Transcranial Magnetic Stimulation for Treatment of Depression

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Transcranial Magnetic Stimulation for Treatment of Depression-MP-MM-1339 06/01/2026 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 Transcranial Magnetic Stimulation for Treatment of Depression-MP-MM-1339 Effective Dat e: 06/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectTranscranial Magnetic Stimulation for Treatment of Depression B. BackgroundTranscranial magnetic stimulation (TMS) was originally introduced in 1985 as a noninvasive treatment modality for treatment-resistant Major Depressive Disorder (MDD) . Brief, repetitive pulses of magnetic energy are sent to the scalp via a large electromagnetic coil, generating a low level of electrical stimulation. These magnetic fields pass through the skull and induce electrical currents that depolarize neurons in a focal area of the surface cortex. The magnetic field g enerated by this type of stimulation is very small and cannot be felt by the patient but is strong enough to flow into the brain without inducing seizures or creating a need for anesthesia. TMS is generally an outpatient procedure with conscious patients and sessions that varybetween 30 to 40 minutes. Treatment can be delivered as a single pulse or as a series of pulses. Despite variability in the number of pulses delivered per session and the number of sessions per patient, research indicates that typical TMS consist of treatment up to 5 days a week for up to 6 weeks. A tapering schedule is used to end treatment. C. Definitions Acute (Index) Course of Treatment The initial series of treatment given to relieve acute symptoms of the MDD . Adequate Trial Taking a drug at least 4 weeks at or near the maximum dose for the specific medication as approved by the F ood and Drug Administration (FDA) or documentation exists that higher doses were not tolerated when the dose is less than the FDA-approved maximum. Continuation TMS Treatment beginning after the acute/index course lasting up to 6 months and designed to prevent the worsening of symptoms and continue d treatment for a depressive episode that has not yet remitted. Depression Rating Scale Scales standardized for national use that reliably assess the range of symptoms , both type and magnitude, most commonly observed in adults with MDD . Listed below are examples of commonly used scale s: o Beck Depression Inventory (BDI) o Geriatric Depression Scale (GDS) o Hamilton Depression Rating Scale (HAM-D) o Patient Health Questionnaire-9 (PHQ-9) o Quick Inventory of Depressive Symptomatology (QIDS) Maintenance TMS Regularly scheduled TMS sessions on a weekly, biweekly, or monthly basis to prevent relapse of depressive symptoms. Medication Side Effects Unexpected effects that cause significant distress, inhibit daily function, have the potential to worsen health, or are life threatening. Remission The absence of significant signs or symptoms of a major depressive episode during the previous 2 months. Transcranial Magnetic Stimulation for Treatment of Depression-MP-MM-1339 Effective Dat e: 06/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 D. PolicyI. A review of medical necessity is required for initial and continuation courses of TMS. II. TMS is considered medically necessary when all the following criteria are met:A. Member is 18 years of age or older .B. There is a c onfirmed diagnosis of MDD , single or recurrent, with a current severe episode as evidenced by a recent score on a standardized depression rating scale and at least 1 of the following: 1. resistance to treatment evidenced by a lack of a clinically significant response during a current or previous depressive episode and adequate trials of 2 antidepressant agents , including at least 2 different agent classes at or near the maximum effective dose and duration for each class approved by the FDA 2. inability to tolerate a therapeutic dose of medications evidenced by documentation in the medical record of 2 trials of antidepressant agents with distinct side effects 3. history of response to TMS in a previous depressive episode , as evidenced by a greater than 50% improvement on a standard ized depression rating scale 4. currently receiving or is a candidate for and has declined electroconvulsive therapy (ECT) with TMS considered a less invasive treatment option C. Completion of a trial of evidence-based psychotherapy for MDD with appropriate frequency and duration without significant improvement for 12 weeks , alone or combined with psychopharmacologic agents . D. None of the following conditions or contraindications are present: 1. epilepsy or history of seizure or presence of other neurologic disease s or disorders that may lower seizure threshold (eg, cerebrovascular accident, severe head trauma, increased intracranial pressure) or family history of epilepsy (parent, sibling, child) 2. acute or chronic psychotic symptoms or disorders (eg, schizophrenia, schizophreniform, schizoaffective disorder) 3. bipolar disorder 4. cochlear implant s or deep brain stimulator s 5. current use of substances that may significantly lower seizure threshold (eg, alcohol or stimulants) or recent discontinuation of alcohol, benzodiazepines or anticonvulsants; sleep deprivation ; active illicit substance abuse 6. metallic hardware or implanted magnetic-sensitive medical device s (eg, implanted cardioverter-defibrillator s, pacemaker s, metal aneurysm clips or coils , intracardiac lines, medication pumps ) or other metal fragments at a distance within the electromagnetic field of the discharging coil (eg, less than or equal to 30 cm to the discharging coil) 7. unstable medical disorders (eg, recent heart attack, severe uncontrolled hypertension) 8. tattoos in the head or neck with ferromagnetic-containing ink Transcranial Magnetic Stimulation for Treatment of Depression-MP-MM-1339 Effective Dat e: 06/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 III. Additional treatment courses of TMS are considered medically necessary when all the following have been met : A. 30 days since last session of TMS B. a history of response to TMS in a previous depressive episode evidenced by a greater than 50% improvement on a standardized depression rating scale C. medical necessity is met per Section II above IV. TMS m aintenance treatment is not considered medically necessary. There is not sufficient evidence in peer reviewed literature to assess net benefit versus harm for patients. V. Additional criteria :A. TMS must be administered by an FDA-cleared device for the treatment of MDDin a safe and effective manner according to the manufacturers user manual and specified stimulation parameters. B. A treatment course should not exceed 5 days a week for 6 weeks (total of 30 sessions), followed by a 3-week taper of 3 treatments in 1 week, 2 treatments the next week, and 1 treatment in the last week. C. TMS can be ordered by and performed under direction of a neurologist, licensed psychiatrist, or psychiatric nurse practitioner who has examined the member, reviewed the record when it is within scope of practice, and has experience in administering TMS the rapy within scope of practice. E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesMedical Necessity Determinations H. Review/Revision HistoryDATE ACTIONDate Issued 07/12/2018Date Revised 08/31/2022 10/25/202201/19/202308/02 /2023 06/19/2024 06/04/2025 Annual review. Combined individual policies (GA 0861, IN 0237, KY 0239, OH 0235, WV 0240).Added IA MP. Evote received 12/8/22. Changed title for clarity. Removed IA. Annual review. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Annual review. Changed medication trial prior to TMS from 4 to 2. Updated references. Approved at Committee. Transcranial Magnetic Stimulation for Treatment of Depression-MP-MM-1339 Effective Dat e: 06/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 03/11 /2026 Annual review, updated Section II.D. Updated references. Approved at Committee.Date Effective 06 /01/202 6 Date Archived I. References1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revised . American Psychiatric Association; 2022. 2. Holtzheimer PE. Unipolar major depression: administering transcranial magnetic stimulation (TMS). Up ToDate. Updated July 21, 2025 . Accessed February 6, 2026 . www.uptodate.com 3. Holtzheimer PE. Unipolar depression in adults: indications, efficacy, and safety of transcranial magnetic stimulation (TMS). Up ToDate. Updated July 21, 2025 . Accessed February 6, 2026 . www.uptodate.com 4. Jarrett R, Vittengl J. Major depressive disorder in adults : Continuation and maintenance treatment. Up ToDate. Updated October 3, 2024. Accessed February 6, 2026 . www.uptodate.com 5. National Institute of Mental Health. Brain Stimulation Therapies . National Institutes of Health; 2023. NIH publication 0925-0648. Accessed February 6, 2026 . www.nimh.nih.gov 6. Perera T, George MS, Grammer G, et al. The Clinical TMS Society consensus review and treatment recommendations for TMS therapy for major depressive disorder. Brain Stimul . 2016;9(3):336-346. doi:10.1016/j.brs.2016.03.010 7. Thase M, Connolly R. Treatment-resistant unipolar major depression (major depressive disorder) in adults UpToDate. Updated November 17, 2025 . Accessed February 6, 2026 . www.uptodate.com 8. Transcranial Magnetic Stimulation : B-801-T. MCG Health, 29th ed. Updated June 13, 2025. Accessed February 6, 2026. www.careweb.careguidelines.com

Mechanical Stretching Devices

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Mechanical Stretching Devices-MP-MM-1382 06/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 Mechanical Stretching Devices-MP-MM-1382Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMechanical Stretching Devices B. Background Mechanical stretching devices are intended to restore range of motion (ROM) for joint stiffness or contracture by stretching joints. These devices provide passive stretching to an adjustable degree for a selected duration for multiple sessions. A variety of mechanical stretching devices are available for extension or flexion of the shoulder, elbow, wrist, fingers, knee, ankle, and toes. These devices can provide stretching for longer periods than a physical therapist (PT) and are generally used as adjunct treatment to physical therapy and/or exercise. Mechanical Stretching Devices (also known as dynamic splinting systems) include: low-load prolonged duration stretch devices (LLPS) static progressive stretch (SPS) splint devices patient actuated serial stretch (PASS) devices C. Definitions Low-load Prolonged Duration Stretch Devices (LLPS) These devices permit resisted active and passive motion (elastic traction) within a limited range. LLPS devices maintain a set level of tension by means of incorporated rubber bands or springs. Patient Actuated Serial Stretch (PASS) Devices These devices hold the joint in a set position but allow for manual modification of the joint angle and may allow for active motion without resistance (inelastic traction). This type of device itself does not exert a stress on the tissue unless the joint angle is set at the maximum ROM. Static Progressive Stretch Devices (SPS) These devices hold the joint in a set position but allow for manual modification of the joint angle and may allow for active motion without resistance (inelastic traction). D. Policy I. CareSource considers dynamic splinting devices medically necessary durable medical equipment (DME) as an adjunct treatment to physical therapy, massage, and/or exercise for an existing joint contracture when the following clinical criteria are met: A. Medically necessary only for the following joints: knee, elbow, wrist, finger, ankle and toe. B. After 3 weeks of exercise, PT and skilled therapy in the initial subacute injury or post-operative period in members with: 1. signs and symptoms of persistent joint stiffness or contracture 2. limited range of motion that poses a meaningful functional limitation as judged by a physician C. documentation showing compliance with wear and compliance with any additional activity and exercise recommended by medical professional Mechanical Stretching Devices-MP-MM-1382Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 D. may be used for an initial period of 4 weeks, a subsequent 4-week period with reevaluation, and then up to 4 months based on continued improvement E. documentation to show objective ROM and functional improvement II. In the acute post-operative period for members who have undergone additional surgery to improve the range of motion of a previously affected joint, CareSource considers use of an LLPS device medically necessary for: A. an initial 4-week period B. an additional 4-week period, if improvement was noted after the initial 4 weeks, for up to 4 months III. Non-Covered ServicesA. CareSource considers the use of dynamic splinting experimental and investigational for the following indications, including but not limited to: 1. adhesive capsulitis 2. carpal tunnel syndrome 3. cerebral palsy 4. foot drop associated with neuromuscular diseases, 5. hallux valgus 6. head and spinal cord injuries 7. Improvement of outcomes following botulinum toxin injection for treatment of limb spasticity 8. injuries of the ankle and shoulder 9. multiple sclerosis 10. muscular dystrophy 11. plantar fasciitis 12. rheumatoid arthritis 13. stroke 14. trismus B. CareSource considers the following devices experimental and investigational due to insufficient scientific evidence of efficacy: 1. Patient Actuated Serial Stretch (PASS) devices (for example, ERMI Knee Extensionater and ERMI Shoulder Extensionater) 2. Static Progressive Stretch devices (SPS) (for example, Joint Active Systems (JAS) splints (for example, JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and JAS Pronation-Supination) E. Conditions of CoverageAll claims for LLPS are subject to post-payment review by CareSource. F. Related Policies/Rules NA G. Review/Revision History DATE ACTION Mechanical Stretching Devices-MP-MM-1382Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 Date Issued 11/09/2023 New PolicyDate Revised 02/15/2023 06/07/202305/22/202403/12/2025 03/11/2026 e-voted addition of ankle and toe to policy to match fee schedule and MCG. Annual review. Added examples of PASS and SPS devices. Annual review. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee Added compliance documentation requirements to Sec.I. C. and ROM and improvement documentation to I. E. Date Effective 06/01/2025 Date Archived H. References1. Furia JP, Willis FB, Shanmugam R, et al. Systematic review of contracture reduction in the lower extremity with dynamic splinting. Adv Ther . 2013;30(8):763-770. Accessed February 3, 2026. www.ncbi.nlm.nih.gov 2. Dynamic Joint Extension and Flexion Devices: ACG A-0882. MCG. 29th ed.. Accessed February 3, 2026. www.careweb.careguidelines.com 3. Glasgow C, Tooth LR, Fleming J, et al. Dynamic splinting for the stiff hand after trauma: predictors of contracture resolution predictors of contracture resolution. J Hand Ther . Accessed January 26, 2026. www.jhandtherapy.org 4. Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev. 2010;(9):CD007455. Published 2010 Sep 8. doi:10.1002/14651858.CD007455.pub2 5. Karjalainen TV, Lusa V, Page MJ, O'Connor D, Massy-Westropp N, Peters SE. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev. 2023;2(2):CD010003. Published 2023 Feb 27. doi:10.1002/14651858.CD010003.pub2. 6. Medical Technology Directory. Mechanical Stretching Devices for the Treatment of Joint Contractures of the Extremities. Hayes; 2022. Accessed February 3, 2026. www.hayesinc.com 7. Zatarain LA, Smith DK, Deng J, et al. A randomized feasibility trial to evaluate use of the jaw dynasplint to prevent trismus in patients with head and neck cancer receiving primary or adjuvant radiation-based therapy. Integr Cancer Ther . 2018;17(3):960- 967. doi:10.1177/1534735418784363. Independent medical review 12/21

