Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007 STATE OF INDIANA Family and Social Services Administration Office of Medicaid Policy and Planning INDIANA MEDICAID MEDICAL ASSISTANCE PROGRAM MEDICAL POLICY MANUAL TABLE OF CONTENTS Page I. PREFACE 6 II. INDIANA HEALTH COVERAGE PROGRAMS OVERSIGHT 7-24 AND DELIVERY SYSTEMS III. OTHER STATE PROGRAMS 25 IV. SERVICES, LIMITATIONS AND EXCLUSIONS 26-29 V. PRIOR AUTHORIZATION 30 VI. MEDICAL POLICIES BY TOPIC Abortion 31-33 Anesthesia Services 34-44 Bariatric Surgery and Revisions 45-53 Cardiac Rehabilitation 54-60 Case Management—Pregnant Women 61-65 Chiropractic Services 66-78 Clinic Services—FQHC and Rural Health Clinic Services 79-83 Clinical Trials 84-97 Collagen Implants for Stress Urinary Incontinence 98-100 Consultations—Second Opinions 101-106 Dental Services 107-122 Dermatology 123-125 Diabetes Self-Management Training 126-128 01/31/2007 Index 1 Medical Policy Manual IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007 Diagnostic Studies 129-130 Emergency Medicine—Cardiopulmonary Resuscitation (CPR) 131-132 Emergency Medicine—Emergency Room 133-136 Emergency Medicine—Emergency Services 137-144 EPSDT—HealthWatch 145-156 Evaluation and Management Services 157-162 Family Planning 163-169 Gastroenterology 170-173 Genetic Testing—BRCA1 and BRCA2 for Breast and Ovarian Cancer 174-178 Gynecology Services 179-187 HIV Care Coordination 188-196 Home Health Services 197-226 Hospice 227-243 Hospital Inpatient 244-254 Hospital Inpatient—Readmissions/General/Same Provider 255-256 Hospital Outpatient 257-263 Hyperbaric Oxygen 264-267 Immunizations and Vaccines 268-277 Intermediate Care Facilities for the Mentally Retarded 278-287 Laboratory Services 288-294 Laboratory Services—Group A Beta Hemolytic Streptococcal Pharyngitis Tests 295-296 Laboratory Services—HER 2/neu Gene Detection Test 297-299 01/31/2007 Index 2 Medical Policy Manual IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007 Laboratory Services—Human Immunodeficiency Virus (HIV) Testing 300-302 Laboratory Services—Sweat Chloride Test 303-304 Laboratory Services—Salivary Estriol 305-306 Locum Tenens & Substitute Physician Policy 307-311 Long-Term Acute Care Hospitals 312-318 Medical Supplies and Durable Medical Equipment (DME) Overview 319-332 Medical Supplies and Equipment —Automatic External Defibrillators 333-337 Medical Supplies and Equipment—Beds 338-344 Medical Supplies and Equipment—Gloves 345-348 Medical Supplies and Equipment—Implantable Infusion Pumps 349-354 Medical Supplies and Equipment—Incontinence Supplies 355-358 Medical Supplies and Equipment—Monitoring Devices 359-362 Medical Supplies and Equipment—Negative Pressure Wound Therapy 363-366 Medical Supplies and Equipment—Non-Invasive Respiratory Assist Devices 367-374 Medical Supplies and Equipment—Patient-Activated Event Recorder— Implantable Loop Recorder (ILR) 375-379 Medical Supplies and Equipment—Phrenic Nerve Stimulator 380-383 Medical Supplies and Equipment—Power Wheelchairs 384-391 Medical Supplies and Equipment—Programmable Hearing Aids 392-395 Medical Supplies and Equipment—Prothrombin Time 396-399 Medical Supplies and Equipment—Standers 400-406 Medical Supplies and Equipment—Standing Wheelchair 407-408 Medical Supplies and Equipment—ThAIRapy Vest 409-411 01/31/2007 Index 3 Medical Policy Manual IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007 Medical Supplies and Equipment – Vagus Nerve Stimulator for Epilepsy 412-419 Medical Supplies and Equipment—Ventricular Assist Device (VAD) 420-431 Medical Supplies and Equipment—Wheelchair Accessories 432-448 Mental Health/Behavioral Health—Inpatient Services 449-459 Mental Health/Behavioral Health—Outpatient Services 460-470 Nursing Facilities 471-480 Nursing Services 481-490 Obstetric Care 491-513 Oncology 514-517 Oncology—Breast and Cervical Cancer 518-520 Ophthalmologic Services 521-534 Osteogenic Bone Growth Stimulator 