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Clinical Coverage Guidelines (CCGs)

 

Medicaid Policies

A

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 criteria for allogeneic hematopoietic progenitor cell therapies, which include Omisirge® (omidubicel) and RegenCyte™ (HPC Cord Blood).

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

Cartilage transfer procedures include autologous chondrocyte implantation, osteochondral allograft transplantation (OAG or OCA).

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

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

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.

Biofeedback or neurofeedback is a noninvasive technique intended to enable an individual to learn how to change a physiological activity for the purpose of improving health and performance.

Bone-anchored hearing aids (BAHAs) are an alternative to conventional hearing aids when physical or medical complications prevent adequate functional improvement in hearing.

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

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

C

Epidural steroid injections (ESIs) are a non-surgical treatment that involve the administration of a glucocorticoid, or steroid, and/or anesthetic via a needle inserted in the space between the ligamentum flavum and the dura. 5,24 Epidural injections are performed utilizing three approaches in the lumbar spine: caudal, interlaminar, and transforaminal.2,5 Computed tomography (CT) or standard fluoroscopy can be used during administration to provide guidance and anatomic detail.22

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

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 proteincoding 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).

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.

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.

Carrier screening is performed to identify individuals at risk of having offspring with inherited recessive or X-linked single-gene disorders.

Prenatal Cell-Free DNA Testing is a sequencing test performed on placental cell-free DNA found in maternal serum.

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.

Oncology prognostic and algorithmic tests are developed to aid in determining the likelihood that an individual has cancer, the prognosis for a patient diagnosed with cancer, and/or surveillance for recurrence.

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 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

Deep Transcranial Magnetic Stimulation (dTMS) is a non-invasive tool that stimulates deep regions of the brain.

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 due to bilateral paralysis or severe paresis of the diaphragm.

Discography is an invasive, intradiscal diagnostic technique that uses imaging and pain to diagnose discogenic pain.1

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

Electric tumor treating fields (TTF), also known as alternating electric field therapy, are used for the treatment of glioblastoma.

Endometrial ablation is a minimally invasive surgical procedure used to treat premenopausal abnormal uterine bleeding.

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. Neck pain related to whiplash injury is also thought to be related to the cervical zygapophyseal facet joint

Polysomnography (PSG) is the continuous and concurrent monitoring and recording of various physiological and pathophysiological parameters of sleep that includes physician evaluation, interpretation and dissemination.

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.

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 a noninvasive neuroimaging 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.

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

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

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.

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), who have failed continuous positive airway pressure.

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.

Medical necessity criteria for intensity-modulated radiotherapy (IMRT).

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

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

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

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.

Lipedema is a chronic, progressive disease characterized by abnormal adipose tissue distribution, resulting in pain and functional impairment.

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.

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 associated with epidural fibrosis or adhesions.

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.

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 use of certain prescription medications and non-prescribed substances with intrauterine exposure of the fetus during pregnancy can lead to withdrawal symptoms in the infant after delivery

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

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

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

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

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.

O

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

The American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation define cardiac rehabilitation for coronary heart disease as “coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality.”

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

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

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.

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.

Kidney transplantation is the preferred treatment option for pediatric patients with advanced chronic kidney disease (CKD) and end stage renal disease (ESRD).

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

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.

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.

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.

This policy describes the medical necessity requirements for Psychiatric Residential Treatment Facilities Levels I and II.

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, also known as breast reduction surgery, is a surgical procedure to reduce the weight, mass, and size of the breast in those with a female reproductive system.1-2

Medical necessity guidelines for repair of nasal valve compromise.

S

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

Treatment for sacroiliac joint (SIJ) pain and dysfunction is usually conservative (non-surgical) and focuses on pain relief

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. S

Patients receiving treatment with a skin substitute graft should be under the care of a wound care physician or surgeon and systemic disease should be monitored/treated to ensure adequate healing of the wound site. T

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.

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 6 months of the first course.

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.

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

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.

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.

Transcranial Magnetic Stimulation (TMS) is a non-invasive treatment that uses pulsed magnetic fields to induce an electric current in a localized region of the cerebral cortex.

The pre-transplant evaluation provides the opportunity to identify conditions that can affect an individual’s ability to have a successful transplant.

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

U

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.

W

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

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Y0020_WCM_178064E_M Last Updated On: 10/1/2025