially older vehicles and larger car seats. A trial of the car seat is recommended to find the most appropriate car Special Needs Car Seats-MP-MM-1439Effective Dat e: 01/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 seat to address the needs of the user and specific restrain ts and dimensions and configuration of the vehicle. C. Definitions Booster Seat A seat used for a child during transportation that lifts the child by several inches, designed for use with an adult seat belt. Car Safety Seat (CSS) A portable seat for a person weighing under 80 pounds that attaches to an automobile seat and holds the person safely. Child Passenger Safety Technician (CPST) Trained educators in the field of occupant protection knowledgeable in child safety seat installation, best practices, and education. They provide support and guidance to caregivers with child safety seat questions and concerns. Federal Motor Vehicle Safety Standard 213 (FMVSS No. 213) Requires child restraint systems (CRSs) to be equipped with attachments that enable the CRS to attach to the vehicle’s child restraint anchorage system. The agency added a height provision to make the new standard’s applicability clear to booster seat manuf acturers who choose not to label their restraints with a weight. National Highway Traffic Safety Administration (NHTSA) A division of the U.S. Department of Transportation dedicated to achieving the highest standards of excellence in motor vehicle and highway safety. Neck Loading The dynamic loading of the neck that occurs when the torso is suddenly stopped by the seat belt while the head continues pulling from the neck. Travel Vest Optimizes the existing vehicle seat belt system to protect the child by keeping a low center of gravity and allowing the vehicle seat belt and seat cushion to manage the crash forces. D. PolicyI. CareSource considers a special needs car seat medical ly necessary when ALL the following clinical criteria are met: A. The car seat is a child restraint system that meets National Highway Traffic Safety Administration Federal Motor Vehicle Safety Standard (FMVSS No. 213 ). B. The car restraint system is not modified or used in a manner other than that specified by the manufacturer unless the modified restraint system has been crash tested and has met all applicable FMVSSs approved by the NHTSA. C. The special needs car seat is the most cost-effective option while still addressing the medical /functional needs of the member. D. The safety and effectiveness of the special needs car seat has been substantiated by current evidence-based national, state, and peer-reviewed medical guidelines. E. The length or weight limits of a conventional CRS with an internal 5-point harness has been outgrown and at least one of the following criteria is met. 1. The member has respiratory issues or conditions that require enhanced positioning for safety, including any of the following (not an all-inclusive list): a. hypotonia b. craniofacial abnormalities Special Needs Car Seats-MP-MM-1439Effective Dat e: 01/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 c. primary airway problems d. cerebral palsy 2. The member has a physical condition (eg, seizure or hypertonicity/spasms) that prevents the independent maintenance of a seated position or requires support to allow a functional position or prevent further disability. 3. The member has gastrointestinal issues, including but not limited to: a. emesis b. gastroesophageal reflux (GERD) c. gastrostomy feeding tube 4. The member uses a spica cast. F. Documentation that the member has been evaluated by a CPST for ALL the following: 1. Diagnosis 2. Objective and subjective clinical information on ability and impairments 3. Reason why commercial car seats are not appropriate 4. Member age, height, and weight 5. The size of larger car seats may limit space for others traveling with the member or other car seats in the vehicle. Notes need to show that this has been considered when identifying the most appropriate car seat or vest restraint. 6. Medical equipment, casts, orthoses, and space necessary to transport the member 7. Type of vehicle that will transport the member and compatibility of tethering systems in the vehicle II. Where applicable, a trial of the car seat should be documented that shows the following: A. The car seat can be used safely and as intended to meet the stated goals. B. Education has been provided to the member or the caregiver with demonstrated understanding and safety use. Education should include instruction for quickly extracting the member from the car seat in case of an emergency. C. If no trial seat is available documentation should show the following: 1. Caregivers have demonstrated the ability to complete the type of transfer necessary to safely use the type of vehicle restraint requested. 