Medical Policy Manual

1 Medical Policy Manual Table of Contents 1. Library Reference Number: Revision Date: December 2014. Version: Table of Contents Contents 9. Abortion Services .. 27. Anesthesia Services .. 34. Bariatric Surgery and Revisions .. 46. Cardiac Rehabilitation .. 55. 63. Clinic Services Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) Services .. 76. Clinical Trials .. 81. Collagen Implants for Stress Urinary Incontinence (SUI) .. 85. Consultations Second Opinions .. 88. Dental Services .. 99. Dermatology .. 120. Diabetes Self-Management Training .. 122. Diagnostic 126. Emergency Medicine Cardiopulmonary Resuscitation (CPR) .. 128. Emergency Medicine Emergency Room .. 130. Table of Contents 2. Library Reference Number: Revision Date: December 2014. Version: Emergency Medicine Emergency Services .. 134. early and periodic screening , Diagnosis, and Treatment (EPSDT).

2 HealthWatch Program .. 141. Evaluation and Management Services .. 154. Family Planning .. 166. Family Planning Eligibility Program .. 171. Freestanding Birthing Centers .. 210. Gastroenterology .. 213. Genetic Testing - Overview .. 216. Genetic Testing Breast Cancer Susceptibility Gene 1 (BRCA1) and Breast Cancer Susceptibility Gene 2 (BRCA2) for Breast and Ovarian Cancer .. 220. Genetic Testing Chromosomal Microarray 225. Genetic Testing Oncotype DX Testing for Breast Cancer .. 228. Gynecology 231. Hearing 241. Home Health Services .. 254. Hospice Services .. 278. Hospital Inpatient Services .. 294. Hospital Inpatient Readmissions .. 316. Hospital Outpatient Services .. 318. Table of Contents 3. Library Reference Number: Revision Date: December 2014. Version: Hyperbaric Oxygen Therapy .. 323. Immunizations and Vaccines .. 327. Intermediate Care Facilities for Individuals with Intellectual Disabilities.

3 331. Laboratory Services .. 342. Laboratory Services Group A Beta Hemolytic Streptococcal Pharyngitis Tests .. 349. Laboratory Services Human Epidermal growth factor Receptor 2. (HER-2/neu) Gene Detection Test and HER-2 Protein Expression Test .. 351. Laboratory Services Human Immunodeficiency Virus (HIV) Testing .. 354. Laboratory Services Placental Alpha Microglobulin-1 (PAMG-1) Test for Detection of Rupture of Membranes (ROM) .. 358. Laboratory Services Sweat Chloride 360. Locum Tenens and Substitute Physician .. 362. Long Term Acute Care 365. Medical Supplies and Durable Medical Equipment Overview .. 372. Medical Supplies and Equipment Automatic External Defibrillators .. 385. Medical Supplies and Equipment Cardiac 390. Medical Supplies and Equipment Continuous Glucose Monitors .. 396. Table 1 - Continuous Glucose Monitor Prior Authorization .. 399. Table of Contents 4.

4 Library Reference Number: Revision Date: December 2014. Version: Medical Supplies and Equipment Gloves .. 401. Medical Supplies and Equipment High Frequency Chest Wall Oscillation System (Formerly ThAIRapy , aka the Vest) .. 405. Medical Supplies and Equipment Hospital and Specialty Beds .. 408. Medical Supplies and Equipment Implantable Cardioverter Defibrillator .. 416. Medical Supplies and Equipment - Implantable Infusion Pumps .. 424. Medical Supplies and Equipment Incontinence Supplies .. 429. Medical Supplies and Equipment Monitoring 441. Medical Supplies and Equipment Negative Pressure Wound Therapy (NPWT).. 445. Medical Supplies and Equipment- Non-invasive Respiratory-Assist Devices (Continuous Positive Airway Pressure [CPAP] and Bi-level Positive Airway Pressure [BiPAP]) .. 449. Medical Supplies and Equipment Patient-activated Event Recorder . ILR .. 458. Medical Supplies and Equipment Phrenic Nerve Stimulator.

5 462. Medical Supplies and Equipment Spinal Cord Stimulators .. 467. Medical Supplies and Equipment Standers .. 474. Medical Supplies and Equipment Standing Wheelchairs .. 481. Medical Supplies and Equipment Vagus Nerve Stimulator for Epilepsy .. 484. Medical Supplies and Equipment Ventricular Assist Device (VAD). Table of Contents 5. Library Reference Number: Revision Date: December 2014. Version: .. 492. Medical Supplies and Equipment Wheelchairs and Accessories .. 500. Mental Health/Behavioral Health Inpatient Services .. 528. Mental Health/Behavioral Health Outpatient Services .. 537. Non-Cancer 556. Nursing Facilities .. 587. Nursing Services .. 599. Obstetric Care .. 611. Oncology .. 631. Oncology Breast and Cervical Cancer 634. Ophthalmological Services .. 636. Osteogenic Bone-Growth Stimulator .. 649. Out-of-State Services .. 653. Physician Administered Drugs .. 657.

