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Clinical Coverage Guidelines (CCGs)

Medicaid Policies

A

Inpatient Services are medical services provided to a beneficiary admitted to an acute inpatient hospital.

This policy describes the medical necessity criteria for Allergy Immunotherapy.

This policy describes the medical necessity criteria for Allergy Testing.

This policy describes the medical necessity criteria for Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemias.

This policy describes the medical necessity criteria for Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms.

Ambulance services provide medically necessary treatment for NC Medicaid beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated.

This policy describes the Art Therapy Value Added Benefit provided to members.

B

Balloon Ostial Dilation (BOD) also known as balloon dilation sinuplasty, balloon catheter sinusotomy, sinus ostial dilation or balloon sinuplasty, is a procedure that involves placing a balloon in the sinus ostium and inflating the balloon to stretch the opening.

A bone-anchored hearing aid (BAHA) is a surgically implanted osseointegrated prosthetic device that provides bone conduction hearing for recipients with moderate to severe, bilateral conductive or mixed hearing loss.

This policy describes the medical necessity requirements for breast surgeries including mastectomy/breast conserving surgery, male gynecomastia, prophylactic mastectomy, reduction mammoplasty and breast reconstructive surgery.

BT is a bronchoscopic procedure that utilizes radiofrequency ablation to reduce airway smooth muscle cells.

C

This policy outlines the medical necessity criteria for CAR-T Cell therapy.

The release of cardiac biomarkers is among the cascade of events that occur during acute coronary syndromes and cardiac ischemia. This policy discusses the medical necessity requirements for testing of these cardiac biomarkers.

Cell-free fetal DNA testing is a screening test of the woman’s blood taken after 10 weeks of pregnancy. It measures the relative amount of free fetal DNA and indicates if the fetus is at increased risk of having Down syndrome (trisomy 21), Edwards syndrome (trisomy 18) and Patau syndrome (trisomy 13).

Child First Services is an intensive, early childhood, two-generation, home visiting intervention that works with the most vulnerable young children (prenatal through age five years) and their families.

Replacement and repair of external components of a cochlear or auditory brainstem implant device that are necessary to maintain the device’s ability to analyze and code sound, therefore providing an awareness and identification of sounds and facilitating communication for individuals with profound hearing impairment.

A cochlear implant is an electronic medical device designed to restore some ability to perceive sounds and understand speech by individuals with severe to profound hearing loss.

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.

D

This policy describes medical necessity criteria for Diagnostic Assessment.

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.

Dietary Evaluation and Counseling offers direction and guidance for specific nutrient needs related to a beneficiary’s diagnosis and treatment.

Electroencephalography (EEG) is a significant component of epilepsy diagnosis, along with a thorough medical history and neurological workup.

In lumbar discography, contrast medium is injected into a lumbar intervertebral disc that is thought to be the cause of low back pain

This policy discusses the medical necessity criteria for deep brain stimulation (DBS).

This policy describes the medical necessity criteria for Drug Testing for Opioid Treatment and Controlled Substance Monitoring.

E

Electric tumor treating fields (TTF), also known as alternating electric field therapy, are used for the treatment of glioblastoma, and are delivered by Optune® (NovoCureTM), a portable medical device that generates low-intensity electric fields termed Tumor Treating Fields

An electroencephalogram (EEG) is a non-invasive method for assessing neurophysiological function.

Epidural steroid injections have been used for pain control in patients with radiculopathy, spinal stenosis, and nonspecific low back pain, despite inconsistent results as well as heterogeneous populations and interventions in randomized trials.

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

Extended ophthalmoscopy is a method of examining the posterior portion of the eye when the level of examination requires a complete view of the back of the eye and documentation is greater than that required during routine ophthalmoscopy.

External ocular photography documents the external eye, lids and ocular adnexa.

This policy discusses the medical necessity criteria for extracorporeal shock wave lithotripsy.

This policy describes the medical necessity guidelines for an endometrial ablation. Endometrial ablation is a minimally invasive surgical procedure used to treat premenopausal abnormal uterine bleeding.

Endovascular stent grafting for the repair of descending thoracic aorta and an abdominal aortic aneurysm is an option for treatment of aneurysms and may be covered for patients who meet the required criteria.

This document describes policies and procedures that direct-enrolled providers shall follow to receive reimbursement for covered enhanced benefit behavioral health services provided to eligible members.

Types of evoked potentials include somatosensory, brainstem auditory, visual and motor. Sensory evoked potentials evaluate electrical activity in the nervous system in response to stimulation of specific nerve pathways.

