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Clinical Coverage Guidelines (CCGs)

 

Medicaid Clinical Coverage Guidelines (CCGs)

A

Medically appropriate air ambulance transportation is a covered service regardless of the State or region in which it is rendered.

B

Baha® devices are FDA-approved, bone-anchored, bone conduction hearing aids and, according to the FDA and manufacturer, are specifically indicated for patients over five years of age.

There are two categories of bariatric surgery: restrictive procedures and malabsorptive procedures.

Johns Hopkins Health Library defines burns as a type of painful wound caused by thermal, electrical, chemical, or electromagnetic energy.

C

Medical necessity guidelines for routine costs of clinical trials in accordance with Centers for Medicare & Medicaid (CMS) and the Patient Protection and Affordable Care Act (PPACA) requirements.

Diabetes mellitus is characterized by hyperglycemia due to impaired pancreatic insulin secretion or inefficient use of insulin by the body.

This policy outlines medical necessity criteria for the replacement of cochlear implants and/or cochlear implant components.

This policy will provide general guidelines as to when cosmetic and reconstructive surgery is or is not medically necessary. Not all cosmetic procedures are listed in this policy

D

Some medical conditions may result in a condition called lipoatrophy, characterized by facial wasting of fat under the skin of the face and other parts of the body.

Genetic testing can be performed for several reasons; predominantly among these reasons are 1) using genetic testing as a diagnostic tool, and 2) using testing as a mechanism for predicting the presence of a specific disease in those with a familial history.

Diaphragmatic/phrenic nerve stimulator devices are indicated for certain ventilator-dependent individuals who lack voluntary control of their diaphragm muscles to enable independent breathing without the assistance of a mechanical ventilator for at least four continuous hours a day.

Testing for drugs of abuse is performed to detect the use of prescription medications and illegal substances for the purpose of medical treatment.

A joint contracture is characterized by chronically reduced range of motion (ROM) secondary to structural changes in non-bony tissues including muscle, tendons, ligaments, and skin

E

Evidence from the reviewed studies indicates that exhaled NO demonstrates moderate to good accuracy in diagnosing asthma and may be useful in predicting and monitoring inflammatory responses indicative of asthma exacerbation before and during anti-inflammatory treatment.

This policy outlines general guidelines to use in determining coverage of experimental or investigational, or potentially experimental or investigational medical and behavioral health technologies.

F

Fecal incontinence defined as the uncontrolled passage of feces or gas over at least 1 month’s duration, in an individual of at least four years of age, who had previously achieved control.

Uterine fibroids (or leiomyomas) are benign soft tissue neoplasms that arise from smooth muscle. These lesions can develop wherever smooth muscle is present, but malignant transformation probably does not occur.

G

Gender reassignment therapy, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics.

Growth Hormone Deficiency (GHD) is a rare disorder characterized by the inadequate secretion of growth hormone (GH) from the anterior pituitary gland, a small gland located at the base of the brain that is responsible for the production of several hormones.

H

Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear.

Hyperbilirubinemia is the most common condition requiring medical attention in newborns.

International Normalized Ratio (INR) or prothrombin time (PT) is the standard measurement for reporting the blood's clotting time and allows physicians to determine the level of anticoagulation in a patient

Non-invasive ventilation (NIV) refers to the administration of ventilatory support without using an invasive artificial airway (endotracheal tube or tracheostomy tube).

Per CMS, for purposes of coverage under Medicare, hyperbaric oxygen therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure.

Hyperhidrosis is defined as excessive sweating beyond a level required to maintain normal body temperature in response to heat exposure or exercise.

I

The implanted device measures and monitors daily pulmonary artery (PA) pressure. The data is used by physicians for heart failure management with the goal of reducing heart failure hospitalizations.

J

The individual has engaged in an act of sexual abuse to another individual within the past 90 days (or more, if delay occurs due to delayed discovery or legal system.) or patient has a history of having committed a sexual offense, is in outpatient treatment, and is demonstrating behavior suggesting to the treating clinician that new offending behavior is imminent.

