PA Lookup

Approximately 40 percent of all individuals with epilepsy have medically refractory seizures.

Primarily generalized seizures are the most common type of intractable seizures in children;

while in adults, complex partial seizures are the most common intractable seizure type. Medically refractory seizures are those seizures that are not completely controlled by medical therapy. That means that seizures continue to occur despite treatment with a maximally tolerated dose of a firstline anti-epilepsy drug (AED) as monotherapy or in at least one combination with an adjuvant medication. The terms "intractable" or "medically refractory" are interchangeable.

In the past 10 years, significant advances have occurred in surgical treatment for epilepsy and in medical treatment of epilepsy with newly developed and approved medications. Despite these advances, however, 25–50 percent of patients with epilepsy experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs. Vagus Nerve Stimulation (VNS) has been investigated as a treatment alternative in patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed.

Vagus Nerve Stimulation (VNS) is performed by an implantable stimulator as a treatment for refractory seizures. VNS treatment sends preprogrammed, intermittent electrical pulses through the vagus nerve in the neck to the brain. These pulses originate in a small generator device that is implanted in the chest. The exact mechanism of the antiepileptic effects of VNS are not fully understood, but the procedure may reduce the severity or the frequency of seizures in selected candidates who have an intact vagus nerve.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Exclusions

Medicaid covers VNS for the treatment of seizures when it is determined to be medically necessary because BOTH of the following criteria are met:

• a. The beneficiary has medically refractory* seizures; AND *Medically refractory means 1. seizures that occur in spite of therapeutic levels of anti-epileptic drugs; OR 2. seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse side effects.
• b. The beneficiary has failed or is not eligible for surgical treatment.

Additional Service Specifics

Inpatient Hospital, Outpatient Hospital, and Independent Diagnostic Testing Facility (IDTF) for services 95976, 95977, 95983, and 95984.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No.:1A-33
• Records Management and Documentation Manual

Approximately 40 percent of all individuals with epilepsy have medically refractory seizures.

Primarily generalized seizures are the most common type of intractable seizures in children;

while in adults, complex partial seizures are the most common intractable seizure type. Medically refractory seizures are those seizures that are not completely controlled by medical therapy. That means that seizures continue to occur despite treatment with a maximally tolerated dose of a firstline anti-epilepsy drug (AED) as monotherapy or in at least one combination with an adjuvant medication. The terms "intractable" or "medically refractory" are interchangeable.

In the past 10 years, significant advances have occurred in surgical treatment for epilepsy and in medical treatment of epilepsy with newly developed and approved medications. Despite these advances, however, 25–50 percent of patients with epilepsy experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs. Vagus Nerve Stimulation (VNS) has been investigated as a treatment alternative in patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed.

Vagus Nerve Stimulation (VNS) is performed by an implantable stimulator as a treatment for refractory seizures. VNS treatment sends preprogrammed, intermittent electrical pulses through the vagus nerve in the neck to the brain. These pulses originate in a small generator device that is implanted in the chest. The exact mechanism of the antiepileptic effects of VNS are not fully understood, but the procedure may reduce the severity or the frequency of seizures in selected candidates who have an intact vagus nerve.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Exclusions

Medicaid covers VNS for the treatment of seizures when it is determined to be medically necessary because BOTH of the following criteria are met:

• a. The beneficiary has medically refractory* seizures; AND *Medically refractory means 1. seizures that occur in spite of therapeutic levels of anti-epileptic drugs; OR 2. seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse side effects.
• b. The beneficiary has failed or is not eligible for surgical treatment.

Additional Service Specifics

Inpatient Hospital, Outpatient Hospital, and Independent Diagnostic Testing Facility (IDTF) for services 95976, 95977, 95983, and 95984.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No.:1A-33
• Records Management and Documentation Manual

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evicore site for specific requirements

Unit Value

1 unit = 30 minute

Limits

3 units (1 unit = 30 minutes) 90 minutes total.