Genetic Testing and Counseling

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Genetic Testing and Counseling-MP-MM-1322 06/01/2026 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 ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Genetic Testing and Counseling-MP-MM-1322Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectGenetic Testing and Counseling B. BackgroundAdvancements in technology have contributed to the rapid expansion of identified genetic variations . S ome of these variations have been identified as disease-causing, while others are considered common variants with no clinical impact. With the ever – expanding number of genetic tests available, it can be clinically difficult to determine the most appropriat e tests for a particular patient. When clinically appropriate, genetic testing may provide diagnostic and/or actionable therapeutic results which can impac t a patients outcome. Due to the complexity of genetic tests and possible results, consultation with m edical genetics professionals and counselors may be required to assist members . According to the National Society of Genetic Counselors of the United States, genetic counseling is meant to integrate the following goals: 1) interpretation of family and medical histories to assess the chance of disease occurrence or recurrence; 2) educa tion about the natural history of the condition, inheritance pattern, testing,management, prevention, support resources, and research; 3) counseling to promote informed choices in view of risk assessment, family goals, ethical and religious values; and 4) support to encourage the best possible adjustment to the disorder in an affected family member and/or to the risk of recurrence of that disorder. Genetic counselors are healthcare professionals trained to provide this care; however, access issues may requ ire other healthcare professionals to assume this role. Genetic counseling, whether provided by a certified genetic counselor or other qualified healthcare professional, is an integral component of genetic testing that is informative and supportive to memb ers, both before and after the completion of testing. C. Definitions Genetic Screening Th e process of testing a population for a genetic disease to identify a subgroup of people who either have the disease or the potential to pass it to offspring. Genetic Testing A medical test that identifies changes in genes, chromosomes, or proteins to confirm or rule out a suspected genetic condition either hereditary or acquired. Human Leukocyte Antigen (HLA) Typing A test used to match patients and donors for bone marrow or cord blood transplants. Inherited Genetic Variant A type of DNA sequence change passed from parent to offspring (ie, germline). Precision Medicine A field of medicine that selects pharmacotherapies based on the patients genetics. Somatic Gene Variant A type of DNA sequence change that is not inherited from a parent but acquired during a persons life. Genetic Testing and Counseling-MP-MM-1322Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 D. PolicyI. Prior authorization may be required for genetic testing. This includes both somatic and germline genetic testin g. II. CareSource will review for medical necessity using published MCG criteria when available and the Medical Necessity Determinations administrative policy. This policydoes not apply to requests that have MCG or InterQual guidelines with clear genetic counseling requirements/recommendations.III. Proprietary panel testing requires evidence-based documentation per the MedicalNecessity Determinations administrative policy. Individual genetic tests may be requested separately based on the Medical Necessity Determinations administrative policy for panels not meeting medical necessity requirements. IV. Genetic counseling is required for all germline genetic testing , as indicated by ALLthe following: A. Counseling is provided by a healthcare professional with education and training in genetic issues relevant to the genetic tests under consideration. B. Counseling is provided to enable members informed decision making concerning proposed testing (eg, purpose of testing, management that may be informed by result, heritable nature informed by 3-generation family history, range of possible results, potentia l benefits and risks of testing (eg, psychological, social, economic). V. Somatic genetic testing does not require genetic counsel ing described above.VI. Human leukocyte antigen (H LA ) typing is not part of the genetic testing policy and does not require pre-authorization. VII. While most inherited genetic testing is only necessary once in a lifetime, CareSource recognizes that a germline genetic test could be appropriately repeated in extraordinary circumstances due to changes in technology. This situation will be considered wit h the proper medical necessity documentation.E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesMedical Necessity Determinations Cystic Fibrosis Testing Genetic Testing and Counseling-MP-MM-1322Effective Dat e: 06/01/2026The 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 05/25/2022 New PolicyDate Revised 05/10 /2023 04/10 /202407/03/202404/23/202503/11 /2026Annual review: updated background, definitions, and references , rephrased genetic counseling process . Approved at Committee. Review: updated references, moved state-specific information to section E, approved at Committee. Review: clarified genetic counseling requirements, added language regarding MCG. Approved at Committee Review: updated references, approved at Committee. Review: updated references, approved at Committee. Date Effective 06/01/2026 Date Archived I. References1. Ambulatory care: genetic medicine. MCG Health . 29 th ed. Accessed January 30, 2026 . www.careweb.careguidelines.com 2. Cohen SA, Bradbury A, Henderson V, et al. Genetic counseling and testing in a community setting: quality, access, and efficiency . Am Soc Clin Oncol Educ Book. 2019 ;e34-e44. doi:10.1200/EDBK_238937 3. Crooke A, Jacobs C, Newton-John T, et al. Genetic counseling and testing practices for late-onset neurodegenerative disease: a systematic review. JNeurol. 2022;269(2):676-692. doi:10.1007/s00415-021-10461-5 4. Mundy J, Davies HL, Radu M, et al. Research priorities in psychiatric genetic counselling: how to talk to children and adolescents about genetics and psychiatric disorders. Eur JHum Genet. 2023;31(3):262-264. doi:10.1038/s41431-022-01253-0 5. National Center for Biotechnology Information (NCBI). Genetic Testing Registry (GTR) National Library of Medicine. Accessed January 30, 2026 . www.ncbi.nlm.nih.gov 6. National Human Genome Research Institute. Coverage and Reimbursement of Genetic Tests. National Institutes of Health. Updated February 6, 2024 . Accessed January 30, 2026 . www.genome.gov 7. National Human Genome Research Institute. Regulation of Genetic Tests. National Institutes of Health. Updated February 19, 2024. Accessed January 30, 2026 . www.genome.gov 8. Nowaczyk MJM. Genetic testing. UpToDate. Updated July 10, 2025 . Accessed January 30, 2026 . www.uptodate.com 9. Raby BA, Kohlmann W. Genetic counseling: family history interpretation and risk assessment. UpToDate . Updated April 9 , 2024. Acces sed January 30, 2026 . www.uptodate.com 10. Sarata AK. Genetic Testing: Background and Policy Issues . Congressional Research Service Report ; 2015 . RL33832. Accessed January 30,2026 . www.sgp.fas.org 11. Senter L, Austin JC, Carey M, et al. Advancing the genetic counseling profession through research: identification of priorities by the National Society of Genetic Genetic Testing and Counseling-MP-MM-1322Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 Counselors Research Task Force. JGenet Couns . 2020;29(6):884-887. doi:10.1002/jgc4.1330 12. White S, Jacobs C, Phillips J. Mainstreaming genetics and genomics: a systematic review of the barriers and facilitators for nurses and physicians in secondary and tertiary care. Genet Med. 2020;22(7):1149-1155. doi:10.1038/s41436-020-0785-6