F

Chronic low back pain is frequently attributed to disorders of the facet joint. Neck pain related to whiplash injury is also thought to be related to the cervical zygapophyseal facet joint.

Facility-Based Crisis Service for children and adolescents is a service that provides an alternative to hospitalization for an eligible beneficiary who presents with escalated behavior due to a mental health, intellectual or development disability or substance use disorder and requires treatment in a 24-hour residential facility.

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.

The introduction of saline-diluted fecal matter derived from a healthy human donor into the GI tract of an individual diagnosed with recurrent clostridium difficile infection, who has failed multiple attempts at conventional antibiotic therapy.

This policy describes the medical necessity requirements for performing fetal surgery. This becomes an option when it is predicted that the fetus will not live long enough to survive delivery or after birth.

This policy details the medical necessity criteria for Fetal Surveillance.

Intravenous fluorescein angiography or fluorescent angiography is a technique for examining the circulation of the retina and choroid using a fluorescent dye and a specialized camera.

G

This policy describes the medical necessity criteria for Geropsychiatric Units in Nursing Facilities.

Multiplex molecular panels allow for the qualitative detection of nucleic acid from multiple viral, parasitic, and bacterial pathogens in stool samples from those with symptoms of gastroenteritis or infectious colitis.

Gonioscopy involves using a concave contact lens in conjunction with oblique mirrors to view the iridocorneal angle.

H

Helicobacter pylori (H. pylori) is the most prevalent chronic bacterial infection and is associated with peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, and gastric mucosa associated lymphoid tissue (MALT) lymphoma.

This policy addresses covered and non-covered hearing aid services.

This policy describes the medical necessity criteria for Heart/Lung Transplantation.

Heart (cardiac) transplantation is the surgical excision of a heart and the main arteries from a human, brain-dead donor, with subsequent implantation into a beneficiary who has had his heart surgically removed in a similar manner.

This policy describes the medical necessity of Hematopoietic Stem-Cell Transplantation (HSCT) in the Treatment of Germ Cell Tumors.

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) for Leukemia.

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) for Lymphoma.

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) For Multiple Myeloma and Primary Amyloidosis.

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) for solid tumors of childhood

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) for Central Nervous System (CNS) Embryonal Tumors & Ependymoma.

This policy describes the Hippotherapy Value Added Benefit provided to members.

This policy details medical necessity criteria for home phototherapy for the treatment of neonatal hyperbilirubinemia.

Homocysteine is a nonproteinogenic amino acid that is generated during the conversion of methionine to cysteine.

Hyperbaric oxygen (HBO) therapy consists of the exposure of the entire body to 100% oxygen at pressures greater than one atmosphere absolute (ATA) in accordance with accepted clinical protocols for duration and pressure in a mono- or multi-place pressurized chamber.

Hyperemesis gravidarum is a term reserved to describe the most severe cases of nausea and vomiting in pregnancy (NVP).

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

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

A planned home birth is an elective alternative to delivery in a birthing center or hospital setting.

Home Health Services include medically necessary skilled nursing services, specialized therapies, home health aide services, and medical supplies provided to beneficiaries in any setting, other than a hospital, or nursing facility.

This policy describes the medical necessity criteria for Home Infusion Therapy (HIT).

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).

Various cardiac hemodynamic monitoring techniques have been investigated as a means to remotely guide outpatient heart failure (HF) therapy, including implantable wireless pulmonary artery pressure monitoring (e.g. CardioMEMS®).

The purpose of this policy is to ensure that WellCare of North Carolina® complies with Centers for Medicare and Medicaid Services (“CMS”) regulations, as well as applicable contractual requirements regarding In Lieu of Services (ILOS).

Inpatient Behavioral Health Services provide hospital treatment in a hospital setting 24 hours a day.

Electrical bone growth stimulation is a medical technique to promote bone growth in difficult to heal fractures by applying a low electrical current to the fracture site.

This policy describes the medical necessity criteria for Islet Cell Transplantation.

K

Keloid and hypertrophic scars are the results of dermal tissue following skin injury. They require no treatment unless they cause a functional impairment.

Kidney (renal) transplantation is a surgical procedure to implant a healthy kidney into a beneficiary with kidney disease or kidney failure.

L

Targeted phototherapy utilizes non-ionizing ultraviolet radiation with therapeutic benefit

This policy discusses the medical necessity criteria for liver transplantation.

This policy describes the medical necessity criteria for Long Term Care Hospital (LTCH) Services.

