Skip to main content

Providers

Clinical Coverage Guidelines (CCGs)

Medicaid Policies

A

Medically appropriate air ambulance transportation is a covered service regardless of the State or region in which it is rendered.

This policy describes the medical necessity requirements for allogeneic hematopoietic cell transplants for β–thalassemia

Cartilage transfer procedures include autologous chondrocyte implantation, osteochondral allograft transplantation (OAG or OCA).

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders in children, with an increasing prevalence of diagnosis in adults.

B

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.

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

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 addresses the use of tests that combine biomarkers and/or clinical data into an algorithm to generate a disease risk assessment, prognostic result, or clinical recommendation for treatment.

This policy addresses the use of genetic and biomarker tests that aim to screen for specific cancers in individuals who are at risk to develop them.

This policy addresses the use of diagnostic testing related to malignancies of the hematologic system.

This policy addresses the use of molecular profiling for a known or suspected solid tumor (e.g. broad molecular profiling, including Minimal Residual Disease (MRD) Testing, Tumor Mutational Burden (TMB), cytogenetic / fusion testing, or circulating tumor DNA (ctDNA)).

This policy addresses the use of tests for the diagnosis and management of inherited and sporadic cardiovascular conditions, including structural or electrical defects, disorders of the blood vessels, cholesterol disorders, and lipid profiling.

This policy addresses the use of tests for fungal infection of the nails (onychomycosis), which can sometimes affect surrounding skin.

This policy addresses the use of tests to measure various hormones and assess for diseases and conditions that primarily affect the endocrine system.

This policy addresses the use of tests for common gastroenterologic (non-cancerous) conditions, such as Crohn’s disease, hereditary hemochromatosis, and others.

This policy addresses the evaluation of genetic or molecular testing, as well as general laboratory testing, that has not been more specifically addressed by other criteria.

This policy addresses the use of diagnostic tests for benign (non-cancerous) hematologic conditions.

This policy addresses the use of genetic testing for hereditary cancer susceptibility.

This policy addresses the use of tests for the confirmation of laboratory specimens.

This policy addresses the use of tests for autoimmune conditions and inherited immunodeficiency disorders.

This policy addresses the use of broad and targeted tests for the diagnosis of suspected genetic disorders that affect multiple body systems.

This policy addresses the use of tests for known or suspected kidney disorders, including testing of asymptomatic potential living donors.

This policy addresses the use of tests for evaluation for neurological conditions.

This policy addresses the use of tests for nutrition and metabolism.

Because many genes involved in ophthalmologic disorders are now identified, scientists have developed a better understanding of how these genes influence vision and eye health.

This policy addresses the use of tests for rare skeletal dysplasias and other bone disorders.

This policy addresses the use of tests to identify a cause of hereditary hearing loss, or for other tests related to ear, nose, and throat disorders.

This policy addresses the use of tests that analyze biopsied cells from an embryo as a part of an assisted reproductive procedure.

This policy addresses the use of tests intended to determine parental carrier status for genetic disorders before or during pregnancy.

This policy addresses the use of tests for genetic disorders during pregnancy and following a pregnancy loss.

This policy addresses the use of tests for fetal screening of genetic disorders during pregnancy.

This policy addresses the use of diagnostic tests for disorders that affect the lungs.

This policy addresses the use of tests for drug and treatment response and toxicity testing.

This policy addresses the use of tests for diagnosis and screening during the process of solid organ transplantation, either using tissue or peripheral blood.

Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, surgery, infection, tumors or disease.1

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.

This policy describes the medical necessity requirements for a donor lymphocyte infusion (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.

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

F

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.

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.

This policy describes the medical necessity requirements for performing fetal surgery. This becomes an option when it is predicted that the fetus will not live long enough to survive delivery or after birth.

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

Gastric electrical stimulation (GES) has been used in patients who are proven refractory to conventional treatment for gastroparesis.

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.

H

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

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

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

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

I

This policy describes the medical necessity criteria for immobilized lipase cartridges (RELiZORB®) for use with enteral feeding.

An implantable, intrathecal drug delivery system consists of an implanted pump and catheter that delivers a drug directly into the spinal fluid.

The implanted device measures and monitors daily pulmonary artery (PA) pressure. The data is used by physicians for heart failure management with the goal of reducing heart failure hospitalizations.

This policy describes the medical necessity criteria for the review of intestinal and multivisceral transplant requests.

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

L

Targeted phototherapy utilizes non-ionizing ultraviolet radiation with therapeutic benefit.

Lipedema is a chronic, progressive disease characterized by abnormal adipose tissue distribution, resulting in pain and functional impairment.

Low-frequency ultrasound debridement is a noncontact debridement method that provides simultaneous cleansing and debridement of wounds.

Medical necessity criteria for the review of lung transplantation requests.

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

Mechanical stretching devices are used for the prevention and treatment of joint contractures of the extremities, with the goal to maintain or restore range of motion (ROM) to the joint.

N

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

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.

Allogeneic hematopoietic stem cell transplants that do not destroy all of the hematopoietic cells in the bone marrow are termed reduced-intensity or nonmyeloablative conditioning regimens.

O

Orthognathic surgery is the surgical correction of abnormalities of the mandible, maxilla, or both.

Electrical osteogenic stimulation can be performed invasively or non-invasively. Invasive osteogenic stimulators provide electrical stimulation directly to the non-healing fracture or bone fusion site through percutaneously placed cathodes or by implantation of a coiled cathode wire.

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.”

P

This policy describes the medical necessity requirements for pancreas transplantation procedures.

Pediatric heart disease may be a progressive disease, affecting cardiac structure and function in infants and children.

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

To provide guidelines for the authorization of outpatient or home care speech therapy, occupational therapy, and/or physical therapy evaluation and treatment services.

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

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

Proton beam therapy (PBT) is a form of external beam radiation therapy (EBRT) that utilizes protons (positively charged subatomic particles) to precisely target a specific tissue mass.

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

Medical necessity guidelines for repair of nasal valve compromise.

S

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.

Peripheral nerve stimulation (PNS) is intended to decrease chronic and acute pain by stimulating peripheral nerves with leads placed adjacent or parallel to the affected nerve.

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.

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

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.

The pre-transplant evaluation provides the opportunity to identify conditions that can affect an individual’s ability to have a successful transplant.

U

Ultrasound is the most common fetal imaging tool used today.

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

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.

Contact Us icon

Need help? We're here for you.

Contact Us
Y0020_WCM_178064E_M / H9916_WCM 178009E_M Last Updated On: 11/10/2025