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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).

El trastorno por déficit de atención con hiperactividad (ADHD) es uno de los trastornos neuroconductuales más comunes en niños, con una prevalencia en aumento de diagnóstico en adultos.

La acupuntura consiste en la estimulación manual y/o eléctrica de agujas delgadas, sólidas y metálicas insertadas en la piel.

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.

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

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.

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

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

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.

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

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.

La incontinencia fecal se define como la evacuación descontrolada de heces o gases durante 1 mes, como mínimo, en una persona de al menos cuatro años de edad que anteriormente tenía control sobre ello.

FerriScan® R2-MRI es una solución basada en imágenes por resonancia magnética (MRI) para medir la concentración de hierro en el hígado (LIC) en pacientes con sobrecarga de hierro.

En esta política se describen los requisitos de necesidad médica para realizar la cirugía fetal. Esta una opción viable cuando se predice que el feto no vivirá el tiempo suficiente para sobrevivir al parto o después del nacimiento.

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

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

Los paneles moleculares múltiples permiten la detección cualitativa de ácido nucleico a partir de múltiples patógenos virales, parasitarios y bacterianos en muestras de heces de personas con síntomas de gastroenteritis o colitis infecciosa.

H

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

La homocisteína es un aminoácido no proteinogénico generado durante la conversión de metionina en cisteína.

Hospice is a coordinated, integrated program developed by a multidisciplinary team of professionals to provide end-of-life care.

La hiperhidrosis se define como la sudoración excesiva más allá de un nivel requerido para mantener la temperatura corporal normal como respuesta a la exposición al calor o al ejercicio.

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.

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.

El dispositivo implantado mide y controla a diario la presión de la arteria pulmonar (PA). Los médicos utilizan los datos para controlar la insuficiencia cardíaca con el objetivo de reducir las hospitalizaciones.

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

En esta política se describen los criterios de necesidad médica para evaluar las solicitudes de trasplante intestinal y multivisceral.

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.

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

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

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.

El desbridamiento por ultrasonido de baja frecuencia es un método de desbridamiento sin contacto que proporciona limpieza y desbridamiento de heridas de forma simultánea.

Criterios de necesidad médica para evaluar las solicitudes de trasplante de pulmón.

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

Los dispositivos de estiramiento mecánico se utilizan para prevenir y tratar las contracturas articulares de las extremidades con el objetivo de mantener o restaurar el rango de movimiento (ROM) de la articulación.

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

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.

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.

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.

O

Criterios de necesidad médica para los programas de atención obstétrica a domicilio brindados por proveedores como 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

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

La paniculectomía es la extirpación quirúrgica de un panículo o exceso de piel y tejido adiposo que cuelga sobre el área genital y/o del muslo y dificulta la higiene personal, caminar y demás actividades físicas.

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.

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.

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.

Criterios de necesidad médica para la prueba respiratoria de reacción en cadena de la polimerasa (PCR) múltiple.

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

La terapia con haz de protones (PBT) es una clase de radioterapia de haz externo (EBRT) que utiliza protones (partículas subatómicas con carga positiva) para dirigirse con precisión a una masa de tejido específica.

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

Lineamientos de necesidad médica para reparar la válvula nasal colapsada.

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

La estimulación nerviosa periférica (PNS) se emplea para disminuir el dolor agudo crónico mediante la estimulación de los nervios periféricos con electrodos colocados de forma adyacente o paralela al nervio afectado.

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.

El óxido nítrico inhalado (iNO) es un vasodilatador pulmonar selectivo cuyo mecanismo de acción produce la relajación del músculo liso.

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.

El corazón artificial total (TAH) temporal SynCardia (SynCardia Systems Inc.), anteriormente conocido como corazón artificial total CardioWest, es una bomba pulsátil biventricular que sustituye a las válvulas y los ventrículos nativos del paciente.

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.

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

U

Ultrasound is the most common fetal imaging tool used today.

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.

El estudio urodinámico es una parte importante de la evaluación integral de la disfunción miccional.

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.

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: 11/10/2025