L

Lymphedema is an accumulation of lymphatic fluid in the interstitial tissue, principally in the subcutaneous fatty issues.

M

Mechanical stretching devices are used for the prevention and treatment of joint contractures of the extremities, with the goal to maintain or restore range of motion (ROM) to the joint.

N

NMES involves the use of a device which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes.

O

The term "feeding disorder" refers to a condition in which a patient is unable or refuses to eat, or has difficulty eating, resulting in failure to grow normally.

Orthognathic surgery is the surgical correction of abnormalities of the mandible, maxilla, or both.

Of the estimated 5.6 million fractures that occur annually in the United States, approximately 5% to 10% will demonstrate signs of delayed or impaired healing.

Optic nerve (ON) sheath decompression involves direct decompression (fenestration) of the ON sheaths just behind the globe. The approach and technique for an ON sheath fenestration varies. This policy describes the medical necessity requirements for ON decompression surgery.

Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxemia.

P

Obstructive sleep apnea syndrome (OSAS) is a disorder of breathing in which prolonged partial upper airway obstruction and/or intermittent complete obstruction occurs during sleep disrupting normal ventilation and normal sleep patterns.

Amplification with hearing instruments should be considered for a child who demonstrates a significant hearing loss, including sensorineural, conductive, or mixed hearing losses of any degree.

Diabetes mellitus is characterized by hyperglycemia due to impaired pancreatic insulin secretion or inefficient use of insulin by the body.

Goals of oral function therapy are to identify the child’s optimal feeding methods, maximize safety and avoid the risk of medical complications and help the child achieve age appropriate functional skills.

Developmental disability is defined as an inability to perform age-appropriate functional skills as indicated by standard test scores less than 85, scaled score less than 7, percentile less than 16, Z-score less than −1.00 or developmental quotient (DQ) less than 80.2.

Atrial fibrillation (AF) is the most commonly encountered sustained tachyarrhythmia and is associated with a 5-fold increased risk of stroke, and stroke risk increases with age.

The Peristeen® Anal Irrigation System is intended to instill water into the colon through a rectal catheter, which incorporates an inflatable balloon, inserted into the rectum to promote evacuation of the contents of the lower colon.

Patent foramen ovale (PFO) is a congenital cardiac lesion which is generally asymptomatic and affects up to a quarter of the population.

Hyperbilirubinemia is the most common condition requiring medical attention in newborns.

Post–acute care refers to a wide range of services, which include skilled nursing facilities, inpatient rehabilitation facilities, home health aides, outpatient physical and occupational therapy, and long-term care facilities.

R

Medical necessity criteria for radiofrequency ablation of uterine fibroids.

Reduction mammoplasty is the surgical reduction of breast size. It was developed as a means of alleviating physical and emotional symptoms associated with excessive breast size and breast ptosis.

Beneficiaries may have a combination of developmental, neurological and medical conditions necessitating the need for certain dental services to be provided in an operating room as an outpatient hospital service.

Reduction mammoplasty is the surgical reduction of breast size. It was developed as a means of alleviating physical and emotional symptoms associated with excessive breast size and breast ptosis.

S

Fecal incontinence is defined as the involuntary loss of solid or liquid feces.

Sclerotherapy is a minimally invasive procedure to diminish abnormally dilated and symptomatic veins.

Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Speech therapy is the study, diagnosis and treatment of speech, language and communication in people of all ages to enable them to communicate to the best of their ability.

Stem-cell transplantation refers to the transplantation of hematopoietic stem cells (HSCs) into a patient.

According to the Centers for Medicare & Medicaid Services (CMS), chronic wounds of the lower extremities, including venous stasis ulcers (VSU), venous leg ulcers (VLU), Diabetic foot ulcers (DFU) and pressure sores, are a major public health problem.

T

Telehealth and telemedicine are often used interchangeably; WellCare uses the following distinction

Implantable testosterone pellets may be indicated as second-line testosterone replacement therapy for males.

DiGeorge syndrome (DGS) is a disorder in which there is a defect in the development of the pharyngeal pouch system. The syndrome is most commonly caused by a chromosomal deletion at 22q11.2.