2. The vehicle restraint system in the vehicle used to transport the member is appropriate to secure the car seat based on manufacturer instructions. III. Persons with a tracheostomy tube should not use a CRS with a harness or seat belts that could dislodge the tube. It is strongly recommended that an occupational therapist or passenger safety technician with training and experience in the safetransportation of persons with special needs provide guidance for appropriate equipment selection and use .IV. A special needs car seat will not be considered medical necessary for any of the following: A. The special needs car seat is a more recent advancement in technology when Special Needs Car Seats-MP-MM-1439Effective Dat e: 01/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 the members current special needs car seat can meet the members basic medical /functional needs.B. The special needs car seat is considered investigational, experimental, or has unproven medical indications for use. E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 03/01/2023 New policyDate Revised 02/28/2024 02/12/202510/08/2025Annual review: updated car seat definition, added D.I.C-D., D.I.E.2, and D.II-III, updated references. Approved at Committee. Annual review: updated criteria in D.I.E. and references. Approved at Committee. Annual r eview . Updated background, added CPST documentation, trialing requirements and updated references. Approved at Committee. Date Effective 01/01/2026 Date Archived I. References1. Adams AJ, Johnson MA, Ryan KA, et al. Safe transportation in-spica following surgical treatment of infantile DDH: solutions and threats. JPediatr Orop . 2019;39(7):e488-e493. doi:10.1097/BPO.0000000000001317 2. Angsupaisal M, Maathuis CGB, Hadders-Algra M. Adaptive seating systems in children with severe palsy across International Classification of Functioning, Disability and Health for Children and Young version domains: a systematic review. Dev Med Child Neurol. 2015;57(10):919-930. doi:10.1111/dmcn.12762 3. Car seats and booster seats. National Highway Traffic Safety Administration. Accessed September 29, 2025 . www.nhtsa.gov 4. Car seat safety. National Child Passenger Safety Board. Accessed September 29, 2025 . www.cpsboard.org 5. Child passenger safety. American Academy of Pediatrics. Accessed September 29, 2025 . www.aap.org 6. Huang PP, Durbin DR. Promoting safety in children with disabilities. UpToDate. Updated March 12, 2025 . Accessed September 29, 2025 . www.uptodate.com Special Needs Car Seats-MP-MM-1439Effective Dat e: 01/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 7. 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 8. Legare JM, Adam MP, Feldman J, et al . Achondroplasia . GeneReviews; 2023. Revised May 11, 2023. Accessed September 29, 2025 . www.ncbi.nlm.nih.gov 9. ONeil J, Hoffman B, American Academy of Pediatrics Council on Injury, Violence, and Poison. Transporting Children with Special Health Needs. Pediatrics . 2019;143(5):e20190724. doi:10.1542/peds.2019-0724 10. Rigby P, Ryan S, Campbell K. Effect of adaptive seating devices on the activity performance of children with cerebral palsy. Arch Phy Med Rehabil . 2009;90(8):1389-1395. doi:10.1016/j.apmr.2009.02.013 11. Ryan SE. Lessons learned from studying the functional impact of adaptive seating interventions for children with cerebral palsy. Dev Med Child Neurol . 2016;58(4):78 – 82. doi:10.1111/dmcn.13046 12. Smith VC, Stewart J. Discharge planning for high-risk newborns. UpToDate. Updated May 23, 2025 . Accessed September 29, 2025 . www.uptodate.com 13. Vives-Torres CM, Valdamo M, Jimenez-Octavio JR, et al. Comparison of upper neck loading in young adult and elderly volunteers during low speed frontal impacts . Frontiers Bioeng Biotechnol. 2021;9: 682974 . doi :10.3389/fbioe.2021.682974 Independent med ical review 02/15/2023
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Safety Beds-MP-MM-1458 01/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. …. 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 I. References ………………………….. ………………………….. ………………………….. …………………….. 4 Safety Beds-MP-MM-1458Effective Dat e: 01/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectSafety Beds B. BackgroundHealthy sleep requires adequate duration, appropriate timing, good quality, regularity, and the absence of sleep disturbances. The American Academy of Sleep Medicine has issued recommendations for sleep needs by age. An individuals bedtime environment is an important consideration, with factors, such as the bed and mattress, affecting the quality and duration of sleep. A safety bed is an enclosed bed, typically fitted with a mesh canopy, padded walls,and/or a specially designed mattress. A safety bed may be necessary to ensure the safety of an individual with a variety of medical or behavioral health diagnoses (eg, epilepsy, intracranial injury, hydrocephalus , intellectual disabilities , autistic spectrum disorder ). The use of these beds increases patient safety by eliminating falls and preventing injuries and wandering when the patient should be sleeping . Ongoing individual evaluation and monitoring is recommended for appropriate use and prescribing. C. Definitions Crib Canopy A cover that attaches to the top of a crib that