This policy describes the medical necessity criteria for Lung Transplantation.

M

Maternal care skilled nurse home visits assess and treat pregnant women who have one or more of the high-risk medical conditions specified below.

Description Vitamin D is metabolized in the liver to 25-hydroxyvitamin D [25(OH)D], (also known as calcidiol), and then in the kidney to 1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol.

Male circumcision is the surgical removal of the foreskin (prepuce), which is the layer of skin covering the head (glans) of the penis.

N

Maternal drug use and intrauterine exposure of the fetus during pregnancy can lead to drug withdrawal in the infant after delivery.

The CDC defines early onset sepsis as a blood or cerebrospinal fluid culture-proven infection occurring within the first seven days of life.

Nerve blocks are the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks created by the injection of local anesthetic solutions.

The purpose of this guideline is to assist with continuing care, discharge planning, and the transition to outpatient and home care of babies affected by ongoing neonatal apnea and bradycardia events.

Infants who require neonatal admission remain at increased risk for morbidity and mortality following discharge.

Non-Emergency Medical Transportation (NEMT) is transportation to and from medical services on a non-emergent basis.

This policy discusses medical necessity criteria for Nursing Equipment and Supplies.

A nursing facility is a medical health facility, or a distinct part of a facility (for example, a hospital enrolled by the NC Medicaid (Medicaid) program as a swing-bed provider of nursing facility services), that is licensed and certified by the Division of Health Service Regulation (DHSR) and enrolled with Medicaid to provide nursing facility level of care services.

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.

This policy describes the medical necessity criteria for Orthotics & Prosthetics.

Out-of-State services are determined to be medically necessary, and care and services that are provided within 40 miles of the NC border in the contiguous states of Georgia, South Carolina, Tennessee, and Virginia are covered to the same extent and under the same conditions as medical care and services provided in NC, except for the services found in this policy.

Outpatient behavioral health services are psychiatric and biopsychosocial assessment, medication management, individual, group, and family therapies, psychotherapy for crisis, and psychological testing for eligible members.

P

This policy addresses three transplantation services: 1. a simultaneous pancreas and kidney transplant; 2. a pancreas transplant some time following a kidney transplant; and 3. a pancreas transplant alone.

Peer Support Services (PSS) are an evidenced-based mental health model of care that provides community-based recovery services directly to a Medicaid-eligible adult beneficiary diagnosed with a mental health or substance use disorder.

Phase II outpatient cardiac rehabilitation is a comprehensive program of medical evaluation designed to recondition the cardiovascular system and restore beneficiaries with cardiovascular heart disease to active and productive lives. A

Durable Medical Equipment (DME) is primarily and customarily used to serve a medical purpose, is generally not useful to an individual in the absence of a disability, illness or injury, can withstand repeated use, and can be reusable or removable.

Physician fluoride varnish services are defined as preventive procedures provided by or under the supervision of a physician.

The Physicians Drug Program (PDP) covers many, but not all, primarily injectable drugs that are purchased and administered by a medical professional in a physician’s office or in an outpatient clinic setting.

This policy addresses WellCare of North Carolina® beneficiaries’ collection, storage, and transplantation of placental and umbilical cord blood (“cord blood”) as a source of stem cells for allogeneic and autologous stem-cell transplantation.

Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing.

Posterior tibial nerve stimulation (PTNS), also known as peripheral tibial nerve stimulation, is a minimally invasive form of electrical neuromodulation used to treat overactive bladder (OAB) syndrome.

Substantial, complex, and continuous skilled nursing service that is considered supplemental to the care provided to a beneficiary by the beneficiary’s family, foster parents, and delegated caregivers, as applicable.

Private Duty Nursing (PDN) is a substantial, complex, and continuous skilled nursing service that is considered supplemental to the care provided to a beneficiary by the beneficiary’s family, foster parents, and delegated caregivers, as applicable.

R

Medical necessity criteria for radiofrequency ablation of uterine fibroids.

This policy describes the medical necessity criteria for Reconstructive and Cosmetic Surgery.

Research-Based-Behavioral Health Treatments (RB-BHT) services are researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary.

This policy describes the medical necessity criteria for Respiratory Equipment and Supplies.

This clinical coverage policy discusses the medical necessity criteria for Rhinoplasty and/or Septoplasty.

Clinical trials are scientific investigations of treatment alternatives designed to help compare the safety and efficacy of new, untested or non-standard treatments to standard currently accepted treatments.

