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Clinical Coverage Guidelines (CCGs)

Medicaid Policies

A

Inpatient Services are medical services provided to a beneficiary admitted to an acute inpatient hospital.

This policy describes the medical necessity criteria for Allergy Immunotherapy.

This policy describes the medical necessity criteria for Allergy Testing.

This policy describes the medical necessity criteria for Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemias.

This policy describes the medical necessity criteria for Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms.

Ambulance services provide medically necessary treatment for NC Medicaid beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated.

Ambulatory Withdrawal Management (WM) without Extended On-Site Monitoring is an organized outpatient service that provides medically supervised evaluation, withdrawal management, and referral in a licensed facility

Ambulatory Withdrawal Management with Extended On-Site Monitoring is an organized outpatient service that provides medically supervised evaluation, withdrawal management, and referral in a licensed facility.

B

Balloon Ostial Dilation (BOD) also known as balloon dilation sinuplasty, balloon catheter sinusotomy, sinus ostial dilation or balloon sinuplasty, is a procedure that involves placing a balloon in the sinus ostium and inflating the balloon to stretch the opening.

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

This policy describes the medical necessity requirements for breast surgeries including mastectomy/breast conserving surgery, male gynecomastia, prophylactic mastectomy, reduction mammoplasty and breast reconstructive surgery.

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

C

This policy outlines the medical necessity criteria for CAR-T Cell therapy.

The release of cardiac biomarkers is among the cascade of events that occur during acute coronary syndromes and cardiac ischemia. This policy discusses the medical necessity requirements for testing of these cardiac biomarkers.

Child First Services is an intensive, early childhood, two-generation, home visiting intervention that works with the most vulnerable young children (prenatal through age five years) and their families.

Chiropractic is the science of adjusting the cause of disease by realigning the spine, releasing pressure on nerves radiating from the spine to all parts of the body, and allowing the nerves to carry their full quota of health current (nerve energy) from the brain to all parts of the body.

Replacement and repair of external components of a cochlear or auditory brainstem implant device that are necessary to maintain the device’s ability to analyze and code sound, therefore providing an awareness and identification of sounds and facilitating communication for individuals with profound hearing impairment.

A cochlear implant is an electronic medical device designed to restore some ability to perceive sounds and understand speech by individuals with severe to profound hearing loss.

Craniofacial surgery encompasses a broad spectrum of reconstructive procedures of the cranium and face. The objectives of these procedures are to correct deformities of the face and skull bones that result from birth defects, trauma, or disease and to restore craniofacial form and function by medical and surgical means.

D

This policy describes medical necessity criteria for Diagnostic Assessment.

Diaphragmatic/phrenic nerve stimulator devices are indicated for certain ventilator-dependent individuals who lack voluntary control of their diaphragm muscles to enable independent breathing without the assistance of a mechanical ventilator for at least four continuous hours a day.

Dietary Evaluation and Counseling offers direction and guidance for specific nutrient needs related to a beneficiary’s diagnosis and treatment.

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

In lumbar discography, contrast medium is injected into a lumbar intervertebral disc that is thought to be the cause of low back pain

This policy discusses the medical necessity criteria for deep brain stimulation (DBS).

This policy describes the medical necessity criteria for Drug Testing for Opioid Treatment and Controlled Substance Monitoring.

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), a portable medical device that generates low-intensity electric fields termed Tumor Treating Fields

An electroencephalogram (EEG) is a non-invasive method for assessing neurophysiological function.

An implantable, intrathecal drug delivery system consists of an implanted pump and catheter that delivers a drug directly into the spinal fluid. The device can be programmed for continuous or variable rates of infusion. Intrathecal drug delivery systems offer an invasive alternative for the long-term management of select patients with intractable pain.

This policy outlines general guidelines to use in determining coverage of experimental or investigational, or potentially experimental or investigational medical and behavioral health technologies.

Extended ophthalmoscopy is a method of examining the posterior portion of the eye when the level of examination requires a complete view of the back of the eye and documentation is greater than that required during routine ophthalmoscopy.