prevents a toddler from climbing out of the crib or, i n some cases, pets from climbing into the crib. Hospital Bed A bed used for individual s that can be adjusted to raise the head end, foot end, or middle , as required . The overall bed height is also adjustable. Safety Bed A bed to prevent individuals from leaving a bed at night without supervision, preventing injuries, falls, and wandering, and can be called institutional, adaptive, enclosure bed, enclosed bed system , net bed, or special needs beds. Standard Bed A fixed height bed that is typically sold as furniture and consists of a frame, box spring, and mattress. D. PolicyI. CareSource considers a safety bed medically necessary when ALL the following criteria are met : A. Member has a behavioral health or medical diagnosis that may lead to safety concerns. B. Member requires a safety bed that prevents the member from leaving the bed at night without a supervisor. C. There should be regular, periodic face-to-face (in-person) monitoring while the member is in the safety bed. D. An in-home assessment has been conducted to ensure that less restrictive measures have been tried and are in place. E. The safety bed is to be used for sleep and short naps and not to be used as a restraint , for playtime, for discipline , or as part of a behavior modification program . Safety Beds-MP-MM-1458Effective Dat e: 01/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 F. Documentation submitted to CareSource for review must show that the member meets the above criteria, and:1. Bed alarms, door alarms, standard rail padding , bed rails, bed on the floor , video/audio monitors , removal of safety hazards from the members room (eg , small ingestible items, items that can fall on the child or they can climb and jump off of including unsecured dressers, bookcases, TVs, etc.), child protection devices (eg, locks outside of the reach of the child , alarms, gates, furniture anchors , etc. ), treatment plan to help with calming and sleep failed to meet the medical needs of the member. 1. The safety bed is for the benefit of the member and not for any caregiver, family member, or provider. 2. The provider order for the safety bed includes: a. medical necessity for the safety bed b. plan for transitioning away from the safety bed 3. The person-centered service plan is retained and updated. a. Includes a safety bed monitoring plan: 01. defined duration of safety bed use 02. time intervals member will be monitored while inside the safety bed 03. how members personal care needs will be met during safety bed use 04. how medical conditions will be managed during safety bed use 05. safety concerns of potential entrapment and endangerment or injury b. Includes a mental health management plan with member-specific medical/clinical interventions that have been tried to mitigate behaviors, improve quality of sleep and safety when sleeping c. Includes emergency preparedness plan to ensure the safety of the member in case of emergency (eg, natural disaster) as the member is not able to exit the enclosure independently 4. The invoice for the safety bed is retained and submitted along with the prior authorization and reimbursement requests. G. The safety bed must be the lowest cost alternative that addresses the members health condition. II. CareSource considers technology addons and nontechnology accessories as non-medical in nature and therefore not medically necessary. E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesMedical Necessity Determinations Safety Beds-MP-MM-1458Effective Dat e: 01/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 H. Review/Revision HistoryDATE ACTIONDate Issued 03/01/2023 New policy.Date Revised 11/08/2023 05/08/202411/06/202410/0 8/2025 Annual review. Coverage language refined. Approved at committee. Annual review: adjusted title, revised background and definitions, condensed coverage criteria , removed sections D.I. and D.IV., and updated references. Approved at Committee. Annual review: added documentation requirements. Annual r ev iew . Update d D.I. Added documentation requirements, in-home assessment, and clarification of purpose. Added D. II. Updated references. Approved at Committee. Date Effective 01/01/2026 Date Archived I. References1. Caggiari G, Talesa GR, Toro G, et al. What type of mattress should be chosen to avoid back pain and improve sleep quality? Review of the literature. JOrthop Traumatol . 2021;22(1):51. doi:10.1186/s10195-021-00616-5 2. DeGeorge KC, Neltner CE, Neltner BT. Prevention of unintentional childhood injury. Am Fam Physician . 2020;102(7):411-417. Accessed September 29, 202 5. www.aafp.org 3. Paruthi S, Brooks LJ, DAmbrosio C, et al. Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. JClin Sleep Med . 2016 ;2(6):785-786. doi: 10.5664/jcsm.5866 4. Sherburne E, Snethen JA, Kelber S. Safety profile of children in an enclosure bed. Clin Nurse Spec . 2017;31(1):36-44. doi:10.1097/NUR.0000000000000261 Independent med ical review 02/15/2023
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