Metabolic and Bariatric Surgery

MEDICAL POLICY STATEMENTWest Virginia Marketplace Policy Name & Number Date Effective Metabolic and Bariatric Surgery-WV MP-MM-0795 06/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definition…………………………………………………………………………………………………………….. 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 5 F. Related Polices/Rules …………………………………………………………………………………………… 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 6 Metabolic and Bariatric Surgery-WV MP-MM-0795Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMetabolic and Bariatric Surgery B. Background Obesity continues to be a major health threat in the United States affecting an increasingly larger proportion of adults and children. The Centers for Disease Control and Prevention (CDC) estimates that over 40.3% of adults in the United States older than the age of 20 are obese (2021-2024). Obesity in adults aged 40 to 59 is higher (46.4%) than those under aged 40 (35.5%). Statistics indicate that there has been a significant increase in obesity from 1999 through 2020. Only tobacco has a higher modifiable risk factor in adult mortality. If continuing to trend at the current rate, obesity will become the number one modifiable risk factor in adult mortality. Obesity-related health problems include hypertension, type II diabetes, hyperlipidemia, atherosclerosis, heart disease, stroke, diseases of the gallbladder, osteoarthritis, sleep apnea, and certain cancers. The primary goals in achieving optimal health outcomes for CareSource members are to provide noninvasive approaches to reduce or prevent obesity by promoting healthy life-styles that will improve long-term outcomes. For individuals not able to manage obesity though non-surgical interventions, metabolic and bariatric surgery options may be an effective intervention. C. Definition Body Mass Index (BMI) A persons weight in kilograms divided by the square of height in meters. Substance Use Disorder (SUD) A cluster of cognitive, behavioral, and physiological symptoms indicating continued use of substances despite significant substance-related problems, encompassing 10 separate classes of drug criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition . Behavioral Health Provider A provider of behavioral health services, including a psychologist, psychiatrist, and psychiatric nurse practitioner. Weight Loss Surgery Surgery also known as bariatric and metabolic surgery. These terms are used to reflect the impact of these operations on patients weight and the health of their metabolism (breakdown of food into energy). In addition to their ability to treat obesity, these operations are very effective in treating diabetes, high blood pressure, sleep apnea and high cholesterol, among many other diseases. D. PolicyI. Metabolic and bariatric surgery is considered medically necessary when all the following criteria are met: A. primary diagnosis of obesity B. member is 13 years of age or older C. one of the following BMI requirements are met: 1. BMI 35 kg/m 2 or greater (32.5 or greater in Asian patients) Metabolic and Bariatric Surgery-WV MP-MM-0795Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 2. BMI 30 to 34.9 kg/m 2 (27.5 to 32.4 in Asian patients) and at least one serious obesity related condition, such as: a. high risk for type II diabetes mellitus (DM) (insulin resistance, prediabetes, and/or metabolic syndrome) b. osteoarthritis of knee or hip c. improving outcomes of knee or hip replacement d. obstructive sleep apnea (CPAP should be considered prior to undergoing surgery) e. non-alcoholic fatty liver disease f. non-alcoholic steatohepatitis g. pseudotumor cerebri h. gastroesophageal reflux disease i. severe urinary stress incontinence j. poorly controlled hypertension on multiple drug therapy or 3. BMI >30 kg/m2 with type II DM, if documentation is provided that type II DM is inadequately controlled despite optimal medical treatment by either oral or injectable medications, including insulin. II. Written clinical documentation and supporting information from the attending surgeon must include all of the following: A. Evidence of informed consent B. Letter from the Primary Care Physician (PCP) or appropriate specialist, including the following content: 1. medical necessity for procedure 2. health-related behaviors, such as smoking history or adherence, have been addressed C. Evidence that member is receiving treatment in a multi-disciplinary program that can provide ALL of the following: 1. preoperative medical consultation 2. preoperative mental health consultation 3. nutritional counseling 4. exercise counseling 5. patient support programs D. Substance use screening results E. Evidence that harm reduction related to substance use was discussed F. Evidence that risks of nicotine were discussed G. Evidence that vitamin Bdeficiencies were monitored and treated as needed prior to surgery H. Evidence that member is free of endocrine disease as supported by an endocrine study consisting of a T3, T4, blood sugar, and a 17-Keto Steroid or Plasma Cortisol I. Documentation illustrating the member has been evaluated from a psychological standpoint within the past 6 months by the treating behavioral health provider, including consideration of all of the following: Metabolic and Bariatric Surgery-WV MP-MM-0795Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 1. list of co-existing psychiatric conditions 2. family and social support 3. evidence that the member understands the surgical procedure and can make a responsible decision 4. evidence that the member is stable enough to a. understand the risks and benefits b. change lifestyle through diet moderation and strategic eating c. follow through with the extensive aftercare plan d. withstand the rigors of surgery e. not show evidence of the likelihood of being suicidal or significantly decompensate if the procedure is not successful in helping to lose weight J. Complete history and physical, including an assessment, diagnoses, height, weight, BMI, and treatment plan, must be provided. The exclusion or diagnosis of genetic or syndromic obesity, such as Prader-Willi Syndrome, must also be documented. K. For women with reproductive capacity, appropriate conception counseling was discussed and documented, including the following: 1. Clear documentation that supports that the member has agreed to avoid pregnancy for at least 1 year postoperatively. 2. Potential birth defects from nutritional deficiencies that can occur if becoming pregnant during the weight stabilization period following surgery. III. Contraindications/Noncovered proceduresA. Surgery is contraindicated in the following: 1. a medically correctable cause of obesity 2. current or planned pregnancy within one year of procedure 3. active suicidality or self-harm 4. active psychosis 5. active substance use disorder 6. ongoing substance abuse disorder within the previous year 7. severe coagulopathy 8. uncontrolled and untreated eating disorders and 9. inability to comply with postoperative long-term follow-up care B. The intended procedure is not covered if it is experimental or investigational. These include, but are not limited to: 1. endoscopic bariatric and metabolic therapies, such as intragastric balloon (IGB) 2. endoscopic sleeve gastroplasty (ESG) 3. aspiration therapy (AT) IV. The following members should be referred to an accredited comprehensive center A. BMI >55kg/m 2 B. Members with any of the following issues: 1. organ failure 2. organ transplant Metabolic and Bariatric Surgery-WV MP-MM-0795Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 3. significant cardiac or pulmonary impairment 4. on a transplant list 5. non-ambulatoryE. Conditions of CoverageN/A F. Related Polices/Rules Metabolic and Bariatric Surgery: Revision G. Review/Revision History DATE ACTIONDate Issued 02/24/2015 IssuedDate Revised 04/05/2016 06/05/2019 07/22/2020 01/08/2021 06/23/2021 06/22/2022 06/21/2023 06/19/2024 02/26/2025 Included MCG 23 rd Ed. Revisions to content and Table A. Included MCG 20 th Ed. Revisions to Table A Updated conservative approaches prior to surgery & BMI requirements; added SUD & health related behaviors, Vitamin B, and nicotine requirements; updated psychological evaluation, conception counseling, contraindications/ noncovered procedures, separated into a separate policy the revision criteria; updated referral to comprehensive center. Clarified high risk type II diabetes PA language replaced by medical necessity criteria. PA enforced by inclusion on the PA list. Updated references. Updated demographic info in background. Removed documentation requirement from III. J. member not currently pregnant. Added E&I devices to IV. B. Title changed to Metabolic and Bariatric Surgery in Adults 19 and Older to reflect state law. Added definition for Weight Loss Surgery. Added new MCG criteria, changed title and combined adolescent and adult in all markets. Updated references. Approved at Committee. Removed I.C., added D. Note: Mandatory participation in a preoperative weight loss regimen prior to weight loss surgery is not required. (Health Equity consideration). Removed II.B.2. Documentation that member has been evaluated by a nutritionist/dietician during supervised weight loss. Updated references. Approved at Committee Added Asian BMI criteria to Sec. D.I.C. 1 and 2. Updated references. Approved at Committee Date Effective 06/01/2026 Date Archived Metabolic and Bariatric Surgery-WV MP-MM-0795Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 H. References 1. AAP Updates Recommendations on Obesity Prevention: It's Never Too Early to Begin Living a Healthy Lifestyle. Accessed December 31, 2025. www.aap.org 2. Abdul Wahab R, Al-Ruwaily H, Coleman T, et al. The relationship between percentage weight loss and World Health Organization-Five Wellbeing Index (WHO-5) in patients having bariatric surgery. Obes Surg . 2022;32(5):1667-1672. doi:10.1007/s11695-022-06010-2 3. Adult obesity facts. Centers for Disease Control and Prevention. Accessed December 31, 2025. www.cdc.gov 4. American Diabetes Association. Obesity management for the treatment of Type 2 Diabetes: standards of medical care in diabetes 2020. Diabetes Care. 2020;43(1). doi:10.2337/dc20-S008 5. American Society for Metabolic and Bariatric Surgery. Bariatric surgery procedures. Accessed January 16, 2026. www.asmbs.org 6. Bariatric Surgery. NIDDK. Accessed December 31, 2025. www.niddk.nih.gov 7. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery. JAMA . 2004;292(14):1724. doi:10.1001/jama.292.14.1724 8. Center for Disease Control and Prevention. Prevalence of Obesity in the United States. 2024. Accessed December 31, 2025. www.cdc.gov 9. Chapman A. Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery . 2004;135(3):326-351. doi:10.1016/s0039- 6060(03)00392-1 10. Ellesmere JC. Bariatric operations: late complications with subacute presentations. UpToDate. Updated July 18, 2023. Accessed December 31, 2025. www.uptodate.com 11. Federal Drug Administration. Weight-Loss and Weight-Management Devices . April 27, 2020. Accessed December 31, 2025. www.fda.gov 12. Gastric Restrictive Procedure with Gastric Bypass: S-512. MCG Health; 2025. 29th ed. Accessed January 16, 2026. www.careweb.careguidelines.com 13. Guidelines for Clinical Application of Bariatric Surgery . Accessed December 31, 2025. www.sages.org 14. Health Technology Assessment: Comparative Effectiveness Review of Bariatric Surgeries for Treatment of Obesity in Adolescents. July 21, 2019. Reviewed January 20, 2022. Accessed January 16, 2026. www.hayesinc.com 15. Kiser HM, Pona AA, Focht BC, et al. Associations between psychological evaluation outcomes, psychiatric diagnoses, and outcomes through 12 months after bariatric surgery. Surg Obes Relat Dis . 2023;19(6):594-603. oi:10.1016/j.soard.2022.12.018 16. Lim RB. Bariatric procedures for the management of severe obesity: descriptions. UpToDate. Updated Sep 08, 2025. Accessed January 16, 2026. www.uptodate.com 17. Mechanisk J, et al. AACE/TOS/ASMBS/OMA/ASA 2019 Guidelines. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures 2020 update: cosponsored by American Association of Clinical Endocrinologist/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Metabolic and Bariatric Surgery-WV MP-MM-0795Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity . 2020;28(4). Accessed January 16, 2025. www.onlinelibrary.wiley.com18. Obesity and Severe Obesity Prevalence in Adults: United States, August 2021 August 2023. NCHS Data Brief no. 508. September 2024. Accessed January 16, 2026. www.cdc.gov 19. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of Obesity Among Adults and Youth: United States, 20112014 . NCHS data brief no. 219. National Center for Health Statistics; 2015. 20. Pant S. Bariatric Surgery May Cut Costs and Weight More Than GLP-1 Drugs. JAMA . 2025;334(17):1506. doi:10.1001/jama.2025.17483 21. Potential Candidates for Bariatric Surgery. National Institute of Diabetes and Digestive and Kidney Diseases. Accessed January 16, 2025. www.niddk.nih.gov 22. Shekelle, P. Mental health assessment and psychological interventions for bariatric surgery. Accessed December 31, 2025. www.hsrd.research.va.gov 23. The Practical Guide to Identification and Treatment of Overweight and Obesity in Adults . Health and Human Services Dept; 2000. Accessed January 16, 2026. www.nhlbi.nih.gov 24. Updated Guidelines for Bariatric Surgery. Accessed January 16, 2026. www.hayesinc.com 25. Yung-Chieh Y, Huang C, Tai C. Psychiatric aspects of bariatric surgery. Curr Opinion Psychiatry . 2014;27(5). doi:10.1097/YCO.0000000000000085. Independent medical review 7/2020