Place of Service

Inpatient, Outpatient, Office, Laboratory

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-9, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

Carrier genetic screening is a type of genetic test carried out to detect a beneficiary who may be susceptible to producing offspring with inherited recessive single gene disorders. While carriers themselves are typically unaffected by the disease, they can transmit harmful genetic variations to their children. This screening can be conducted during the preconception or prenatal stages. Prenatal genetic tests consist of non-invasive prenatal testing (cell-free DNA testing, nuchal translucency ultrasound), and prenatal diagnostic testing (amniocentesis, CVS), which are aspects of prenatal care that focus on detecting problems with the pregnancy as early as possible. These may be anatomic and physiologic problems with the health of the zygote, embryo, or fetus, either before gestation even starts or as early in gestation as practicable. A screening test can detect problems such as neural tube defects, chromosome abnormalities, and gene mutations that would lead to genetic disorders and birth defects, such as spina bifida, cleft palate, Down syndrome, Tay–Sachs disease, sickle cell anemia, thalassemia, cystic fibrosis, muscular dystrophy, and fragile X syndrome. Some tests are designed to discover problems which primarily affect the health of the mother, such as Pregnancy-Associated Plasma Protein A (PAPPA) to predict pre-eclampsia or glucose tolerance tests to diagnose gestational diabetes. Screening tests can also detect anatomical defects such as hydrocephalus, anencephaly, heart defects, and amniotic band syndrome.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evicore site for specific requirements

Unit Value

1 unit = 30 minute

Limits

Medicaid shall not cover whole exome sequencing (WES) or whole genome sequencing (WGS) for ANY of the following scenarios:

• 1. When the CCP criteria are not met;
• 2. For uncomplicated autism spectrum disorder, developmental delay, and

mild to moderate global developmental delay;

• 3. For screening during pregnancy to diagnose fetal conditions;
• 4. For testing an embryo before implantation;
• 5. For screening genetic carriers;
• 6. Genetic disorders in every other circumstance; or
• 7. The test is used to determine ancestry.

Comparator genome sequence analysis requires that whole genome sequencing be performed simultaneously or have been previously performed. For whole genome sequencing beneficiary must be currently admitted to or recently discharged from a NICU or PICU

Length of Stay

once per pregnancy

Place of Service

Inpatient, Outpatient, Office, Laboratory

Additional Service Specifics

3 units (1 unit = 30 minutes) 90 minutes total.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-10, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

Gene expression refers to the mechanism through which the genetic information stored in a gene is transformed into a functional outcome. This predominantly transpires by transcribing RNA molecules that encode proteins or non-coding RNA molecules with alternative roles. Gene expression can be likened to an "on off switch," determining the timing and location of RNA molecules and proteins production, and a "volume control," dictating the quantity of these products generated. The process of gene expression is meticulously regulated and undergoes significant changes based on various conditions and cell types. Numerous RNA and protein products derived from genes play a role in governing the expression of other genes. The extent, timing, and manner in which a gene is expressed can be evaluated by assessing the functional activity of its product or observing the phenotype associated with the gene

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

Medicaid shall not cover whole exome sequencing (WES) or whole genome sequencing (WGS) for ANY of the following scenarios:

• 1. When the CCP criteria are not met;
• 2. For uncomplicated autism spectrum disorder, developmental delay, and

mild to moderate global developmental delay;

• 3. For screening during pregnancy to diagnose fetal conditions;
• 4. For testing an embryo before implantation;
• 5. For screening genetic carriers;
• 6. Genetic disorders in every other circumstance; or
• 7. The test is used to determine ancestry.

Comparator genome sequence analysis requires that whole genome sequencing be performed simultaneously or have been previously performed. For whole genome sequencing beneficiary must be currently admitted to or recently discharged from a NICU or PICU

Length of Stay

Once each primary cancer occurrence

Exclusions

Breast cancer gene expression profiling is not covered when CCP Specific criteria are not met or when used to predict response to specific chemotherapy regimens, for known metastatic cancer, for ductal carcinoma in situ when DCIS is the sole breast cancer histology, for the same tumor or more than one site when the primary tumor is multifocal, or to determine risk after the beneficiary has already decided to undergo or forego chemotherapy. Breast cancer management testing is also not covered when a gene expression profiling test other than the specified covered assays is used.

Thyroid nodule gene expression profiling is not covered when the additional criteria in the CCP are not met.

AlloMap is not covered for beneficiaries with a history of antibody-mediated rejection, for uses outside heart transplant rejection monitoring, or when results would not affect clinical management such as when a biopsy is already planned based on other risk factors.

Age Group Details

Thyroid nodule gene expression profiling is limited to beneficiaries age 21 years and older.

AlloMap molecular expression testing is limited to beneficiaries age 15 years and older.