S

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

Transforaminal epidural steroid injections (TFESIs) and selective nerve root blocks (SNRBs) are alternatives to interlaminar epidural steroid injections for the treatment of radicular pain.

Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, immobility, ischemia, or other neurological impairments; over 90% of the lesions are related to venous stasis disease and diabetic neuropathy.

This policy addresses three different transplantation services: 1. small bowel transplant, 2. small bowel/liver transplant, and 3. small bowel/liver and multi-visceral transplants.

A bone-anchored hearing aid (BAHA) is a surgically implanted osseointegrated prosthetic device that provides bone conduction hearing for recipients with moderate to severe, bilateral conductive or mixed hearing loss.

Special ophthalmological services are special evaluations of part of the visual system, which go beyond the services included under general ophthalmological services or in which special treatment is given.

State Plan Personal Care Services (PCS) provide Personal Care Services in the beneficiary’s living arrangement by paraprofessional aides employed by licensed home care agencies, licensed adult care homes, or home staff in licensed supervised living homes.

Stereotactic pallidotomy is a surgical technique used in the treatment of severe Parkinson’s disease

Sterilization is a permanent method of birth control. Sterilization procedures for women are called tubal occlusion. The procedure for men is called vasectomy.

This policy describes the medical necessity criteria for Surgery for Ambiguous Genitalia.

Clinically Severe Obesity is defined as a BMI 35-39.9 kg/m2 with co-morbid conditions. Morbid Obesity is defined as a BMI greater than or equal to 40 kg/m2.

Surgery of the lingual frenulum includes incision, excision, or surgical alteration of a short frenulum (otherwise known as ankyloglossia, tongue-tie, or high frenulum attachment) in order to free the tongue and allow greater range of motion.

T

This policy is intended to provide new definitions and overarching guidance related to the delivery of services via telehealth, virtual communications and remote patient monitoring that are not otherwise included in a WellCare of North Carolina® program or service-specific clinical coverage policy.

This policy describes the medical necessity guidelines for teleretinal screening as an alternative to retinopathy evaluation by an Ophthalmologist or Optometrist.

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

Various diagnostic methods are available to identify the etiology of the signs and symptoms of vaginitis.

The SynCardia temporary Total Artificial Heart (TAH) (SynCardia Systems Inc.), formerly known as the CardioWest Total Artificial Heart, is a biventricular pulsatile pump that replaces the patient’s native ventricles and valves.

U

Sacral neuromodulation (SNM) or sacral nerve stimulation (SNS) refers to stimulation of nerves that innervate the bladder and pelvic floor to treat lower urinary tract dysfunction.

Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction.

V

Vagus Nerve Stimulation (VNS) is performed by an implantable stimulator as a treatment for refractory seizures.

A ventricular assist device (VAD) is surgically attached to one or both intact heart ventricles and used to assist or augment the ability of a damaged or weakened native heart to pump blood.

This policy describes the medical necessity of routine eye examination and visual aids for beneficiaries under the age of 21.

A visual field acuity test is a painless test that determine a patient’s visible field of view.

W

This policy describes the medical necessity criteria for Wireless Capsule Endoscopy

The wireless motility capsule (WMC) assesses gastroparesis or delayed gastric emptying.

Medicare Policies

A

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

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders in children, with an increasing prevalence of diagnosis in adults.

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.

Cartilage transfer procedures include autologous chondrocyte implantation, osteochondral allograft transplantation (OAG or OCA) [i.e., including repair of anterior cruciate ligament and meniscus], and osteochondral autograft transplantation [mosaicplasty, Osteochondral Autograft Transplantation System (OATS)].

Diagnostic infertility services to determine the cause of infertility and treatment are covered only when specific coverage is provided under the terms of a member’s/enrollee’s benefit plan.

This policy describes the medical necessity requirements for allogeneic hematopoietic cell transplants for sickle cell anemia and β–thalassemia

B

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

Biofeedback therapy provides visual, auditory or other evidence of the status of certain body functions so that a person can exert voluntary control over the functions

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

The release of cardiac biomarkers is among the cascade of events that occur during acute coronary syndromes and cardiac ischemia

Epidural steroid injections have been used for pain control in patients with radiculopathy, spinal stenosis, and nonspecific low back pain, despite inconsistent results as well as heterogeneous populations and interventions in randomized trials.

"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.

Cell-free fetal DNA testing is a screening test of the woman’s blood taken after 10 weeks of pregnancy.

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

Medical necessity guidelines for dental anesthesia in the inpatient or ambulatory surgery setting

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.