535-539 Out-of-State Services 540-544 Pharmacy 545-566 Pharmacy—Botulinum Toxin Type A (BOTOX) 567-572 Pharmacy—Synagis® and Respigam® 573-576 Plasmapheresis 577-579 Podiatry 580-586 Radioimmunotherapy 587-595 Radiology 596-607 Radiology-PET Scans 608-614 Screening Services—Newborn Screening 615-618 01/31/2007 Index 4 Medical Policy Manual IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007 Smoking Cessation 619-622 Speech and Hearing 623-634 Substance Abuse 635-639 Surgery—Multiple Procedures/Same Operative Session 640-641 Surgery—Office Visits 642-643 Surgery—Plastic Reconstructive Surgery–Genitourinary Breast 644-649 Surgery—Plastic Reconstructive Surgery–Facial and Maxillofacial 650-671 Surgery—Plastic Reconstructive Surgery–Panniculectomy 672-675 Surgery—Removal of Implants 676-678 Surgery—Services Requiring Prior Authorization 679-680 Surgery—Surgeon and Assistant Surgeon, Same Provider 681-682 Surgery— Surgery and Anesthesia by the Same Provider 683-684 Surgery—Surgical Services 685-692 Surgery—Suture of Wounds 693-696 Surgery—Transplants 697-729 Therapy Services 730-740 Transportation Services 741-765 01/31/2007 Index 5 Medical Policy Manual IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007 I. PREFACE Health Care Excel, Incorporated, is a private, not-for-profit corporation established for the purpose of providing clinically-based, objective, and independent monitoring of the quality, appropriateness, and medical necessity of health care services. Health Care Excel, in its role as the Indiana Health Coverage Programs’ (IHCP) Medical Policy and Review Services contractor, is responsible for the Medical Policy (MP), Prior Authorization (PA), and Surveillance and Utilization Review (SUR) business functions. The Medical Policy Manual has been developed to ensure the success of the IHCP. This manual will be used as a reference handbook for the Family and Social Services Administration’s (FSSA) Office of Medicaid Policy and Planning (OMPP), Health Care Excel (HCE), and other State contractors and partners. Within the Medical Policy and Review Services contract, the formulation of, and support for, 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. 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 health care delivery system. This manual addresses the policies of the IHCP. The information regarding prior authorization, 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 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. 01/31/2007 Narrative 6 Medical Policy Manual IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007 II. INDIANA HEALTH COVERAGE PROGRAMS OVERSIGHT AND DELIVERY SYSTEMS A. Overview of the Indiana Family and Social Services Administration The Indiana Family and Social Services Administration (FSSA) is the umbrella agency responsible for administering Indiana’s public assistance programs. FSSA includes the offices and divisions listed below. ♦ Office of Medicaid Policy and Planning (OMPP) ♦ Division of Disability and Rehabilitative Services (DDARS) ♦ Division of Family Resources (DFR) ♦ Division of Mental Health and Addiction (DMHA) ♦ Division of Aging (IDA) The Director of Medicaid and Health Policy is responsible for OMPP. Other agencies that administer programs that impact IHCP include the Division of Disability and Rehabilitative Services, Division of Family Resources, Division of Mental Health and Addiction, and Division of Aging. These agencies are described below. ♦ Division of Disability and Rehabilitative Services (DADRS) 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. 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 the blind and visually impaired. ♦ Division of Family Resources (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. 01/31/2007 Narrative 7 Medical Policy Manual IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007 ♦

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