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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.

Allergy testing is performed to determine immunologic sensitivity or reaction to antigens for the purpose of identifying the cause of the allergic state.

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

This policy describes the medical necessity requirements for aquatic therapy.

B

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

Documentation in a medical record facilitates patient safety, decreases error, improves quality of care, and ensures regulatory and reimbursement compliance.

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.

This policy describes the medical necessity requirements for bronchial thermoplasty (BT).

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

C

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.

Hereditary connective tissue disorders are a group of disorders that affect the connective tissues that support the skin, bones, joints, heart, blood vessels, eyes, and other organs.

Arrhythmias and cardiomyopathies can be multifactorial, hereditary, or caused by a known environmental factor, such as a drug.

Genetic testing for dermatologic conditions and disorders that have many dermatologic findings may be used to confirm a diagnosis in a patient who has signs and/or symptoms of the disease.

Genetic testing for hereditary epilepsy, neurodegenerative, and neuromuscular disorders may be used to confirm a diagnosis in a patient who has signs and/or symptoms of the disease, but conventional diagnostic methods have been unsuccessful.

Exome sequencing (ES) (also known as ‘whole exome sequencing (WES)’) involves sequencing and often copy number variant (CNV) analysis of the portion of the genome that contains protein coding DNA, which are termed exons.

Age-related macular degeneration (AMD) is an eye condition that causes damage to the central portion of the retina (the macula), affecting the ability to see objects straight ahead.

Genetic testing for gastroenterologic (non-cancerous) disorders may be used to confirm a diagnosis in a patient who has signs and/or symptoms of a specific gastroenterologic disorder.

Genetic testing refers to the use of technologies that identify genetic variation, which include genomic, transcriptional, proteomic, and epigenetic alterations, for the prevention, diagnosis, and treatment of disease.

Hereditary hearing loss can be classified as syndromic or nonsyndromic.

Genetic testing for hematologic (non-cancerous) conditions may be used to confirm a diagnosis in a patient who has signs and/or symptoms of a specific hematologic condition.

Genetic testing for hereditary cancer susceptibility is performed when an individual has risk factors that increase suspicion that they could develop an inherited form of cancer.

Immunodeficiency disorders typically result from the use of a drug or from a long-lasting significant disorder (e.g., cancer), however a subset of immunodeficiency disorders are inherited.

Inherited kidney disorders and inherited disorders that indirectly affect the kidneys can be more common, such as autosomal dominant polycystic kidney disease, or more rarely Lowe syndrome and Fabry disease.

One of the most common forms of inherited lung disorders is alpha-1 antitrypsin deficiency (AATD). AATD is an autosomal recessive genetic disorder that results in decreased production of the alpha-1 antitrypsin (AAT) protein, or production of abnormal types of the protein that are functionally deficient.

Hereditary metabolic disorders, also known as inborn errors of metabolism, are genetic disorders that interfere with the body’s metabolism.

Genetic testing for rare hereditary diseases may be used to confirm a diagnosis in a patient who has signs and/or symptoms of a rare disease, but conventional diagnostic methods have been unsuccessful.

Non-invasive prenatal screening (NIPS) is a sequencing test performed on placental cell-free DNA found in maternal serum and is most commonly used to screen for fetal aneuploidy (trisomy 21, trisomy 13, and trisomy 18).

Pharmacogenetic tests are germline genetic tests that are developed to aid in assessing an individual's response to a drug treatment or to predict the risk of toxicity from a specific drug treatment.

Preimplantation genetic testing involves analysis of biopsied cells from an embryo as a part of an assisted reproductive procedure.

There are more than 1,300 inherited recessive disorders (autosomal or X-linked) that affect 30 out of every 10,000 children.

Prenatal diagnostic testing may be used to identify genetic conditions in fetuses at an increased risk based on prenatal screening or for women who choose to undergo diagnostic testing due to other risk factors.

Skeletal dysplasias are a category of rare genetic disorders that affect bones and joints and are estimated to affect 2.4 per 10,000 births, and some forms of skeletal dysplasia can be suspected based on prenatal ultrasound.