Electroencephalography (EEG) is a significant component of epilepsy diagnosis

DME is defined as equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, and is generally not useful to a person in the absence of an illness or injury

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.

This policy describes the medical necessity requirements for a donor lymphocyte infusion (DLI).

Urine drug testing is a key diagnostic and therapeutic tool that is useful for patient care and monitoring of adherence to a controlled substance treatment regimen and to identify drug misuse or addiction prior to starting or during treatment with controlled substances.

E

This policy describes the medically necessary indications for neurophysiologic evoked potentials.

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

An electroencephalogram (EEG) is a non-invasive method for assessing neurophysiological function.

Electric tumor treating fields (TTF), also known as alternating electric field therapy, are used for the treatment of glioblastoma, and are delivered by Optune® (NovoCureTM), a portable medical device that generates low-intensity electric fields termed Tumor Treating Fields.

The electrodiagnostic medicine (EDX) evaluation is considered to be an important extension of the clinical evaluation of patients with disorders of the peripheral and/or central nervous system.

Essure® is a permanent birth control method that involves the bilateral placement of coils into the fallopian tubes

F

Chronic low back pain is frequently attributed to disorders of the facet joint.

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.

FerriScan® R2-MRI is a magnetic resonance imaging (MRI)-based solution for measuring liver iron concentration (LIC) in patients with iron overload.

Male and female fertility may be transiently or permanently affected by medical treatments such as gonadotoxic therapy, cytotoxic chemotherapy, or radiation therapy, as well as by other iatrogenic causes.

This policy describes the medical necessity requirements for performing fetal surgery. This becomes an option when it is predicted that the fetus will not live long enough to survive delivery or after birth.

Functional magnetic resonance imaging (fMRI) is an imaging procedure in which an MRI is used to localize regions of activity in the brain by measuring blood flow and/or metabolism following task activation.

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.

This policy includes criteria for making medical necessity determinations for genetic tests when specific criteria are not available for the requested genetic or pharmacogenetic test.

Multiplex molecular panels allow for the qualitative detection of nucleic acid from multiple viral, parasitic, and bacterial pathogens in stool samples from those with symptoms of gastroenteritis or infectious colitis.

H

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

Heart-lung transplantation is treatment of choice for patients with both end-stage heart and endstage lung disease

This policy provides medical necessity guidelines for Holter monitoring up to 48 hours.

A planned home birth is an elective alternative to delivery in a birthing center or hospital setting.

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.

Homocysteine is a nonproteinogenic amino acid generated during the conversion of methionine to cysteine.

Hospice is a coordinated, integrated program developed by a multidisciplinary team of professionals to provide end-of-life care primarily focused on relieving pain and symptoms specifically related to the terminal diagnosis of members/enrollees with a life expectancy of six months or less.

Helicobacter pylori (H. pylori) is the most prevalent chronic bacterial infection and is associated with peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, and gastric mucosa associated lymphoid tissue (MALT) lymphoma

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

Hyperemesis gravidarum is a term reserved to describe the most severe cases of nausea and vomiting in pregnancy (NVP) which results in the inability to rehydrate and replenish nutritional reserves.

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

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).

An implantable, intrathecal drug delivery system consists of an implanted pump and catheter that delivers a drug directly into the spinal fluid.

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.

Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator in which its mechanism of action results in smooth muscle relaxation.

Medical necessity criteria for intensity-modulated radiotherapy (IMRT). IMRT is an advanced form of 3-dimensional (3-D) conformal radiation therapy that delivers a more precise radiation dose

This policy describes the medical necessity criteria for the review of intestinal and multivisceral transplant requests.

Intradiscal steroid injections involve injecting glucocorticoids directly into the spinal disc that has been identified as the source of pain.

L

Targeted phototherapy utilizes non-ionizing ultraviolet radiation with therapeutic benefit.

Nursing home care includes both long term residential care and short-term post-acute or rehabilitative care. This policy addresses long term care (LTC) placement ranging from basic custodial care to more intense care needed due to dementia or other complex medical needs.

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

Medical necessity criteria for the review of lung transplantation requests.

M

This policy addresses when measurement of 1,25(OH)2D is appropriate and medically necessary.

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.

Multiple Sleep Latency Testing (MSLT) objectively measures an individual’s tendency to fall asleep and is a component of the routine evaluation for suspected narcolepsy or idiopathic hypersomnia.

N

Maternal drug use and intrauterine exposure of the fetus during pregnancy can lead to drug withdrawal in the infant after delivery. Clinically important neonatal withdrawal most commonly results from intrauterine opioid exposure.