External ocular photography documents the external eye, lids and ocular adnexa.

This policy discusses the medical necessity criteria for extracorporeal shock wave lithotripsy.

This policy describes the medical necessity guidelines for an endometrial ablation. Endometrial ablation is a minimally invasive surgical procedure used to treat premenopausal abnormal uterine bleeding.

This document describes policies and procedures that direct-enrolled providers shall follow to receive reimbursement for covered enhanced benefit behavioral health services provided to eligible members.

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.

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.

Facility-Based Crisis Service for children and adolescents is a service that provides an alternative to hospitalization for an eligible beneficiary who presents with escalated behavior due to a mental health, intellectual or development disability or substance use disorder and requires treatment in a 24-hour residential facility.

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.

The introduction of saline-diluted fecal matter derived from a healthy human donor into the GI tract of an individual diagnosed with recurrent clostridium difficile infection, who has failed multiple attempts at conventional antibiotic therapy.

This policy details the medical necessity criteria for Fetal Surveillance.

Intravenous fluorescein angiography or fluorescent angiography is a technique for examining the circulation of the retina and choroid using a fluorescent dye and a specialized camera.

G

General Ophthalmological Services include a medical examination and evaluation with the initiation or continuation of a diagnostic and treatment program.

Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions.

This policy describes the medical necessity criteria for Geropsychiatric Units in Nursing Facilities.

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.

Gonioscopy involves using a concave contact lens in conjunction with oblique mirrors to view the iridocorneal angle.

H

This policy addresses covered and non-covered hearing aid services for adult members ages 21 years and older

This policy addresses covered and non-covered hearing aid services for adult members under age 21.

This policy describes the medical necessity criteria for Heart/Lung Transplantation.

Heart (cardiac) transplantation is the surgical excision of a heart and the main arteries from a human, brain-dead donor, with subsequent implantation into a beneficiary who has had his heart surgically removed in a similar manner.

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.

This policy describes the medical necessity of Hematopoietic Stem-Cell Transplantation (HSCT) in the Treatment of Germ Cell Tumors.

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) for Leukemia.

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) for Lymphoma.

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) For Multiple Myeloma and Primary Amyloidosis.

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) for solid tumors of childhood

This policy describes the medical necessity criteria for Hematopoietic Stem-Cell Transplantation (HSCT) for Central Nervous System (CNS) Embryonal Tumors & Ependymoma.

Homocysteine is a nonproteinogenic amino acid that is generated during the conversion of methionine to cysteine.

The North Carolina Medicaid and NC Health Choice hospice benefit is a comprehensive set of services, identified and coordinated by a hospice interdisciplinary group (IDG).

Hyperbaric oxygen (HBO) therapy consists of the exposure of the entire body to 100% oxygen at pressures greater than one atmosphere absolute (ATA) in accordance with accepted clinical protocols for duration and pressure in a mono- or multi-place pressurized chamber.

Hyperhidrosis is defined as excessive sweating beyond a level required to maintain normal body temperature in response to heat exposure or exercise.

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

Home Health Services include medically necessary skilled nursing services, specialized therapies, home health aide services, and medical supplies provided to beneficiaries in any setting, other than a hospital, or nursing facility.

This policy describes the medical necessity criteria for Home Infusion Therapy (HIT).

I

A bone-anchored hearing aid (BAHA) is a surgically implanted osseointegrated prosthetic device that provides bone conduction hearing for recipients with moderate to severe, bilateral conductive or mixed hearing loss

Various cardiac hemodynamic monitoring techniques have been investigated as a means to remotely guide outpatient heart failure (HF) therapy, including implantable wireless pulmonary artery pressure monitoring (e.g. CardioMEMS®).

The purpose of this policy is to ensure that WellCare of North Carolina® complies with Centers for Medicare and Medicaid Services (“CMS”) regulations, as well as applicable contractual requirements regarding In Lieu of Services (ILOS).

Inpatient Behavioral Health Services provide hospital treatment in a hospital setting 24 hours a day.

Electrical bone growth stimulation is a medical technique to promote bone growth in difficult to heal fractures by applying a low electrical current to the fracture site.