Metabolic and Bariatric Surgery-Revision

MEDICAL POLICY STATEMENTWest Virginia Marketplace Policy Name & Number Date Effective Metabolic and Bariatric Surgery-Revision-WV MP-MM-1062 06/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Metabolic and Bariatric Surgery-Revision-WV MP-MM-1062Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectMetabolic and Bariatric Surgery: Revision B. Background Revision procedures are typically done because of complications from or a failure of the initial surgical procedure. Complications may include surgical or anatomical complications as well as nutritional or metabolic complications. A failure of the initial bariatric surgery may result in an inadequate weight loss or a weight regain. C. Definitions Revisional Bariatric Surgery (RBS) Surgery to address those patients whose original operation was unsuccessful in achieving satisfactory weight loss goals, or in whom complications from the original operation have occurred. Inadequate Weight Loss Less than 50% expected weight loss and/or weight remains greater than 40% over ideal body weight (normal body weight BMI parameter = 18.5-24.9). D. Policy I. CareSource considers surgical revision of a bariatric surgery procedure a covered service when medically necessary. II. An inadequate weight loss due only to non-compliance with dietary, behavior, or exercise recommendations is not a medically necessary indication for a revision procedure. I. A revision procedure is medically necessary when all of the following criteria are met and documented in the medical record: A. Surgery/procedure selected is a proven procedure and not considered experimental/investigational. B. A technical failure or major complication has occurred from the initial procedure that cannot be managed medically. Technical failure and major complication examples include the following: 1. persistent pain and recurrent bleeding occur 2. chronic stenosis remains after multiple dilations 3. faulty component or malfunction that cannot be repaired 4. candy cane roux syndrome 5. complications that cannot be corrected with band manipulation, adjustments or replacement including band slippage and port leakage or 6. obstruction confirmed by imaging studies. NOTE: Stretching of a stomach pouch formed by a previous bariatric surgery due to overeating is not considered a complication and therefore is not considered an indication for revision. . Metabolic and Bariatric Surgery-Revision-WV MP-MM-1062Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 II. In the absence of a technical failure or major complication, individuals with weight loss failure 2 years following the initial bariatric surgery procedure must meet the medical necessity criteria in the medical policy for an initial bariatric surgery. E. Conditions of Coverage N/A F. Related Policies/Rules Medical Necessity Determinations Metabolic and Bariatric Surgery Experimental and Investigational Item or Service Evidence of Coverage and Health Insurance Contract West Virginia G. Review/Revision History DATE ACTIONDate Issued 07/22/2020 New policy Separated out from adult and adolescent policiesDate Revised 06/23/2021 06/22/2022 06/21/2023 06/19/2024 02/26/2025 02/25/2026 PA language replaced by medical necessity criteria. PA enforced by inclusion on the PA list. Updated references. Re-wording of section IV re: medical necessity for revision bariatric surgery. Updated references Annual review; no changes. Updated references. Review: Added definition of Revisional bariatric surgery (RBS), updated references. Approved at Committee. Review: Updated references. Approved at Committee. Added Medical Necessity Determinations to Related Policies. Updated references. Approved at Committee Date Effective 06/01/2026 Date Archived H. References1. Chen S, Chiang J, Ghanem O, et al. Decision-making Considerations in Revisional Bariatric Surgery. Surg Laparosc Endosc Percutan Tech . 2024;34(4):400-406. doi:10.1097/SLE.0000000000001296 2. Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federal for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis . 2022;18(12):1345-1356. Accessed January 08, 2026. www.soard.org 3. Ellsmere, J. Bariatric operations: late complications with subacute presentations. UpToDate. Updated June 13, 2025. Accessed January 6, 2026. www.uptodate.com 4. Federal Drug Administration. Updated Sept. 15, 2023. Weight-Loss and Weight- Management Devices. Accessed January 16, 2026. www.fda.gov 5. Gastric Restrictive Procedure with Gastric Bypass: S-512. MCG Health. 29th ed. Updated June 13, 2025. Accessed January 08, 2026. careweb.careguidelines.com Metabolic and Bariatric Surgery-Revision-WV MP-MM-1062Effective Date: 06/01/2026The MEDICAL Policy Statement detailed above has received due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 6. Mechanick J, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures 2019 update: cosponsored by American Association of Clinical Endocrinologist/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity . 2020;28(4):683-839. doi:10.1002/oby.22719 7. Mirkin K, Alli VV, Rogers AM. Revisional Bariatric Surgery. Surg Clin North Am . 2021;101(2):213-222. doi:10.1016/j.suc.2020.12.008 8. Salas-Parra RD, Smolkin C, Choksi S, Pryor AD. Bariatric Surgery: Current Trends and Newer Surgeries. Gastrointest Endosc Clin NAm . 2024;34(4):609-626. doi:10.1016/j.giec.2024.06.005 9. Yung-Chieh, Y, Huang, C, Tai, C. Psychiatric aspects of bariatric surgery. Current Opinion in Psychiatry . 2014;27(5):374-379. doi:10.1097/YCO.00000000000000 Independent medical review 7/2020

Standing Frames

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Standing Frames-MP-MM-1336 06/01/2026 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 ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Standing Frames-MP-MM-1336Effective Dat e: 06/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 F. Conditions of CoverageCareSource reserves the right to request additional information if medical necessity is not adequately documented. G. Related Policies/RulesMedical Necessity Determinations Durable Medical Equipment (DME) Modifiers Durable Medical Equipment Repairs H. Review/Revision HistoryDATE ACTIONDate Issued 08/31/2022 New policy.Date Revised 08/02 /2023 07/17 /2024 05/07/2025 02/11/202 6 Annual review. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Annual review : updated references. Approved at Committee. Periodic review. Added requirement for evaluation with qualified 0053005500520049demonstrated safe use in the home. Updated references. Approved at Committee. Date Effective 06/01/2026 Date Archived I. References1. Capati V, Covert SY, Paleg G. Stander use for an adolescent with cerebral palsy at GMFCS level with hip and knee contra ctures. A . 2020;32(6):335-341. doi:10.1080/10400435.2019.1579268 2. Definitions, GEORGIA CODE ANN . 26-4-5 (2024). 3. Definitions , OHIO REV . CODE 4752.01 (2024 ). 4. Definitions-Home Medical Equipment , OHIO ADMIN . CODE 4729:11-1-01 ( 2025 ). 5. Definitions, W . VA. CODE 11-15B-2 ( 2025) . 6. Durable Medical Equipment , IND . ADMIN . CODE 6-2.5-1-18 ( 2024 ). 7. Edemekong PF, Bomgaars DL, Sukumaran S, et al . Activities of Daily Living. In: S . Updated May 4, 2025. 8. Ferrarello F, Deluca G, Pizzi A. et al . Passive standing as an adjunct rehabilitation intervention after stroke: a randomized controlled trial. A . 2015; 5(2). doi:10.1186/s40945-015-0002-05 9. G . CareSource; 2026 . Accessed December 29, 2025 . www .caresource.com 10. Goodwin J, Lecouturier J, Basu A, et al. Standing frames for children with cerebral palsy: a mixed-methods feasibility study. H . 2018;22(50):1-232. doi:10.3310/hta22500 11. Ibitoye MO, Hamzaid NA, Ahmed YK. Effectiveness of FES-supported leg exercise for promotion of paralysed lower limb muscle and bone health 00B1 a systematic review. B . 2023;68(4):329-350. doi:10.1515/bmt-2021-0195

