Medical Policy Manual - Indiana Medicaid Provider Home

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.

2 122. 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). 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.

3 216. 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.

4 323. Immunizations and Vaccines .. 327. Intermediate Care Facilities for Individuals with Intellectual Disabilities .. 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).

5 358. 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. Library Reference Number: Revision Date: December 2014. Version: Medical Supplies and Equipment Gloves.

6 401. 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]).

7 449. Medical Supplies and Equipment Patient-activated Event Recorder . ILR .. 458. Medical Supplies and Equipment Phrenic Nerve Stimulator .. 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.

8 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. Physician Administered Drugs Botulinum Toxin Injections.

9 661. 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.

10 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. 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.