This policy describes the medical necessity criteria for Islet Cell Transplantation.

K

Keloid and hypertrophic scars are the results of dermal tissue following skin injury. They require no treatment unless they cause a functional impairment.

Kidney (renal) transplantation is a surgical procedure to implant a healthy kidney into a beneficiary with kidney disease or kidney failure.

L

This policy discusses the medical necessity criteria for liver transplantation.

This policy describes the medical necessity criteria for Long Term Care Hospital (LTCH) Services.

This policy describes the medical necessity criteria for Lung Transplantation.

M

Maternal care skilled nurse home visits assess and treat pregnant women who have one or more of the high-risk medical conditions specified below.

Description 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.

Medically Monitored Inpatient Withdrawal Management Service is an organized facility based service that is delivered by medical and nursing professionals who provide 24-hour medically directed observation, evaluation, monitoring, and withdrawal management in licensed facility.

Male circumcision is the surgical removal of the foreskin (prepuce), which is the layer of skin covering the head (glans) of the penis.

Medically necessary routine foot care is the cutting or removal of corns and calluses; trimming, cutting, clipping, or debriding of nails.

N

Maternal drug use and intrauterine exposure of the fetus during pregnancy can lead to drug withdrawal in the infant after delivery.

The CDC defines early onset sepsis as a blood or cerebrospinal fluid culture-proven infection occurring within the first seven days of life.

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

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

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

Non-Emergency Medical Transportation (NEMT) is transportation to and from medical services on a non-emergent basis.

This policy discusses medical necessity criteria for Nursing Equipment and Supplies.

A nursing facility is a medical health facility, or a distinct part of a facility (for example, a hospital enrolled by the NC Medicaid (Medicaid) program as a swing-bed provider of nursing facility services), that is licensed and certified by the Division of Health Service Regulation (DHSR) and enrolled with Medicaid to provide nursing facility level of care services.

O

The Opioid Treatment Program (OTP) Service is an organized, outpatient treatment service for a Member with an opioid use disorder (OUD).

Optic nerve (ON) sheath decompression involves direct decompression (fenestration) of the ON sheaths just behind the globe. The approach and technique for an ON sheath fenestration varies.

This policy describes the medical necessity criteria for Orthotics & Prosthetics.

Out-of-State services are determined to be medically necessary, and care and services that are provided within 40 miles of the NC border in the contiguous states of Georgia, South Carolina, Tennessee, and Virginia are covered to the same extent and under the same conditions as medical care and services provided in NC, except for the services found in this policy.

Outpatient behavioral health services are psychiatric and biopsychosocial assessment, medication management, individual, group, and family therapies, psychotherapy for crisis, and psychological testing for eligible members.

P

This policy addresses three transplantation services: 1. a simultaneous pancreas and kidney transplant; 2. a pancreas transplant some time following a kidney transplant; and 3. a pancreas transplant alone.

Peer Support Services (PSS) are an evidenced-based mental health model of care that provides community-based recovery services directly to a Medicaid-eligible adult beneficiary diagnosed with a mental health or substance use disorder.

Phase II outpatient cardiac rehabilitation is a comprehensive program of medical evaluation designed to recondition the cardiovascular system and restore beneficiaries with cardiovascular heart disease to active and productive lives. A

Durable Medical Equipment (DME) is primarily and customarily used to serve a medical purpose, is generally not useful to an individual in the absence of a disability, illness or injury, can withstand repeated use, and can be reusable or removable.

Physician fluoride varnish services are defined as preventive procedures provided by or under the supervision of a physician.

The Physicians Drug Program (PDP) covers many, but not all, primarily injectable drugs that are purchased and administered by a medical professional in a physician’s office or in an outpatient clinic setting.

This policy addresses WellCare of North Carolina® beneficiaries’ collection, storage, and transplantation of placental and umbilical cord blood (“cord blood”) as a source of stem cells for allogeneic and autologous stem-cell transplantation.

Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing.

Substantial, complex, and continuous skilled nursing service that is considered supplemental to the care provided to a beneficiary by the beneficiary’s family, foster parents, and delegated caregivers, as applicable.