Radiofrequency and Microwave Ablation of Tumors

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Radiofrequency and Microwave Ablation of Tumors-MP-MM-1351 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 ………………………….. ………………………….. ………………………….. ……………………. 6 Radiofrequency and Microwave Ablation of Tumors-MP-MM-1351Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectRadiofrequency and Microwave Ablation of Tumors B. BackgroundRadiofrequency and microwave ablation, both types of thermo-ablation, may be appropriate modalities to treat certain types of tumors. Radiofrequency ablation of a tumor involves the delivery of high frequency alternating current to induce thermal injury of targeted tissue. Microwave ablation utilizes microwave energy to cause thermal coagulation and tissue necrosis at the targeted site. Evidence for the use of ablati ve techniques is constantly evolving based on tumor type, size, and location. Hepatocellular carcinoma is the most common type of primary liver cancer. Treatment options include surgical excision, hepatic artery infusion chemotherapy, trans-arterialbland or chemoembolization, selective interstitial radiotherapy (Yttrium 90 microsph eres), percutaneous ethanol injection, cryoablation, and thermo-ablation.Radiofrequency ablation and microwave ablation demonstrated comparable results to other treatment options for smaller tumors. Liver metastases are a common manifestation of many primary cancers. The number, location, size, and patients general health determine the choice of treatment for livermetastases. While s urgical resection with curative intent is ideal, this may not be possible in all patients . Non-surgical ablative techniques may be used for both curative and palliative intent; this includes systemic chemotherapy, targeted therapy, immunotherapy, external beam radiotherapy, cryoablation, thermo-ablation, arterial emboliza tion techniques, and selective internal radiation therapy. Lung cancer is one of the most common types of cancer as well as a common site ofmetastases . Since symptoms often do not appear until advanced disease, prognosis can be poor . Common treatments for primary or metastatic cancer in the lung include surgery, chemotherapy, radiotherapy, photodynamic therapy, thermal ablation, immunotherapy, and biological therapy. Treatment selection is based on type, size, position and stage of c ancer, and the patients overall health. Small renal masses (SRM), less than 4cm is size suspicious for clinical state T1a renal cell carcinoma, are the most common type of kidney tumor encountered. SRMs are often found incidentally with imaging for unrelated indications. Thermo-ablative techniqu es likeRFA and MWA are gaining greater acceptance in clinical practice due to favorable outcomes observed in initial studies, low incidence of complications, low cost and ability to treat patients in the outpatient setting.C. Definitions Tumor Ablation Direct application of energy to eradicate or destroy focal tumors. The method of ablation is dependent on the characteristics of the lesion and risk mitigation. Radiofrequency and Microwave Ablation of Tumors-MP-MM-1351Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 o Microwave Ablation (MWA) Delivery of high-frequency microwave energy to rapidly agitate water molecules in the target tissue; the energy is converted to heat, which causes tissue necrosis. o Radiofrequency Ablation (RFA) Delivery of radio waves to generate heat and induce tissue destruction in the targeted area. D. PolicyI. Microwave ablation for tumor treatment using an FDA-approved device is considered medically necessary when ONE of the following indications are met: A. Member has primary or metastatic hepatic (liver) tumor and ALL the following: 1. The tumor is unresectable due to location of lesion(s) OR the member has comorbid condition(s) that are contraindicative to surgery. 2. The tumor is 5cm in size OR there are no more than 3 nodules, all of which are 3cm in size. 3. Microwave ablation may be used alone or in conjunction with open or minimally invasive resection of other liver tumors. Curative resection of all disease must be the stated goal of therapy. B. Member has primary or metastatic lung tumor and ALL the following: 1. The tumor is unresectable due to location of lesion(s) OR the member has comorbid condition(s) that are contraindicative to surgery. 2. Single tumor is 3cm in size. C. Member has T1 renal cell carcinoma and ONE of the following: 1. Renal mass is 4cm in size and the member is not eligible for surgery or declines surgery. 2. Renal mass is > 4cm but 7cm and the member is not eligible for surgery. II. Microwave ablation is not covered for any other indication, including (but not limited to), the following: A. Microwave ablation for any other tumor type is considered experimental and investigational due to a lack of clinical evidence on its efficacy. B. Microwave ablation for tumors larger than the above indications is considered experimental and investigational due to a lack of clinical evidence on its efficacy compared to other treatment modalities. III. Radiofrequency ablation for tumor treatment is considered medically necessary for ANY of the following indications (NOTE: updates to MCG take precedence to the below criteria ): A. Barrett esophagus with dysplasia B. bone metastases C. hepatocellular carcinoma with ALL the following: 1. Child-Pugh class A or Bliver function (score of 9 or less) 2. surgical evaluation indicates at least one of the following: a. patient is a candidate for surgical resection following radiofrequency ablation Radiofrequency and Microwave Ablation of Tumors-MP-MM-1351Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 b. patient is a candidate for transplant following bridge therapy by radiofrequency ablation c. patient is not a surgical candidate (or elects against surgery) d. patient is not a transplant candidate 3. tumor has all the following: a. location amenable to percutaneous, minimally invasive or open surgical ablation b. margins accessible to ablation c. not in close proximity to critical structures (eg, major vessels, major bile ducts, diaphragm, other intra-abdominal organs) d. single tumor 5cm or smaller in diameter OR no more than 3 tumors, each of which is 3cm or smaller in diameter 4. no portal hypertension D. kidney tumor with ALL the following: 1. clinical stage T1 renal lesion 2. patient is not candidate for or elects against active surveillance 3. patient is not a surgical candidate (or elects against surgery) 4. tumor is not a renal angiomyolipoma E. liver metastases from colorectal carcinoma with ALL the following: 1. patient is not an ideal surgical candidate (or elects against surgery) 2. tumor has all the following: a. location amenable to percutaneous or surgical ablation b. margins accessible to ablation c. not in close proximity to critical structures (eg, major vessels, major bile ducts, diaphragm, other intra-abdominal organs) d. single tumor 5cm or smaller in diameter OR no more than 3 tumors, each of which is 3cm or smaller in diameter 3. no extrahepatic disease F. lung cancer (non-small cell [NSCLC]) with ALL the following: 1. patient is not a surgical candidate (or elects against surgery) 2. tumor with ALL the following: a. less than 3cm in diameter b. node negative (stage I) c. not in close proximity to major pulmonary vessels or esophagus G. osteoid osteoma H. soft tissue sarcoma with at least ONE of the following: 1. gastrointestinal stromal tumor with limited progressive disease (ie, appearance of new lesion, increase in tumor size) 2. soft tissue sarcoma of extremity, superficial trunk, or head/neck, as indicated by both: a. synchronous stage IV disease b. need for treatment of tumor bulk limited to single organ that is amenable to local therapy, or palliation of disseminated metastases I. thyroid cancer with at least ONE of the following: 1. differentiated thyroid carcinoma (eg, follicular, papillary) with at least ONE of the following: Radiofrequency and Microwave Ablation of Tumors-MP-MM-1351Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 a. distant metastasis or persistent disease not amenable to treatment with radioactive iodine b. recurrent disease following treatment of locoregional disease 2. medullary carcinoma with at least ONE of the following: a. palliative treatment of symptomatic metastases or progressive disease needed b. Patient asymptomatic, with at least ONE of the following: 01. disease metastasis 02. persistent disease following treatment of locoregional disease 03. recurrent disease following treatment of locoregional disease J. thyroid nodules, with ALL the following: 1. compressive symptoms from nodules (eg, cough, dysphagia, foreign body sensation, pain, voice changes) 2. patient not a surgical candidate (or elects against surgery) K. uterine leiomyomas with ALL the following: 1. laparoscopic ultrasound-guided procedure planned 2. leiomyomas documented by imaging study (eg, ultrasound or hysteroscopy) 3. patient desires uterine conservation or is not a surgical candidate 4. patient is premenopausal 5. persistent symptoms (3 months or greater in duration) directly attributed to presence of leiomyomas, as indicated by at least ONE of the following: a. abnormal uterine bleeding unresponsive to conservative management (eg, hormonal therapy) b. bowel dysfunction c. dyspareunia d. infertility e. iron deficiency anemia f. pelvic pain or pressure g. urinary dysfunction 6. testing has ruled out other potential ca uses of symptoms E. State-Specific InformationNA F. Conditions of CoverageNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 10/12/2022Date Revised 09/27/2023 08/28/2024 Annual review: updated references, approved at Committee Review: updated references, approved at Committee. Radiofrequency and Microwave Ablation of Tumors-MP-MM-1351Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 06/18/202502/11 /2026Review: added indications for Barrett and thyroid nodules, updated references, approved at Committee.Review: expanded background, added renal MWA indications, approved at Committee. Date Effective 05/01/2026 Date Archived I. References1. Aarts BM, Gomez FM, Lopez-Yurda M, et al. Safety and efficacy of RFA versus MWA for T1a renal cell carcinoma: a propensity score analysis. Eur Radiol . 2023;33(2):1049-1049. doi:10.1007/s00330-022-09110-w. 2. Abdalla M, Collings AT, Dirks R, et al. Surgical approach to microwave and radiofrequency liver ablation for hepatocellular carcinoma and colorectal liver metastases less than 5cm: a systematic review and meta-analysis. Surg Endosc. 2023;37(5):3340-3353. doi:10.1007/s00464-022-09815-5. 3. Cazzato RL, de Rubeis G, de Marini P, et al. Percutaneous microwave ablation of bone tumors: a systematic review. Eur Radiol . 2021;31(5):3530-3541. doi:10.1007/s00330-020-07382-8. 4. Chung SR, Suh CH, Baek JH, et al. Safety of radiofrequency ablation of benign thyroid nodules and recurrent thyroid cancers: a systematic review and meta – analysis. Int JHyperthermia 2017;33:920-930. doi:10.1080/02656736.2017.1337936 5. Cui R, Yu J, Kuang M, et al. Microwave ablation versus other interventions for hepatocellular carcinoma: a systematic review and meta-analysis. JCancer Res Ther . 2020;16(2):379-386. doi:10.4103/jcrt.JCRT_403_19 6. Curley SA, Stuart KE, Schwartz JM, et al. Localized hepatocellular carcinoma: liver – directed therapies for nonsurgical candidates who are eligible for local ablation. UpToDate. Updated April 17 , 2025. Accessed January 23, 2026 . www.uptodate.com 7. Dupuy DE. Image-guided ablation of lung tumors. UpToDate. Updated July 16 2025 . Accessed January 23, 2026 . www.uptodate.com 8. Genshaft SJ, Suh RD, Abtin F, et al. Society of Interventional Radiology quality improvement standards on percutaneous ablation of non-small cell lung cancer and metastatic disease to the lungs. JVasc Interv Radiol . 2021;32:1242.e1-1242.e10. doi:10.1016/j.jvir.2021.04.027 9. Glassberg MB, Ghosh S, Clymer JW, et al. Microwave ablation compared with hepatic resection for the treatment of hepatocellular carcinoma and liver metastases: a systematic review and meta-analysis. World JSurg Oncol . 2019;17(1):98. doi:10.1186/s12957-019-1632-6 10. Golden ED, Mutlu A, Knavel-Koepsel EM, et al. Microwave ablation for renal cell carcinoma: a literature review and clinical insights. EMJ Radiol. 2025;6(1):71-85. doi:10.33590-emjradiol/MQUZ3849 11. Han Y, Yan X, Zhi W, et al. Long-term outcome following microwave ablation of lung metastases from colorectal cancer. Front Oncol . 2022;12:943715. doi:10/3389/fonc.2022.943715. Radiofrequency and Microwave Ablation of Tumors-MP-MM-1351Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 12. Hines A, Goldberg SN. Radiofrequency ablation, cryoablation, and other ablative techniques for renal cell carcinoma. UpToDate. Updated September 3, 2024. Accessed January 23, 2026. www.uptodate.com13. Khandpur U, Haile B, Makary MS. Early-stage renal cell carcinoma locoregional therapies: current approaches and future directions. Clin Med Insights Oncol . 2024;18:18:11795549241285390. doi:10.1177/11795549241285390 14. Matsui Y, Tomita K, Uka M, et al. Up-to-date evidence on image-guided thermal ablation for metastatic lung tumors: a review. Jpn JRadiol . 2022 ;40(10):1024-1034. doi:10/1007/s11603-022-01302-0. 15. McClure T, Lansing A, Ferko N, et al. A comparison of microwave ablation and cryoablation for the treatment of renal cell carcinoma: a systematic literature review and meta-analysis. Urology . 2023;180:1-8. doi:10.1016/j.urology.2023.06.001. 16. National Comprehensive Cancer Network . Clinical Practice Guidelines in Oncology. Hepatocellular Carcinoma. Version 2.2025 . Issued October 22 , 2025 . Accessed January 23, 2026 . www.nccn.org 17. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Kidney Cancer. Version 1.2026. Issued July 24, 2025. Accessed January 23, 2026. www.nccn.org 18. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer. Version 3.202 6. Issued December 24 , 2025. Accessed January 23, 2026 . www.nccn.org 19. National Institute for Health and Care Excellence. Microwave ablation for primary or metastatic cancer in the lung [IPG716]. Published February 2, 2022 . Accessed January 23, 2026 . www.nice.org 20. National Institute for Health and Care Excellence. Microwave ablation for treating liver metastases [IPG553]. Published April 27, 2016 . Accessed January 23, 2026 . www.nice.org 21. National Institute for Health and Care Excellence. Microwave ablation of hepatocellular carcinoma [IPG214]. Published March 28, 2007 . Accessed January 23, 2026 . www.nice.org 22. Nelson DB, Tam AL, Mitchell KG, et al. Local recurrence after microwave ablation of lung malignancies: A Systematic Review. Ann Thorac Surg . 2019;107(6):1876-1883. doi:10.1016-j.athoracsur.2018.10.049 23. Palussiere J, Chomy F, Savina M, et al. Radiofrequency ablation of stage IA non – small cell lung cancer in patients ineligible for surgery: results of a prospective multicenter phase II trial. JCardiothorac Surg . 2018;13(1):91. doi:10/1186/s13019 – 018-0773-y 24. Pierorazio PM, Campbell SC. Clinical diagnosis and management of a small renal mass. UpToDate. Updated September 26, 2025. Accessed January 23, 2026. www.uptodate.com 25. Radiofrequency Ablation of Tumor. ACG: A-0718 (AC). 29th ed. MCD Health; 2025. Updated January 25, 2025. Accessed May 9, 2025. www.careweb.guidelines.com 26. Wang N, Xu J, Wang G, et al. Safety and efficacy of microwave ablation for lung cancer adjacent to the interlobar fissure. Thorac Cancer . 2022 ;13(18):2557-2565 . doi:10.1111/1759-7714.14589 Radiofrequency and Microwave Ablation of Tumors-MP-MM-1351Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 27. Wu X, Uhlig J, Blasberg JD, et al. Microwave ablation versus stereotactic body radiotherapy for stage I non-small cell lung cancer: a cost-effectiveness analysis. JVasc Interv Radiol . 2022;33(8):964-971.e2. doi:10.1016/j.jvir.2022.04.019 Independent med ical review September 2022