Present in many hereditary connective tissue disorders. Medical management may differ based on the underlying genetic etiology. A diagnosis may be made based on clinical examination.

This policy relates to genetic and biomarker tests that aim to screen for specific cancers in individuals who are at risk to develop them.

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.

Cytogenetic analysis of solid tumors and hematologic malignancies aims to both classify the type of tumor or cancer present and also to identify somatic oncogenic mutations in cancer.

The molecular analysis of solid tumors and hematologic malignancies aims to identify somatic oncogenic mutations in cancer.

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

Deep Transcranial Magnetic Stimulation (dTMS) is a non-invasive tool that stimulates deep regions of the brain, such as the anterior cingulate cortex (ACC) or ventral capsule/ventral striatum (VC/VS) region using a coil to pass electrical energy.

Diaphragmatic/phrenic nerve stimulation, also referred to as diaphragm pacing, is a treatment option used to eliminate or reduce the need for ventilator support in those with chronic ventilatory insufficiency.

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

Microdiscectomy or open discectomy (MD/OD) are the standard procedures for symptomatic lumbar disc herniation.

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

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.

E

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.

This policy describes the medical necessity guidelines for an endometrial ablation.

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.

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

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

Fecal incontinence is 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.

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.

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

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

This policy provides medical necessity guidelines for Holter monitoring up to 48 hours. For Holter monitoring beyond 48 hours, see clinical decision support criteria.

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

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

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.

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.

An implantable loop recorder (ILR), also referred to as an insertable or implantable cardiac monitor (ICM), is a subcutaneous monitoring device for the detection of cardiac arrhythmias.

Various cardiac hemodynamic monitoring techniques have been investigated as a means to remotely guide outpatient heart failure (HF) therapy.

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

L

This policy describes the medical necessity criteria for Lantidra (donislecel), an allogeneic pancreatic islet cellular therapy, used for the treatment of type 1 diabetes in those who are unable to reach target hemoglobin A1c (HbA1c).1

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

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

Epidural adhesiolysis, also known as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty, is a minimally invasive surgery for patients with chronic back pain

M

Mechanical stretching devices are used for the prevention and treatment of joint contractures of the extremities.

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

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.

This policy describes the medical necessity requirements for the use of neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES).

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 Nutritional Counseling services.

O

Optic nerve (ON) sheath decompression involves direct decompression (fenestration) of the ON sheaths just behind the globe.

This policy describes the medical necessity requirements for orthognathic surgery to improve form and function through correction of an underlying skeletal deformity.

This policy outlines the medical necessity criteria for electrical and ultrasonic osteogenic stimulators to enhance the bone healing process.

This policy describes the medical necessity guidelines for conventional and intensive outpatient cardiac rehabilitation programs.

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.

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.

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.

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

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

Posterior tibial nerve stimulation (PTNS), also known as peripheral tibial nerve stimulation, is a minimally invasive form of electrical neuromodulation.

Pulmonary function tests (PFTs), also known as lung function tests, include a variety of tests to check how well the lungs are working.

R

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.

This policy describes the medical necessity requirements for respite services.

S

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

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

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.

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

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

Peripheral nerve stimulation (PNS) is intended to decrease chronic and acute pain by stimulating peripheral nerves.

Stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) are radiation therapies delivered via stereotactic guidance to a small, precise target.

T

A tandem transplant, (also known as a sequential or double transplant), refers to a planned second course of high-dose therapy and hematopoietic cell transplant (HCT) within six months of the first course.

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

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

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

This policy describes the medical necessity requirements for transportation services.

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

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.

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.

W

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

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Last Updated On: 1/8/2024

Wellcare will be performing maintenance on Saturday, June 21, from 6 P.M. EDT to 8 A.M. EDT the next day. You might not be able to access systems or fax during this time. We are sorry for any issues this may cause. Thank you for your patience. If you need assistance, contact us.

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