Private Duty Nursing (PDN) is a substantial, complex, and continuous skilled nursing service that is considered supplemental to the care provided to a beneficiary by the beneficiary’s family, foster parents, and delegated caregivers, as applicable.

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

R

This policy describes the medical necessity criteria for Reconstructive and Cosmetic Surgery.

Research-Based-Behavioral Health Treatments (RB-BHT) services are researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary.

This policy describes the medical necessity criteria for Respiratory Equipment and Supplies.

This clinical coverage policy discusses the medical necessity criteria for Rhinoplasty and/or Septoplasty.

Clinical trials are scientific investigations of treatment alternatives designed to help compare the safety and efficacy of new, untested or non-standard treatments to standard currently accepted treatments.

This policy describes the medical necessity of routine eye examination and visual aids for beneficiaries under the age of 21.

S

Sclerotherapy is a minimally invasive procedure to diminish abnormally dilated and symptomatic veins.1 In this procedure, liquid, foam, or glue irritants are injected into unwanted varicose veins, causing their eventual reduction.1-2 This policy describes the medical necessity requirements for sclerotherapy, and endovenous ablation with chemical adhesives.

Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, immobility, ischemia, or other neurological impairments; over 90% of the lesions are related to venous stasis disease and diabetic neuropathy.

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns.

This policy addresses three different transplantation services: 1. small bowel transplant, 2. small bowel/liver transplant, and 3. small bowel/liver and multi-visceral transplants.

A bone-anchored hearing aid (BAHA) is a surgically implanted osseointegrated prosthetic device that provides bone conduction hearing for recipients with moderate to severe, bilateral conductive or mixed hearing loss.

Special ophthalmological services are special evaluations of part of the visual system, which go beyond the services included under general ophthalmological services or in which special treatment is given.

State Plan Personal Care Services (PCS) provide Personal Care Services in the beneficiary’s living arrangement by paraprofessional aides employed by licensed home care agencies, licensed adult care homes, or home staff in licensed supervised living homes.

Stereotactic pallidotomy is a surgical technique used in the treatment of severe Parkinson’s disease

Sterilization is a permanent method of birth control. Sterilization procedures for women are called tubal occlusion. The procedure for men is called vasectomy.

This policy describes the medical necessity criteria for Surgery for Ambiguous Genitalia.

Clinically Severe Obesity is defined as a BMI 35-39.9 kg/m2 with co-morbid conditions. Morbid Obesity is defined as a BMI greater than or equal to 40 kg/m2.

Surgery of the lingual frenulum includes incision, excision, or surgical alteration of a short frenulum (otherwise known as ankyloglossia, tongue-tie, or high frenulum attachment) in order to free the tongue and allow greater range of motion.

T

This policy is intended to provide new definitions and overarching guidance related to the delivery of services via telehealth, virtual communications and remote patient monitoring that are not otherwise included in a WellCare of North Carolina® program or service-specific clinical coverage policy.

This policy describes the medical necessity guidelines for teleretinal screening as an alternative to retinopathy evaluation by an Ophthalmologist or Optometrist.

Various diagnostic methods are available to identify the etiology of the signs and symptoms of vaginitis.

This policy describes North Carolina Medicaid coverage for therapeutic and non-therapeutic abortions.

Congenital athymia is a rare immune disorder in which a child is born without a thymus – an organ that plays a critical role in helping the body learn to fight infections. Children impacted by this disease typically die within the first two years of life and may have repeated, often lifethreatening infections because they lack adequate working T cells.

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.

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.

Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction.

V

Vagus Nerve Stimulation (VNS) is performed by an implantable stimulator as a treatment for refractory seizures.

A ventricular assist device (VAD) is surgically attached to one or both intact heart ventricles and used to assist or augment the ability of a damaged or weakened native heart to pump blood.

A visual field acuity test is a painless test that determine a patient’s visible field of view.

W

This policy describes the medical necessity criteria for Wireless Capsule Endoscopy

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Last Updated On: 1/8/2024