Peripheral Nerve Stimulators for Treatment of Pain

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Peripheral Nerve Stimulators for Treatment of Pain-MP-MM-1403 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 ………………………….. ………………………….. ………………………….. …… 3 I. References ………………………….. ………………………….. ………………………….. …………………….. 3 Peripheral Nerve Stimulators for Treatment of Pain-MP-MM-1403Effective Dat e: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPeripheral Nerve Stimulators for Treatment of Pain B. BackgroundThe role of targeting and treating peripheral nerves as sources of pain when conservative therapy has failed is currently being more extensively explored. Neuromodulation of peripheral nerves to treat refractory pain is one such area of interest. The neuromodulation of peripheral nerves to reduce pain is commonly known as peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS) , and percutaneous-electrical nerve field stimulation (PEN FS) . It has been developed as a minimally invasive pain management modality intended to manage acute and chronic pain. The proposed mechanism of action, referred to as the gate control theory, involves a method by which stimulation of large-diameter sensory neurons reduces transmission ofpainful stimuli from small nociceptive fibers to the brain. The stimulation system is placed adjacent to the nerve, a process commonly known as remote selective targeting. The lead is connected to a small, wearable stimulator. Depending on the device, the wearer may be able to adjust the level of stimulation using Bluetooth technology. C. Definitions Acute Pain Pain lasting 4 weeks or less. Chronic Pain A distressing feeling often caused by intense or damaging stimuli (pain) lasting more than 3 months, considered beyond normal healing time. Sub-Acute Pain Pain lasting between 4 and 12 weeks. D. PolicyI. Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply used in or directly related to the diagnosis, evaluation, or treatment of a disease, injury, illness, or other health condition which CareSource determines in its sole discretion to be experimental or investigational is not covered by CareSource. II. Peripheral nerve stimulators are considered experimental and /or investigational andare unproven for all indications for the reduction of acute, sub-acute , and chronic pain. III. Peripheral nerve stimulators are not covered. This includes but is not limited to:A. IB-Stim (NeurAxis)B. Moventis PNS C. Nalu Neurostimulation System D. Nerivio E. SPRINT PNS System F. StimQ PNS System G. StimRouter Neuromodulation Syste m Peripheral Nerve Stimulators for Treatment of Pain-MP-MM-1403Effective Dat e: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 E. State-Specific InformationN/A F. Conditions of CoverageN/A G. Related Policies/RulesCareSource Evidence of Coverage Experimental or Investigational Item or Service Medical Necessity Determinations H. Review/Revision HistoryDATE ACTIONDate Issued 01/18/2023Date Revised 01/17/2024 06/05/2024 05/07/2024 01/28/2026 Annual Review; updated references. Approved at Committee. Revised Background, added D. III. A. Approved at Committee Annual review, references updated. Approved at Committee Added Nerivio to D.III. Approved at Committee. Date Effective 05/01/2026 Date Archived I. References1. Abd-Elsayed A, Keith MK, Cao NN, Fiala KJ, Martens JM. Temporary peripheral nerve stimulation as treatment for chronic pain. Pain Ther . 2023;12(6):1415-1426. doi:10.1007/s40122-023-00557-3 2. Albright-Trainer B, Phan T, Trainer RJ, et al. Peripheral nerve stimulation for the management of acute and subacute post-amputation pain: a randomized, controlled feasibility trial. Pain Manage . 2022;12(3):357-369. doi:10.2217/pmt-2021-0087 3. Char S, Jin MY, Francio VT, et al. Implantable peripheral nerve stimulation for peripheral neuropathic pain: a systematic review of prospective studies. Biomed . 2022;10(10)2606. doi:10.3390/biomedicines10102606 4. Chogle A, El-Chammas K, Santucci N, et al. A multicenter registry study on percutaneous electrical nerve field stimulation for pediatric disorders of gut-brain. J Pediatr Gastroenterol Nutr . 2024;78(4):817-826. doi:10.1002/jpn3.12174 5. DSouza RS, Jin MY, Abd-Elsayed A. Peripheral nerve stimulation for low back pain: a systematic review. Curr Pain Headache Rep . 2023;27:117-128. doi:10.1007/s11916-023-01109-2 6. Dorfman L, El-Chammas K, Graham K, et al. Repeat round of auricular percutaneous electrical nerve field stimulation for pediatric disorders of gut brain interaction. JPediatr Gastroenterol Nutr . 2025;(81)(2):234-245. doi:10.1002/jpn3.70109 7. Evidence Analysis Research Brief: Peripheral Nerve Stimulation for the Treatment of Superior Cluneal Neuralgia. Hayes; 2024. Accessed December 10, 2025 . www.evidence.hayesinc.com Peripheral Nerve Stimulators for Treatment of Pain-MP-MM-1403Effective Dat e: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 8. Evolving Evidence Review: IB-Stim (NeurAxis) for Treatment of Pain Associated withIrritable Bowel Syndrome in Adolescents. Hayes; 2022. Reviewed July 28,2025. Accessed December 10, 2025 . www.evidence.hayesinc.com 9. Evolving Evidence Review: Nerivio (Theranica Bio-Electronics LTD.) for Treatment of Acute Migraine Episodes in Adults. Hayes; 2025. Accessed December 10, 2025. www.evidence.hayesinc.com 10. Evolving Evidence Review: SPRINT PNS System (SPR Therapeutics) for Chronic Pain. Hayes; 2021. Updated February 27, 2025. Accessed December 10, 2025 . www.evidence.hayesinc.com 11. Hatheway J, Hersel A, Song J, et al. Clinical study of a micro-implantable pulse generator for the treatment of peripheral neuropathic pain: 3-month and 6-month results from the COMFORT-randomised controlled trial. Reg Anesth Pain Med . 2024;0:1-7. doi:10.1136/rapm-2023-105264 12. Health Technology Assessment: Percutaneous Peripheral Nerve Stimulation for Treatment of Chronic Pain. Hayes; 2022. Reviewed May 30, 2025 . Accessed December 10, 2025 . www.evidence.hayesinc.com 13. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain. Hayes; 2021. Reviewed April 17, 2024. Accessed December 10, 2025 . www.evidence.hayesinc.com 14. Helm S, Shirsat N, Calodney A, et al. Peripheral nerve stimulation for chronic pain: a systematic review of effectiveness and safety. Pain Ther . 2021;10(2):985-1002. doi:10.1007/s40122-021-00306-4 15. Huntoon MA, Slavin KV, Hagedorn JM, et al. A retrospective review of real-world outcomes following 60-day peripheral nerve stimulation for the treatment of chronic pain. Pain Physician . 2023;26(3):273-281. Accessed April 10, 2025. www.painphysicianjournal.com 16. Kaye AD, Ridgell S, Alpaugh ES, et al. Peripheral nerve stimulation: a review of techniques and clinical efficacy. Pain Ther . 2021;10(2):961-972. doi:10.1007/s40122 – 021-00298-1 17. Li AH, Gulati A, Leong MS, et al. Considerations in permanent implantation of peripheral nerve stimulation (PNS) for chronic neuropathic pain. an international cross-sectional survey of implanters. Pain Pract . 2022;22(5):508-515. doi:10.1111/papr.13105 18. Luna D, Hettie G, Pirrotta L, et al. Real-world long-term outcomes of peripheral nerve stimulation: a prospective observational study. Pain Manag . 2025;15(1):37-44. doi:10.1080/17581869.2025.2451605 19. McCullough M, Kenney D, Curtin C, et al. Peripheral nerve stimulation for saphenous neuralgia. Reg Anesth Pain Med . 2024;49(6):455-460. doi:10.1136/rapm-2023 – 104538 20. Smith BJ, Twohey EE, Dean KP, DSouza RS. Peripheral nerve stimulation for the treatment of postamputation pain: a systematic review. Am JPhys Med Rehabil . 2023;102(9):846-854. doi:10.1097/PHM.0000000000002237 21. Strand N, DSouza RS, Hagedorn JM. Evidence-based clinical guidelines from the American Society of Pain and Neuroscience for the use of implantable peripheral nerve stimulation in the treatment of chronic pain. JPain Res . 2022;15:2483-2504. doi:10.2147/JPR.S362204 Peripheral Nerve Stimulators for Treatment of Pain-MP-MM-1403Effective Dat e: 05/01/2026 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 22. Vangeison CT, Bintrim DJ, Saha AK, et al. The role of peripheral nerve stimulation in refractory non-operative chronic knee osteoarthritis. Pain Manag . 2023;13(4):213-218. doi:10.2217/pmt-2023-0025 23. West T, Hussain N, Bhatia A, et al. Pain intensity and opioid consumption after temporary and permanent peripheral nerve stimulation: a 2-year multicenter analysis. Reg Anesth Pain Med . 2024. doi:10.1136/rapm-2024-105704 24. Xu J, Sun Z, Wu J, et al. Peripheral nerve stimulation in pain management: a systematic review. Pain Physician . 2021;24(2):E131-E152. Accessed April 10, 2025. www.painphysicianjournal.com