The health plan may implement directed quality improvement initiatives that require the coordination and use of community resources such as transportation services that may or may not be a component of the member’s benefit structure.

Parenteral nutrition (PN) is the intravenous administration of an artificially prepared solution of nutrients that bypasses the gastrointestinal tract and that meets the nutritional requirements of a patient

V

Vagus nerve stimulation (VNS) has been used in the treatment of epilepsy and has been studied for the treatment of refractory depression and other indications

VANTAS® (histrelin implant) is a sterile, non-biodegradable, diffusion-controlled HYDRON® polymer reservoir containing histrelin acetate, a synthetic nonapeptide analog of the naturally occurring gonadotropin releasing hormone (GnRH), also known as luteinizing hormone releasing hormone (LH-RH), possessing a greater potency than the natural sequence hormone.

W

Wound care includes, but is not limited to ulcers, pressure ulcers, open surgical sites, fistulas, tube sites and tumor erosion sites when the skills of a licensed therapist, qualified wound care nurse, nurse or physician/physician extender are required to safely and effectively provide the care necessary for their treatment.

X

Each year in the United States, more than 30,000 patients undergo back surgery for lumbar spinal stenosis, an abnormal narrowing or constriction of spaces in the back that provide pathways for spinal nerves

Medicare Policies

A

Fixed wing (FW) or rotary wing (RW) air ambulance are furnished when the medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate.

B

Sinuplasty, also known as balloon catheter sinusotomy or balloon sinus ostial dilation, is a minimally invasive technique intended to dilate the sinus ostia in patients with chronic sinusitis.

There are two categories of bariatric surgery: restrictive procedures and malabsorptive procedures.

Baha® devices are FDA-approved, bone-anchored, bone conduction hearing aids and, according to the FDA and manufacturer, are specifically indicated for patients over five years of age.

Johns Hopkins Health Library defines burns as a type of painful wound caused by thermal, electrical, chemical, or electromagnetic energy.

C

"Medical necessity guidelines for routine costs of clinical trials in accordance with Centers for Medicare & Medicaid (CMS) and the Patient Protection and Affordable Care Act (PPACA) requirements.

This policy outlines medical necessity criteria for the replacement of cochlear implants and/or cochlear implant components.

This policy will provide general guidelines as to when cosmetic and reconstructive surgery is or is not medically necessary.

Craniofacial surgery encompasses a broad spectrum of reconstructive procedures of the cranium and face. The objectives of these procedures are to correct deformities of the face and skull bones that result from birth defects, trauma, or disease and to restore craniofacial form and function by medical and surgical means.

Diabetes mellitus is characterized by hyperglycemia due to impaired pancreatic insulin secretion or inefficient use of insulin by the body.

D

Diaphragmatic/phrenic nerve stimulator devices are indicated for certain ventilator-dependent individuals who lack voluntary control of their diaphragm muscles to enable independent breathing without the assistance of a mechanical ventilator for at least four continuous hours a day.

Microdiscectomy or open discectomy (MD/OD) are the standard procedures for symptomatic lumbar disc herniation and they involve removal of the portion of the intervertebral disc compressing the nerve root or spinal cord (or both) with or without the aid of a headlight loupe or microscope magnification.

E

This policy outlines general guidelines to use in determining coverage of experimental or investigational, or potentially experimental or investigational medical and behavioral health technologies.

Sudden cardiac death (SCD) is typically defined as unanticipated death due to cardiac causes that occur within 1 hour of the onset of acute symptoms.

F

Fecal incontinence defined as the uncontrolled passage of feces or gas over at least 1 month’s duration, in an individual of at least four years of age, who had previously achieved control.

Fractional exhaled nitric oxide (FeNO) measurement is a noninvasive and simple test thought to reflect eosinophilic airway inflammation.

G

Gastric electrical stimulation (GES) has been used in patients who are proven refractory to conventional treatment for gastroparesis.

Services for gender affirmation most often include hormone treatment, counseling, psychotherapy, complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate, genital reconstruction, facial hair removal, and certain facial plastic reconstruction.