Through the increased incidence of intra-partum antibiotics, early-onset neonatal sepsis is occurring less frequently.

Nerve blocks are the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks created by the injection of local anesthetic solutions.

Allogeneic hematopoietic stem cell transplants that do not destroy all of the hematopoietic cells in the bone marrow are termed reduced-intensity or nonmyeloablative conditioning regimens.

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.

Cell-free circulating tumor DNA (ctDNA) originates directly from the tumor tissue (primary or metastasis); as tumor cells die the contents are released into the bloodstream.

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

This policy describes the medical necessity requirements for pancreas transplantation procedures.

Panniculectomy is the surgical removal of a panniculus or excess skin and adipose tissue that hangs down over the genital and/or thigh area causing difficulty in personal hygiene, walking, and other physical activity.

Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing.

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 disease may be a progressive disease, affecting cardiac structure and function in infants and children.

End stage liver disease presents unique clinical considerations in the pediatric population.

Posterior tibial nerve stimulation (PTNS), also known as peripheral tibial nerve stimulation2 , is a minimally invasive form of electrical neuromodulation used to treat overactive bladder (OAB) syndrome and associated symptoms of urinary urgency, urinary frequency, and urge urinary incontinence.

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.

Proton beam therapy (PBT) is a form of external beam radiation therapy (EBRT) that utilizes protons (positively charged subatomic particles) to precisely target a specific tissue mass.

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.

Medical necessity guidelines for repair of nasal valve compromise.

S

Sacroiliac joint (SIJ) fusion, or arthrodesis, is a surgical technique that fuses the iliac bone to the sacrum for stabilization.

Description Treatment for sacroiliac joint (SIJ) dysfunction is usually conservative (non-surgical) and focuses on trying to restore normal motion in the joint.

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

Selective dorsal rhizotomy (SDR) is a neurosurgical technique developed to reduce spasticity and improve mobility in children with cerebral palsy (CP) and lower extremity spasticity

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.

Criteria for skilled nursing facility (SNF) levels of care, to be used in conjunction with general SNF placement criteria in InterQual®.

Transforaminal epidural steroid injections (TFESIs) and selective nerve root blocks (SNRBs) are alternatives to interlaminar epidural steroid injections for the treatment of radicular pain.

Peripheral nerve stimulation (PNS) is intended to decrease chronic and acute pain by stimulating peripheral nerves with leads placed adjacent or parallel to the affected nerve.

T

A tandem transplant, (also known as a sequential or double transplant), refers to a planned second course of high-dose therapy and stem cell transplant (SCT) within 6 months.

The purpose of this policy is to define medical necessity criteria for the diagnostic evaluation of vaginitis (excluding Trichomonas vaginalis, vaginal pH testing, and microscopic examination with saline and KOH) in members/enrollees ≥ 13 years of age.

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.

Numerous essential metabolic functions are mitigated by hormones produced by, and affecting the thyroid

The SynCardia temporary Total Artificial Heart (TAH) (SynCardia Systems Inc.), formerly known as the CardioWest Total Artificial Heart, is a biventricular pulsatile pump that replaces the patient’s native ventricles and valves.

This policy describes the medical necessity requirements for two types of PN, (A) total parenteral nutrition (TPN), in which all of the necessary macronutrients and micronutrients are supplied to the patient, and (B) intradialytic parenteral nutrition (IDPN), in which nutrition is supplied to end-stage renal disease (ESRD) patients undergoing dialysis as an alternative to regularly scheduled TPN.

Trigger points cause pain at their physical location as well as referred pain to other areas in a specific pattern.

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

U

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today.

Sacral neuromodulation (SNM) or sacral nerve stimulation (SNS) refers to stimulation of nerves that innervate the bladder and pelvic floor to treat lower urinary tract dysfunction.

Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction.

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.

A ventricular assist device (VAD) is a mechanical pump that helps the heart when it is too weak to pump blood through the body. VADs are designed to enhance blood flow to the bodily organs, either in conjunction with, or as a replacement for, a damaged or diseased heart.

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

A global consensus statement recommends against universal screening for vitamin D deficiency in healthy children as there is insufficient evidence that the potential benefits of testing outweigh the potential harms

W

It is the policy of health plans affiliated with Centene Corporation® that special wheelchair seating cushions are medically necessary for certain indications.

The wireless motility capsule (WMC) assesses gastroparesis or delayed gastric emptying

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Last Updated On: 3/28/2022