Peripheral Nerve Blocks for Treatment of Pain

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 ………………………….. ………………………….. ………………………….. ……. 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 5 I. References ………………………….. ………………………….. ………………………….. …………………….. 5 Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPeripheral Nerve Blocks for Treatment of Pain B. BackgroundPeripheral nerve blocks are injections of medication into a specific area of the body where nerves cause pain to a specific organ or body region. Nerve blocks cause the temporary interruption of impulse conduction in peripheral nerves or nerve trunks and may or may not contain a steroid, which can be used to treat pain . Various areas of pain require different types of nerve blocks that can be administered in numerous parts of the body with some of the most common blocks being sympathetic, peripheral, and oc cipital. Sacroiliac and facet joint interventions, epidural steroid injections, and trigger point injections are addressed in other policies.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Ambulatory Surgery Surgery performed in a hospital-based or freestanding ambulatory surgery center (ASC) with patient discharge the same day. Chronic Pain Pain lasting more than 3 months, which is considered beyond normal healing time. Conservative Therapy A multimodality plan including both active and inactive conservative therapies . o Active Conservative Therapies Actions or activit ies 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. 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 due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience and/ or noncompliance without explanation does not constitute inability to complete . o Inactive Conservative Therapies Passive activities by the member that aid in treating symptoms with pain , including rest, ice, heat, medical devices, acupuncture , TENS u se , and/or pharmacotherapy (prescription or over the counter [eg, NSAIDS, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator ( TENS ) A device that utilizes electrical current directed through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulat e the release of endorphins . Use, frequency, duration, and start dates must be documented in the medical record . Emergent Medically necessary care which is immediately needed to preserve life , prevent serious impairment to bodily functions, organs, or parts, or prevent placing the physical or mental health of a patient in serious jeopardy. Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Low-Risk Procedu re Procedures associated with minimal physiologic effect and exclude any intrathoracic, intra-abdominal, vascular, or orthopedic procedures. Sub-Acute Pain Pain lasting between 4 and 12 weeks. D. PolicyI. CareSource considers peripheral nerve blocks (PNB) , single injection, medically necessary when appropriate documentation for the treatment of acute pain or chronic pain are included, only as part of an active component of a comprehensive pain management program. CareSource uses MCG Health guidelines to ad dress criteria for specific nerve blocks. Documentation must include indications that ALL the following criteria are met: A. PNB is performed as an a mbulatory or outpatient procedure that (1) is not treating an emergent condition , (2) is a low risk procedure , and (3) requires no inpatient care for a preoperative disease or condition (eg, altered mental status, hypotension, hypoxemia, tachycardia) . B. Acute, sub-acute or chronic, neuropathic or radicular pain, as indicated by ONE or more of the following: 1. Cancer-related pain 2. Complex Regional Pain Syndrome (CRPS) 3. Peripheral neuropathy with pain that limits activities of daily living, excluding diabetic neuropathy 4. Peripheral vascular disease with rest pain 5. Acute herpes zoster of face or neck and prevention of postherpetic neuralgia 6. Pancreatic pain, pelvic pain, or abdominal pain related to malignancy 7. Chronic, relapsing pancreatitis C. Symptoms poorly controlled by maximum medical therapy or intolerable side effects to such therapy . D. Failure of non-invasive treatment(s) (eg, non-steroidal anti-inflammatory drugs (NSAIDs), exercise, physical therapy, spinal manipulation therapy) . E. No coagulopathy or thrombocytopenia . F. No infection at or underlying the injection site . II. Acute or Sub-Acute PainPNB may provide means of analgesia for acute pain in the following (not an all – inclusive list): A. Patients at risk of respiratory depression related to systemic or neuraxial opioids (eg, obstructive sleep apnea, severe obesity, underlying pulmonary disease, advanced age). B. Patients with another indication to minimize opioid use (eg, chronic opioid use, intolerance to opioids). C. Patients with acute, severe pain poorly managed with systemic medication. D. Patients who cannot tolerate chiropractic or other physical and/or manipulative therapies. Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 III. Chronic PainCareSource considers PNB , single injection, medically necessary when appropriate documentation for the treatment of chronic pain is included, only as part of an active component of a comprehensive pain management program when there has been a failure of conservative therapy, as evidenced by ALL the following: A. Documentation in the medical record of at least 6 weeks of active conservative therapy within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance . B. Documentation in the medical record of at least 6 weeks inactive conservative therapy within the past 6 months . Insufficient evidence support s the following use s of PNB for chronic pain and is notconsidered medically necessary :A. Genicular nerve or branches for chronic knee pain . B. Cluneal nerve injections or blocks for chronic low back pain or pelvic pain . C. Pudendal blocks for chronic pelvic pain conditions. IV. Peripheral Radiofrequency Ablation (RFA) or NeurotomyRadiofrequency ablation and/or neurotomy are considered experimental and investigational, or unproven for any indication, including but not limited to the treatment of acute or chronic pain due to insufficient evidence of efficacy in the peer reviewed literature. V. Limitations and ExclusionsA. A member can receive a maximum of 6 injections per area and anatomical side in a calendar year . B. Up to 2 anatomic sites (eg, specific nerve, plexus, or branch as defined by CPT code description) may be injected at any one session. C. Nerve blocks used as part of a surgical procedure or other medical procedure are not separately reimbursable but an inclusive component of that procedure. These injections will not be compensated separately or unbundled for coverage. D. Any procedure submitted for payment with an incorrect CPT code or description will be denied. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provide d. If requesting a block to a specific part of the body, coding to the highest level of specificity should be used. E. Exclusion s 1. Treatment of peripheral neuropathy due to diabetes. 2. Use of nerve blocks with or without use of electrostimulation for treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases. Medical management using systemic medications is clinically indicated for the treatment of these conditions. E. State-Specific InformationN/A Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 F. Conditions of CoverageInterventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers within their scope of practice who are qualified to deliver these health services . G. Related Policies/RulesEpidural Steroid Injections Experimental or Investigational Item or Service Facet Joint Interventions Sacroiliac Joint Procedures Trigger Point Injections H. Review/Revision HistoryDATE ACTIONDate Issued 05/01/2023Date Revised 02/28/2024 07/03/2024 02/26/2025 01/28/2026 Annual review-editorial changes ; Approved at Committee Revision – clarified limitations in D.V.A. Approved at Committee. Annual review, references updated. Approved at Committee. Annual review , approved at Committee. Date Effective 05/01/2026 Date Archived I. References1. Ailani J, Burch RC, Robbins MS; American Headache Society. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache . 2021;61(7):1021-1039. doi:10.1111/head.14153 2. Allen SM, Mookadam F, Cha SS, et al. Greater occipital nerve block for acute treatment of migraine headache: a large retrospective cohort study. JAm Board Fam Med . 2018;31(2):211-218. doi:10.3122/jabfm.2018.02.170188 3. American Headache Society. AHS consensus statement: The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache . 2019;59(1):1-18. doi:10.1111/head.13456 4. Antolak S, Antolak C, Lendway L. Measuring the quality of pudendal nerve perineural injections. Pain Physician . 2016;19:299-306. Accessed December 3, 2025 . www.pubmed.ncbi.nlm.nih.gov 5. Caponnetto V, Ornello R, Frattale I, et al. Efficacy and safety of greater occipital nerve block for the treatment of cervicogenic headache: a systematic review. Expert Rev Neurotherapeutics . 2021; 21(5):591-597. doi:10.1080/14737175.2021.1903320 6. Chang A, Dua A, Singh K, White BA. Peripheral nerve blocks. StatPearls . StatPearls Publishing; 202 5. Accessed December 3, 2025 . www.ncbi.nlm.nih.gov 7. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated April 29, 2025 . Accessed December 3, 2025 . www.uptodate.com Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 8. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1 9. Evidence Analysis Research Brief: Genitofemoral Nerve Block or Ablation for Treatment of Groin Pain. Hayes; 2024. Accessed December 3, 2025. www.evidence.hayesinc.com 10. Evidence Analysis Research Brief: Radiofrequency Ablation of Cluneal Nerve for Treatment of Chronic Low Back Pain. Hayes; 2023. Accessed December 3, 2025 . 11. Evolving Evidence Review: Middle Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2022. Reviewed February 7, 2025 . Accessed December 3, 2025 . www.evidence.hayesinc.com 12. Evolving Evidence Review: Percutaneous Conventional Radiofrequency Ablation of Medial Branch Nerve(s) for Treatment of Thoracic Spinal Pain. Hayes; 2025. Accessed December 3, 2025 . www.evidence.hayesinc.com 13. Evolving Evidence Review: Pulsed Radiofre quency for the Treatment of Pudendal Neuralgia. Hayes; 2024. Reviewed November 13, 2025. Accessed December 3, 2025. www.evidence.hayesinc.com 14. Evolving Evidence Review: Superior Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2021. Reviewed December 18, 2024. Accessed December 3, 2025 . www.evidence.hayesinc.com 15. Frank FT, Sawsan A. Chronic pelvic pain in adult females: treatment. UpToDate. Updated September 4, 2025 . Accessed December 3 , 2025. www.uptodate.com 16. Garza I. Occipital neuralgia. UpToDate. Updated March 3, 2025 . Accessed December 3, 2025 . www.uptodate.com 17. Garza I, Schwedt TJ. Chronic migraine. UpToDate. Updated October 3, 2024. Accessed December 3, 2025 . www.uptodate.com 18. Gautam S, Gupta N, Khuba S, et al. Evaluation of the efficacy of superior cluneal nerve block in low back pain: a prospective observational study. JBodyw Mov Ther . 2022;30:221-225. doi:10.1016/j.jbmt.2022.03.001 19. Headaches in Over 12s: Diagnosis and Management . National Institute for Excellence; 2012. CG150. Updated June 3, 2025 . Accessed December 3, 2025 . www.nice.org 20. Health Technology Assessment: Cooled or Pulsed Radiofrequency for Chronic Low Back Pain Arising From the Sacroiliac Joint. Hayes; 2022. Reviewed December 10, 2024. Accessed December 3, 2025. www.evidence.hayesinc.com 21. Health Technology Assessment: Genicular Nerve Block for the Treatment of Knee Osteoarthritis. Hayes; 2023. Reviewed December 4, 202 5. Accessed December 9, 2025 . www.evidence.hayesinc.com 22. Health Technology Assessment: Greater Occipital Nerve Blocks for Treatment of Migraine. Hayes; 2019. Reviewed October 10, 2022. Accessed December 3, 2025 . www.evidence.hayesinc.com 23. Health Technology Assessment: Local Injection Therapy for Cervicogenic Headache and Occipital Neuralgia. Hayes; 2017. Reviewed November 15, 2021. Accessed December 3, 2025 . www.evidence.hayesinc.com Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 24. Health Technology Assessment: Pulsed Radiofrequency for Treatment of Chronic Shoulder Pain. Hayes; 2022. Reviewed September 16, 2025. www.evidence.hayesinc.com25. Health Technology Assessment : Radiofrequency Nerve Ablation for the Management of Osteoarthritis of the Knee. Hayes; 2020. Reviewed December 28, 2023. Accessed December 3, 2025. www.evidence.hayesinc.com 26. Hui J, Seko K, Shrikhande G, et al. A novel, nonopiod-based treatment approach to men with urologic chronic pelvic pain syndrome using ultrasound-guided nerve hydrodissection and pelvic floor musculature trigger point injections. Neurourol Urodyn . 2020;39(2):658-664. doi:10.1002/nau.24242 27. Inan L, Inan N, Unal-Artik H, et al. Greater occipital nerve block in migraine prophylaxis: narrative review. Cephalalgia . 2019;39:908-920. doi:10.1177/0333102418821669 28. Isu T, Kim K, Morimoto D, Iwamoto N. Superior and middle cluneal nerve entrapment as a cause of low back pain. Neurospine . 2018;15(1):25-32. doi:10.14245/ns.1836024.012 29. Jeng C, Rosenblatt M. Overview of peripheral nerve blocks. UpToDate. Updated July 30, 2025 . Accessed December 3, 2025 . www.uptodate.com 30. Matsumoto J, Isu T, Kim K, et al. Middle cluneal nerve entrapment mimics sacroiliac joint pain. Acta Neurochir (Wien) . 2019;161(4):657-661. doi:10.1007/s00701-019 – 03861-0 31. Mustafa A, Brooks B, Leishear K, et al. A novel treatment approach for women with chronic pelvic pain syndrome leading to increased pelvic functionality. JWomens Health Gyn . 2020;7:1-10. doi:10.17303/jwhg.2020.7.402 32. Nielsen TD, Moriggl B, Barckman J, et al. Randomized trial of ultrasound-guided superior cluneal nerve block. Reg Anesth Pain Med . 2019;44:772-780. doi:10.1136/rapm-2018-100174 33. Ornello R, Lambru G, Caponnetto V, et al. Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic review and meta – analysis. Expert Rev Neurotherapeutics . 2020;20(11):1157-1167. doi:10.1080/14737175.2020.1809379 34. Plavnik K, Tenaglia A, Hill C, et al. A novel, non-opioid treatment for chronic pelvic pain in women with previously treated endometriosis utilizing pelvic-floor musculature trigger-point injections and peripheral nerve hydrodissection. PM R . 2020;12(7):655 – 662. doi:10.1002/pmrj.12258 35. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on chronic pain management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology . 2010;112(4):810-833. doi:10.1097/ALN.0b013e3181c43103 36. Shauly O, Gould DJ, Sahai-Srivastava S, et al. Greater occipital nerve block for the treatment of chronic migraine headaches: a systematic review and meta-analysis. Plast Reconstr Surg . 2019;144(4):943-952. doi:10.1097/PRS.0000006059 37. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: evaluation. UpToDate. Updated September 11, 2025 . Accessed December 3, 2025 . www.uptodate.com 38. Watson JC. Cervicogenic headache. UpToDate. Updated September 9, 2025 . Accessed December 3, 2025 . www.uptodate.com Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 39. Wray JK, Dixon B, Przkora R. Radiofrequency ablation. StatPearls . StatPearlsPublishing; 2025. Accessed December 3, 2025 . www.ncbi.nlm.nih.gov

