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Clinical Coverage Guidelines (CCGs)

 

Medicaid Policies

A

Se proporcionan ambulancias aéreas de ala fija (FW) o de ala giratoria (RW) cuando el traslado en ambulancia terrestre, total o parcial, no es apropiado debido a la condición médica del paciente.

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

Hay dos categorías de cirugía bariátrica: procedimientos restrictivos y procedimientos de malabsorción.

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.

Los dispositivos Baha® son audífonos de conducción ósea osteointegrados aprobados por la FDA y, según la FDA y el fabricante, están indicados específicamente para pacientes mayores de cinco años.

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

Las inyecciones epidurales de esteroides se utilizan para controlar el dolor en pacientes con radiculopatía, estenosis espinal y lumbalgia inespecífica, a pesar de los resultados incoherentes, así como de las poblaciones heterogéneas y las intervenciones en ensayos aleatorizados.

Lineamientos de necesidad médica para los costos de rutina de los ensayos clínicos según los requisitos de los Centros de Servicios de Medicare y Medicaid (CMS) y la Ley de Protección al Paciente y Atención Asequible (PPACA).

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.

El ADN tumoral circulante sin células (ctDNA) se origina directamente en el tejido tumoral (primario o metástasis); a medida que las células tumorales mueren, el contenido se libera al torrente sanguíneo.

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.

En esta política se describen los criterios de necesidad médica para el reemplazo de implantes cocleares y/o sus componentes.

En esta política se brindan los lineamientos generales para determinar en qué casos la cirugía estética y reconstructiva es o no es médicamente necesaria.

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.

En esta política se describen los requisitos de necesidad médica para una infusión de linfocitos de donantes (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

Un electroencefalograma (EEG) es un método no invasivo para evaluar el funcionamiento neurofisiológico.

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.

En esta política se describen las pautas generales empleadas para determinar la cobertura de tecnologías médicas y de salud conductual experimentales o en investigación, o potencialmente experimentales o en investigación.

F

El dolor lumbar crónico se atribuye con frecuencia a trastornos de la articulación facetaria.

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

La estimulación eléctrica gástrica (GES) se utiliza en pacientes que han demostrado ser insensibles al tratamiento convencional de la gastroparesia.

Los servicios para la afirmación de género suelen incluir tratamiento hormonal, asesoramiento, psicoterapia, histerectomía completa, mastectomía bilateral, reconstrucción o aumento del pecho según corresponda, reconstrucción genital, eliminación del vello facial y determinados tipos de reconstrucción plástica facial.

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.

Un parto en casa planificado es una alternativa al parto opcional en un centro de partos o en un entorno hospitalario.

En esta política se proporcionan los lineamientos generales sobre cuándo los respiradores domésticos no invasivos son o no son médicamente necesarios.

Hospice es un programa coordinado e integrado desarrollado por un equipo multidisciplinario de profesionales para proporcionar atención al final de la vida. Se centra, sobre todo, en aliviar el dolor y los síntomas específicamente relacionados con el diagnóstico terminal de miembros/afiliados con una esperanza de vida de seis meses o menos.

I

La estimulación del nervio hipogloso, también conocida como sistema de estimulación de la vía aérea superior (UAS), se recomienda como estrategia de tratamiento para determinados pacientes con apnea obstructiva del sueño (OSA) de moderada a grave.

El sistema de implante intratecal para la administración de medicamentos consiste en el implante de una bomba y un catéter que envían un medicamento directamente al líquido cefalorraquídeo.

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.

Las inyecciones intradiscales de esteroides consisten en inyectar glucocorticoides directamente en el disco intervertebral que se ha identificado como la fuente del dolor.

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

La fototerapia dirigida utiliza radiación ultravioleta no ionizante con beneficio terapéutico.

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.

La prueba de latencia múltiple del sueño (MSLT) mide objetivamente la tendencia de una persona a quedarse dormida y forma parte de la evaluación rutinaria por la sospecha de narcolepsia o hipersomnia idiopática.

N

Debido al aumento de la incidencia de antibióticos intraparto, la sepsis neonatal temprana es cada vez menos frecuente.

Un bloqueo nervioso es la interrupción temporal de la conducción de impulsos en nervios o troncos nerviosos periféricos originada por la inyección de soluciones anestésicas locales.

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

Los alotrasplantes de células madre hematopoyéticas que no destruyen todas las células hematopoyéticas de la médula ósea se denominan regímenes de acondicionamiento de intensidad reducida o no mieloablativos.

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

En esta política se describen los requisitos de necesidad médica para los procedimientos de trasplante de páncreas.

Panniculectomy is the surgical removal of a panniculus or excess skin and adipose tissue that hangs down over the genital and/or thigh area.

La cardiopatía pediátrica puede ser una enfermedad progresiva que afecta la estructura y la función cardíaca en lactantes y niños.

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

El objetivo de la terapia miofuncional es identificar los métodos de alimentación óptimos del niño, maximizar su seguridad para evitar el riesgo de complicaciones médicas y ayudarlo a desarrollar habilidades funcionales apropiadas para su edad.

La fibrilación auricular (AF) es la taquiarritmia sostenida más frecuente y aumenta 5 veces el riesgo de accidente cerebrovascular, el cual, a su vez, se incrementa con la edad.

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

Se especifican los lineamientos para autorizar los servicios de evaluación y tratamiento mediante terapia del habla, terapia ocupacional y/o fisioterapia para pacientes que requieren atención ambulatoria o en el hogar.

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

La mamoplastia de reducción es la reducción quirúrgica del tamaño de las mamas. Se desarrolló como un medio para aliviar los síntomas físicos y emocionales vinculados al tamaño excesivo de las mamas y la ptosis mamaria.

Lineamientos de necesidad médica para reparar la válvula nasal colapsada.

This policy describes the medical necessity requirements for respite services.

S

La fusión de la articulación sacroilíaca (SIJ), o artrodesis, es una técnica quirúrgica mediante la cual se fusiona el hueso ilíaco con el sacro para estabilizarlo.

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.

Las inyecciones epidurales de esteroides transforaminales (TFESI) y los bloqueos radiculares selectivos (SNRB) son alternativas a las inyecciones epidurales de esteroides interlaminares para tratar el dolor radicular.

En la actualidad, existe una amplia variedad de productos de bioingeniería disponibles para la cobertura del tejido blando que afecta el cierre de heridas.

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.

Los puntos de activación causan dolor en su ubicación física, así como dolor referido en otras áreas según un patrón específico.

U

La neuromodulación sacra (SNM) o la estimulación del nervio sacro (SNS) se refiere a la estimulación de los nervios que inervan la vejiga y el suelo pélvico para tratar la disfunción del tracto urinario inferior.

V

La estimulación del nervio vago (VNS) se emplea para tratar la epilepsia y se ha estudiado para el tratamiento de la depresión refractaria y otras indicaciones.

W

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

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Y0020_WCM_100876E Last Updated On: 1/8/2024