H

Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear.

Hyperbilirubinemia is the most common condition requiring medical attention in newborns.

This policy will provide general guidelines as to when non-invasive home ventilators are or are not medically necessary.

Hyperbaric oxygen therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure.

I

Hypoglossal nerve stimulation, also referred to as an upper airway stimulation (UAS) system, is proposed as a treatment strategy for select patients with moderate to severe obstructive sleep apnea (OSA).

The implanted device measures and monitors daily pulmonary artery (PA) pressure. The data is used by physicians for heart failure management with the goal of reducing heart failure hospitalizations.

L

Low-frequency ultrasound debridement is a noncontact debridement method that provides simultaneous cleansing and debridement of wounds.

M

Mechanical stretching devices are used for the prevention and treatment of joint contractures of the extremities, with the goal to maintain or restore range of motion (ROM) to the joint.

N

Negative Pressure Wound Therapy (NPWT) is defined as the application of subatmospheric pressure to a wound to remove exudate and debris from wounds.

This policy describes the medical necessity requirements for Neuromuscular Electrical Stimulation (NMES; also known as Functional Electrical Stimulation [FES] when used for walking in SCI patients).

O

Medical necessity criteria for obstetrical home health programs offered by vendors such as Optum.

Optic nerve (ON) sheath decompression involves direct decompression (fenestration) of the ON sheaths just behind the globe. The approach and technique for an ON sheath fenestration varies.

This policy describes the medical necessity requirements for orthognathic surgery.

Of the estimated 5.6 million fractures that occur annually in the United States, approximately 5% to 10% will demonstrate signs of delayed or impaired healing.

Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxemia

P

Obstructive sleep apnea syndrome (OSAS) is a disorder of breathing in which prolonged partial upper airway obstruction and/or intermittent complete obstruction occurs during sleep disrupting normal ventilation and normal sleep patterns.

An insulin pump is a device that delivers a continuous subcutaneous infusion of a rapid- or short-acting insulin, supplemented by boluses before each meal or snack.

Amplification with hearing instruments should be considered for a child who demonstrates a significant hearing loss, including sensorineural, conductive, or mixed hearing losses of any degree.

Goals of oral function therapy are to identify the child’s optimal feeding methods, maximize safety and avoid the risk of medical complications and help the child achieve age appropriate functional skills.

Atrial fibrillation (AF) is the most commonly encountered sustained tachyarrhythmia and is associated with a 5-fold increased risk of stroke, and stroke risk increases with age.

Patent foramen ovale (PFO) is a congenital cardiac lesion which is generally asymptomatic and affects up to a quarter of the population.

To provide guidelines for the authorization of outpatient or home care speech therapy, occupational therapy, and/or physical therapy evaluation and treatment services.

Post–acute care refers to a wide range of services, which include skilled nursing facilities, inpatient rehabilitation facilities, home health aides, outpatient physical and occupational therapy, and longterm care facilities.

R

Medical necessity criteria for radiofrequency ablation of uterine fibroids.

Reduction mammoplasty is the surgical reduction of breast size. It was developed as a means of alleviating physical and emotional symptoms associated with excessive breast size and breast ptosis.

Beneficiaries may have a combination of developmental, neurological and medical conditions necessitating the need for certain dental services to be provided in an operating room as an outpatient hospital service.

S

Sclerotherapy is a minimally invasive procedure to diminish abnormally dilated and symptomatic veins.

Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure.

T

DiGeorge syndrome (DGS) is a disorder in which there is a defect in the development of the pharyngeal pouch system. The syndrome is most commonly caused by a chromosomal deletion at 22q11.2.

Lymphedema is an accumulation of lymphatic fluid in the interstitial tissue, principally in the subcutaneous fatty issues.

V

Vagus nerve stimulation (VNS) has been used in the treatment of epilepsy and has been studied for the treatment of refractory depression and other indications.

Video electroencephalographic (VEEG) monitoring is the synchronous recording and display of EEG patterns and video-recorded clinical behavior.

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Last Updated On: 5/25/2021