Place of Service

Inpatient, Outpatient, Office, Laboratory.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-11, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

Next-generation sequencing, also referred to as next-gen sequencing, has revolutionized genetic research and healthcare by enabling the identification of genetic variations. This innovative technique involves determining the sequence of nucleotides, the building blocks of DNA, in a beneficiary’s genetic code, which is known as DNA sequencing. Two commonly employed methods, namely whole exome sequencing and whole genome sequencing, leverage advanced technologies that enable the rapid sequencing of substantial amounts of DNA. These approaches have significantly propelled the field of genetics and serve as invaluable tools in the detection of genetic disorders.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

Medicaid shall not cover whole exome sequencing (WES) or whole genome sequencing (WGS) for ANY of the following scenarios:

• 1. When the CCP criteria are not met;
• 2. For uncomplicated autism spectrum disorder, developmental delay, and

mild to moderate global developmental delay;

• 3. For screening during pregnancy to diagnose fetal conditions;
• 4. For testing an embryo before implantation;
• 5. For screening genetic carriers;
• 6. Genetic disorders in every other circumstance; or
• 7. The test is used to determine ancestry.

Comparator genome sequence analysis requires that whole genome sequencing be performed simultaneously or have been previously performed. For whole genome sequencing beneficiary must be currently admitted to or recently discharged from a NICU or PICU

Length of Stay

once in a lifetime

Age Group Details

Comparator genome sequence analysis is limited to beneficiaries 21 years of age and younger, Whole genome sequencing requires beneficiary to be 21 years of age or younger.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-12, Genetic Testing - Next Generation Sequencing (NGS)
• Records Management and Documentation Manual

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One CPT code = 1 unit of service.

Limits

Up to 9 unmanaged units of 96110: Developmental Testing - Limited.

Exclusions

• 1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
• 2. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
• 3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

Other Information

Modifier(s):

GT: Telehealth

How to Submit

N/A - No authorization is required

Resources

• State-Funded Outpatient Behavioral Health Services Definition
• Records Management and Documentation Manual

An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One service code = 1 unit of service

Limits

• 1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
• 2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• Records Management and Documentation Manual
• Person Centered Planning

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One service code = 1 unit of service

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 10
• Records Management and Documentation Manual
• Person Centered Planning

An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One CPT code = 1 unit of service.

Limits

Up to 9 unmanaged units of 96110: Developmental Testing - Limited.

Exclusions

• 1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
• 2. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
• 3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

Other Information

Modifier(s):

GT: Telehealth

How to Submit

N/A - No authorization is required

Resources

• State-Funded Outpatient Behavioral Health Services Definition
• Records Management and Documentation Manual

An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One service code = 1 unit of service

Limits

• 1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
• 2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• Records Management and Documentation Manual
• Person Centered Planning

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One service code = 1 unit of service

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 10
• Records Management and Documentation Manual
• Person Centered Planning

An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One CPT code = 1 unit of service.

Limits

Up to 9 unmanaged units of 96110: Developmental Testing - Limited.

Exclusions

• 1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
• 2. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
• 3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

Other Information

Modifier(s):

GT: Telehealth

How to Submit

N/A - No authorization is required

Resources

• State-Funded Outpatient Behavioral Health Services Definition
• Records Management and Documentation Manual

An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One service code = 1 unit of service

Limits

• 1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
• 2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.

Other Information

Must be used with 96112.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• Records Management and Documentation Manual
• Person Centered Planning

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One service code = 1 unit of service

Other Information

Must be used with 96112.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 10
• Records Management and Documentation Manual
• Person Centered Planning

Neuropsychological Testing is intended to assess cognition and behavior, examining the effects of any brain injury or neuropathological process that a person may have experienced.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One service code = 1 unit of service.

Limits

Up to 9 unmanaged units of testing administration

Length of Stay

Up to 9 unmanaged units of testing administration

Exclusions

• 1. Testing for the following is not covered: a) for the purpose of educational testing; b) if requested by the school or legal system, unless MN exists for the psych testing; c) if the proposed psych testing measures have no standardized norms or documented validity, OR; d) if the focus is not the symptoms of the DSM-5 diagnosis.
• 2. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
• 3. A Psychiatric Diagnostic Interview is not allowed on the same day as Psychological Testing when provided by the same provider.
• 4. May only be performed by licensed psychologists, licensed psychological associates, and qualified physicians.
• 5. Testing must include all elements detailed in the service definition.
• 6. The provider shall communicate and coordinate care with others providing care.

Level of Care

While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

How to Submit

N/A - No authorization is required

Resources

• State-Funded Outpatient Behavioral Health Services Service Definition
• Records Management and Documentation Manual