6 Physician Administered Drugs Botulinum Toxin Injections .. 661. Physician Administered Drugs Histrelin Implant (Supprelin LA) .. 668. Physician Administered Drugs Histrelin Implant - Vantas .. 671. Physician Administered Drugs Pegloticase Injections .. 674. Plasmapheresis .. 677. Podiatry .. 680. Table of Contents 6. Library Reference Number: Revision Date: December 2014. Version: Radioimmunotherapy .. 688. Radiology .. 692. Radiology Positron Emission Tomography (PET) Scans .. 697. Robotic Therapy .. 702. screening Services - Newborn screening .. 707. Smoking 711. Substance Abuse .. 715. Surgery - Plastic and Reconstructive Surgery Facial and Maxillofacial .. 721. Surgery Plastic and Reconstructive Surgery Genitourinary and Breast .. 752. Surgery Plastic and Reconstructive Surgery - Panniculectomy .. 758. Surgery Surgical 762. Surgery - Transplants .. 773. Telehealth .. 814.

7 Telemedicine Services .. 818. Therapy Services .. 824. Transportation Services .. 836. Transportation Services Rotary Wing Air Transportation .. 859. Traumatic Brain Injury Program .. 864. Appendix A .. 877. Table of Contents 7. Library Reference Number: Revision Date: December 2014. Version: Table of Contents 8. Library Reference Number: Revision Date: December 2014. Version: Preface Overview The Medical Policy Manual has been developed to ensure the success of the Indiana Health Coverage Programs (IHCP). This Manual will be used as a reference handbook for the Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) and other state contractors and partners. The formulation of IHCP Medical policies will involve an array of individuals and a complex set of tasks for each Policy . The management of Medical Policy must involve the careful consideration of the stakeholders the state, the practitioner and provider community, and the IHCP member community.

8 It must be collaborative in nature to promote a positive, effective, and responsive approach to customer service. By its unique nature, Medical Policy must strengthen the foundation of the IHCP, irrespective of the governing agency or healthcare delivery system. This Manual addresses the policies of the IHCP. The information regarding prior authorization (PA), payment methodology, and maximum fees may vary for providers rendering services to members enrolled in the Risk Based Managed Care (RBMC) delivery system. Detailed descriptions of all IHCP-covered services, as well as exclusions and limitations, are also included. The objective is to take a proactive approach in the development of new Policy and the review of existing policies to ensure that the Manual is reflective of the IHCP. The Manual will serve as a living document, providing flexibility to accommodate change and promote ease of use.

9 IHCP Oversight and Delivery Overview of the Indiana Family and Social Services Administration The Indiana FSSA is the umbrella agency responsible for administering Indiana's public assistance programs. FSSA includes the offices and divisions listed below: OMPP. Division of Disability and Rehabilitative Services (DDRS). Division of Family Resources (DFR). Division of Mental Health and Addiction (DMHA). Division of Aging (Aging). Preface 9. Library Reference Number: Revision Date: December 2014. Version The Director of Medicaid is responsible for OMPP. Other agencies that administer programs that impact IHCP include the DDRS, DFR, DMHA, and Aging. These agencies are described below: DDRS manages aging and in-home services, guardianship, and adult protective services, and determines Medical eligibility for the Supplemental Security Income (SSI) and Social Security Disability (SSD) programs for the federal government.

10 It provides case management services for persons with developmental disabilities;. including supervision services for four developmental centers for clients with disabilities, operation of several state institutions, vocational rehabilitation, case management services, independent living services for the deaf and hard of hearing, and services for individuals with blindness and visual impairments. DFR, through its county offices, is responsible for determining eligibility for IHCP. services. Following the eligibility determination, county offices enroll individuals meeting eligibility standards and maintain eligibility files using the Indiana Client Eligibility System (ICES) for the IHCP member population. DMHA ensures the availability of accessible, acceptable, and effective mental health and substance abuse related disorder services for Hoosiers. The division is responsible for providing funding support for mental health and addictions services to target populations with financial need through a network of managed care providers, certifying all community mental health centers (CMHCs) and managed care providers (licensing inpatient psychiatric hospitals and operating state behavioral health hospitals), and administering federal funds earmarked for substance abuse prevention projects.