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Clinical Coverage Guidelines (CCGs)

 

Medicaid Policies

A

Applied Behavior Analysis (ABA) services must meet specific documentation requirements and adhere to applicable regulations, accreditation standards, and professional practice standards.

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.

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

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.

This policy addresses immediate (IgEmediated) hypersensitivity and delayed (cell-mediated) hypersensitivity.

Applied Behavior Analysis (ABA) is the application of behavioral principles to everyday situations, intended to increase skills or decrease targeted behaviors.

Los procedimientos de transferencia de cartílago incluyen el implante de condrocitos autólogos, el trasplante de aloinjerto osteocondral (OAG u OCA) [incluida la reparación del ligamento cruzado anterior y el menisco] y el trasplante de autoinjerto osteocondral [mosaicoplastia, sistema de trasplante de autoinjerto osteocondral (OATS)].

Los servicios de diagnóstico de infertilidad para determinar su causa y tratamiento solo están cubiertos cuando se proporciona cobertura específica según los términos del plan de prestaciones de un miembro/afiliado.

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.

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

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

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 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.

Non-invasive prenatal screening (NIPS) is a sequencing test performed on placental cell-free DNA found in maternal serum.

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 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.

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

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.

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

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

En esta política se describen los requisitos de necesidad médica para una infusión de linfocitos de donantes (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 (e.g., for chronic noncancer pain).

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.1

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

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

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)

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

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

Types of evoked potentials include somatosensory, brainstem auditory, visual and motor.

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

Polysomnography (PSG) is the continuous and concurrent monitoring and recording of various physiological and pathophysiological parameters of sleep.

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.

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.

This policy addresses the medical necessity criteria for Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing.

H

This policy describes the medical necessity requirements for habilitation services.

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.

En esta política se brindan los lineamientos de necesidad médica para el uso de monitores Holter hasta un máximo de 48 horas.

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

This policy describes medical necessity criteria for noninvasive and invasive home ventilators.

This policy describes the medical necessity requirements for testing levels of homocysteine.

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

A global consensus statement recommends against universal screening for vitamin D deficiency in healthy children.

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

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

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.

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). IMRT is an advanced form of 3-dimensional (3-D) conformal radiation therapy that delivers a more precise radiation dose to the tumor while sparing healthy surrounding tissue.

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).

This policy describes the medical necessity requirements for excimer laser based targeted phototherapy.

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.

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

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.

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.

This policy describes the medical necessity requirements for medical day care services in New Jersey.

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

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).

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.

Description This policy describes the medical necessity criteria for Omisirge (omidubicel), a nicotinamidemodified allogeneic hematopoietic progenitor cell therapy, to be delivered following myeloablative conditioning for hematologic malignancies.

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.

En esta política se describen los requisitos de necesidad médica para la cirugía ortognática.

De los 5.6 millones de fracturas que se estiman que ocurren al año en los Estados Unidos, alrededor de entre el 5% y el 10% muestran signos de retraso o deterioro de la curación.

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.”1

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

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

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.

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 used to treat overactive bladder (OAB) syndrome and associated symptoms of urinary urgency, urinary frequency, and urge urinary incontinence.

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.

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.

La hiperbilirrubinemia es la afección más común en los recién nacidos que requiere atención médica.

This policy describes the medical necessity requirements for identification and benefits for the prevention of long term institutionalization program

This policy describes the medical necessity criteria for private duty nursing.

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.

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) pain and dysfunction is usually conservative (non-surgical) and focuses on pain relief.

La escleroterapia es un procedimiento mínimamente invasivo que permite reducir el tamaño de las venas dilatadas, de forma anormal, y sintomáticas.

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.

The purpose of this policy is to ensure that the level of skilled nursing facility care reported by the provider reflects the services performed.

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

El propósito de esta política es definir criterios de necesidad médica para la evaluación diagnóstica de vaginitis (sin incluir Trichomonas vaginalis, prueba de pH vaginal y examen microscópico con solución salina y KOH) en miembros/afiliados ≥ 13 años de edad.

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

Las hormonas que afectan la tiroides y que esta produce mitigan numerosas funciones metabólicas esenciales

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.

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.

Transcranial magnetic stimulation (TMS) is a noninvasive technique approved as a modality for treatment resistant major depression (TRD).

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

En esta política se describen los criterios de necesidad médica para el uso de ultrasonido durante el embarazo. El ultrasonido es la herramienta de diagnóstico por imagen fetal más común en la actualidad.

The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies.

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

This policy determines whether special wheelchair seating cushions are medically necessary for the certain indications.

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

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Last Updated On: 1/8/2024