Insulin Infusion Pump

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Insulin Infusion Pump-MP-MM-1316 05/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.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 Insulin Infusion Pump-MP-MM-1316Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectInsulin Infusion Pump B. Background38.4 million people (11.6% of the population) in the United States have diabetes mellitus (DM), not including an estimated 8.5 million undiagnosed adults. Approximately 5 to 10% of individuals with diabetes have type 1 (T1D), while type 2 (T2D) accounts fo r the remaining 90 to 95% of cases. The incidence of both T1D and T2D in children and adolescents has significantly increased in recent years according to the Centers for Disease Control National Diabetes Statistic Report. Some of the unique challenges ass ociated with caring for children and adolescents include patient size, developmental concerns, and communication concerns regarding symptoms of hypoglycemia. Immediate impacts on both physical and mental well-being are common in both severe hypoglycemia an d extreme hyperglycemia. Patients with diabetes need to be closely monitored. When blood glucose levels are poorly controlled, patients are at risk of complications, including heart disease, stroke, peripheral vascular disease, retinal damage, kidney disease, nerve damage, and imp otence. Patients should also be monitored for comorbidities that may not be presentduring the early stages of the disease but develop as the disease progresses, including hearing impairment, fatty liver disease, sleep apnea, periodontal disease, depressio n,anxiety, cognitive impairment, and fractures. Reasonable glycated hemoglobin (A1C) goals for diabetic patients should be customized for the individual patient, balancing established benefits with prevention of complications and risk of hypoglycemia. Goals vary depending on age, comorbidities, and the benefitsof intensive therapy. Patients with T1D while pregnant may require stricter control.Insulin therapy is the mainstay of treatment for T1D and T2D . External insulin pumps arean option for intensive insulin therapy designed to provide continuous subcutaneous insulin infusion (CSII) to improve glycemic control, meet basal insulin requirements, and supplement bolus insulin delivery to assist in mealti me insulin needs. The AmericanAssociation of Clinical Endocrinologists (AACE), American College of Endocrinology (ACE), and American Diabetes Association (ADA) recommend CSII only in individuals with T1D and patients with T2D who are insulin dependent. Insulin absorption with CSII therapy appears to be less variable and may help members that have not been able to achieve optimum glycemic goals with multiple daily injections. The choice of insulin delivery via multiple daily injections or continuous subcutaneous delivery of a rapid – acting insulin preparation via a pump should be carefully considered and thoroughly explained to the member. Insulin pumps should only be used in patients who are motivat ed and knowledgeable in DM self-care and able to safely manage the device. Additionally, newer, sensor-augmented insulin pump systems are available with continuous glucose monitoring (CGM) integrated into the pump, which may reduce nocturnal hypoglycemia. Insulin Infusion Pump-MP-MM-1316Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 C. Definitions Dawn Phenomenon An observed increase in blood sugar levels that takes place in the early morning, often between 2am and 8am. Insulin Infusion Pump An external pump used to deliver insulin subcutaneously or through an intraperitoneal route in a controlled and programmed way to prevent acute metabolic complications of diabetes and obtain normal blood glucose levels. Moderately Increased Albuminuria Persistent urine albumin-to-creatinine ratio values between 30 and 300mg/gram creatinine. Previously called microalbuminuria, this is usually indicative of diabetic nephropathy (unless there is some other coexistent renal disease). Sensor-Augmented Insulin Pump System An insulin infusion pump equipped with a CGM sensor that uses the glucose readings taken by the CGM sensor to modify the amount of insulin infused . D. PolicyI. CareSource considers the use of external insulin infusion pumps medically necessary when ALL the following criteria are met: A. Documented diagnosis of one of the following: 1. T1D 2. T2D with insulin dependency B. Diabetic education, equipment, and supplies must be ordered in writing by a physician or other appropriately credentialed health care provider . C. The members provider and provider team have an expert level of experience in the management and support of members with insulin infusion pumps . D. Documentation that the patient has completed a comprehensive diabetes education program within the last 12 months by a certified, registered, or licensed provider with expertise in diabetes . E. The member or members caregiver must be knowledgeable in operating the device . F. The member has been on a maintenance program for at least 6 months involving at least 3 injections of insulin per day requiring frequent self-adjustments of insulin dosage . G. The member has performed glucose self-testing at least 4 times per day on average during the last month . H. The member is at high risk for preventable complications of diabetes, early signs of which include: 1. moderately increased albuminuria (eg, microalbuminuria) 2. persistent difficulty in controlling blood sugar levels despite compliance with an intensive multiple-injection regimen, as indicated in documented member log I. The member has at least 1 of the following symptoms or conditions: 1. Hb A1 Cgreater than 7% 2. history of recurring hypoglycemia 3. wide fluctuations in blood glucose before mealtime 4. dawn phenomenon frequently exceeding 200 mg/dl Insulin Infusion Pump-MP-MM-1316Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 5. history of severe glycemic excursions (eg, hypoglycemic unawareness,nocturnal hypoglycemia, extreme insulin sensitivity, and/or extremely low insulin requirements) 6. history or recurrent diabetic ketoacidosis, hypoglycemia, or both, resulting in recurrent and/or prolonged hospitalization II. ExclusionsA. CareSource considers insulin pump therapy not medically necessary when any of the following apply: 1. Member has end-stage complications such as renal failure. 2. Neither the member nor anyone assisting the member is able to operate a pump or to perform frequent blood glucose monitoring. B. CareSource considers the following devices not medically necessary: 1. portable external insulin infusion pumps requested purely for convenience or member preference 2. surgically implanted infusion devices for systems 3. jet pressure devices 4. devices associated with chronic intermittent intravenous insulin therapy (CIIIT) 5. devices associated with pulsatile intravenous therapy (PIVIT) III. Device Replacement or RepairCareSource may cover the repair, adjustment, and/or replacement of purchased equipment, supplies, or appliances when approved. A. The repair, adjustment, or replacement of the purchased equipment, supply, or appliance is covered if: 1. The equipment, supply, or appliance is a covered service . 2. The continued use of the item is medically necessary . 3. There is reasonable justification for the repair, adjustment, or replacement. B. Replacement of a functioning device just because the warranty has expired is not considered medically necessary. C. Replacement of purchased equipment, supplies or appliances may be covered if: 1. The equipment, supply , or appliance is worn out or no longer functions. 2. Repair is not possible or would equal or exceed the cost of replacement. An assessment by a rehabilitation equipment specialist or vendor should be done to estimate the cost of repair. 3. Members needs have changed, and the current equipment is no longer usable due to weight gain, rapid growth, or deterioration of function, etc. 4. The equipment, supply, or allowance is damaged and cannot be repaired. 5. Benefits for repairs and replacement do not include: a. repair and replacement due to misuse, malicious breakage, or gross neglect b. replacement of lost or stolen items Insulin Infusion Pump-MP-MM-1316Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 E. State-Specific InformationA. Georg ia Marketplace 2026 Evidence of Coverage. CareSource. Accessed January 22, 202 6. www.caresource.com B. Indiana Marketplace 2026 Evidence of Coverage . CareSource. Accessed January 22, 2026 . www.caresource.com C. Ohio Marketplace 2026 Evidence of Coverage . CareSource. Accessed January 22, 2026 . www.caresource.com D. West Virginia Marketplace 2026 Evidence of Coverage . CareSource. Accessed January 22, 2026 . www.caresource.com F. Conditions of CoverageN/A G. Related Policies/RulesN/A H. Review/Revision HistoryDATE ACTIONDate Issued 04/13/2022 New policy, replacing individual state policiesDate Revised 03/29/2023 03/13/202402/26/202501/28/2026Annual review: updated references. Approved at Committee. Annual review: editorial changes, updated background, and updated references. Approved at Committee. Annual review : added other provider to D.I.B . Approved at Committee. Review: clarified severe glycemic excursions, added D.I.I.f, approved at Committee. Date Effective 05/01/2026 Date Archived I. References1. American Diabetes Association Professional Practice Committee. Diabetes technology: standards of care in diabetes 2024. Diabetes Care . 2024;47(Suppl 1):S126-S126-S144. doi.org/10.2337/dc24-S007 2. Blonde L, Umpieerez GE, Reddy SS, et al. American Association of Clinical Endocrinology clinical practice guideline: developing a diabetes mellitus comprehensive care plan 2022 update. Endocr Pract . 2022;28(10):923-1049. doi:10.1016/j.eprac.2022.08.002 3. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States. Reviewed May 15, 2024. Accessed January 7, 2026 . www.cdc.gov 4. Glycemic targets: standards of medical care in diabetes 202 3. Diabetes Care . 202 3;46(Suppl 1):S 97-S110 . doi:10.2337/dc23-S006 5. Heinemann L, Fleming GA, Petrie JR, et al. Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a Insulin Infusion Pump-MP-MM-1316Effective Dat e: 05/01/2026The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. DiabetesCare . 2015;38(4):716-722. doi:10.2337/dc15-0168 6. Levitsky L L, Misra M . Type 1 diabetes mellitus in children and adolescents : insulin therapy . UpToDate. Updated November 18, 2025 . Accessed January 7, 2026 . www.uptodate.com 7. Levitsky L L, Misra M. Type 1 diabetes mellitus in children and adolescents: overview of medical care . UpToDate. Updated July 8, 2025 . Accessed January 7, 2026 . www.uptodate.com 8. Levitsky L L, Misra M. Type 1 diabetes mellitus in children and adolescents: prevention and management of hypoglycemia . UpToDate. Updated September 29, 2025. Accessed January 7, 2026 . www.uptodate.com 9. Pharmacologic approaches to glycemic treatment: standards of care in diabetes – 2025. Diabetes Care . 2025; 48(Supplement_1):S181-S206. doi:10.2337/dc25-S009 10. Weinstock RS. Management of blood glucose in adults with type 1 diabetes mellitus. UpToDate. Updated December 24, 2025. Accessed January 7, 2026 . www.uptodate.com 11. Wexler DJ. Overview of general medical care in nonpregnant adults with diabetes mellitus. UpToDate. Updated November 20, 2025 . Accessed January 7, 2026 . uptodate.com Independent med ical review April 2020

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System Details