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Clinical Coverage Guidelines (CCGs)

 

Medicaid 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

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.

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.

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

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

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.

O

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.

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.

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.

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.

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

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.

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.

Medicare Policies

A

Acupuncture involves the manual and/or electrical stimulation of thin, solid, metallic needles inserted into the skin.

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.

Ambulatory electroencephalogram (EEG) testing in the outpatient setting (e.g., at home) is a diagnostic test used to evaluate an individual in whom a seizure disorder or possibly nonepileptic attacks are suspected but not conclusively confirmed by the person's medical history, physical examination, and a previous routine or standard (awake and asleep) EEG.

Ambulatory surgery centers (ASC) operate for the purpose of offering outpatient surgical services to members/enrollees in an environment appropriate for low risk procedures on members/enrollees with low risk health status.

B

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

Caudal Interlaminar ESI: CP.MP.164

"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.

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.

Durable Medical Equipment and Orthotics and Prosthetics Guidelines: CP.MP.107

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.

F

Facet Joint Interventions: CP.MP.171

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.

Fertility Preservation: CP.MP.130

Fetal Surgery in Utero: CP.MP.129

Functional MRI: CP.MP.43

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.

Heart-Lung Transplant: CP.MP.132

Home Birth: CP.MP.136

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

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.

Intestinal and Multivisceral Transplant: CP.MP.58

Intradiscal Steroid Injections: CP.MP.167

L

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

Lung Transplant: CP.MP.57

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

Neonatal Abstinence Syndrome Guidelines: CP.MP.86

Neonatal Sepsis Management: CP.MP.85

Nerve Blocks for Pain Management: CP.MP.170

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).

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

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

Pancreas Transplantation: CP.MP.102

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.

Pediatric Heart Transplant: CP.MP.138

Pediatric Liver Transplant: CP.MP.120

Posterior Tibial Nerve Stimulation for Voiding Dysfunction: CP.MP.133

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.

S

Sacroiliac Joint Interventions: CP.MP.166

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.

SNF Leveling: CP.MP.206

SNRB and TFESI: CP.MP.165

T

Tandem Transplant: CP.MP.162

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.

Trigger Point Injections: CP.MP.169

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

U

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
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