Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder

CP.BH.201

Ambetter

Policy revisions include:

• Additional language to Section I. Policy/Criteria, D. includes:
  • A score indicating moderately severe to severe OCD throughout the current course of treatment (or other standardized scale indicating moderately severe to severe OCD);
    • a. The Y-BOCS provides five rating dimensions for obsessions and compulsions: time spent or occupied; interference with functioning or relationships; degree of distress; resistance; and control (i.e., success in resistance)
  • The 10 Y-BOCS items are each scored on a four-point scale from 0 = "no symptoms" to 4 = "extreme symptoms." The sum of the first five items is a severity index for obsessions, and the sum of the last five an index for compulsions
  • A translation of total score into an approximate index of overall severity is:  Subclinical <8, Mild 8-15, Moderate 16-23, Severe 24-31 Extreme 32-40: a. Generally, a reduction in Y-BOCS score of 25% or 35% with a final Y-BOCS is considered the criteria for response to treatment
  • There is also a Children’s YBOCS however, these procedures are currently only approved for adults

• Changed all medical necessity statements to require medical director review
• Moved YBOC scale information in section I to the background

Durable Medical Equipment and Orthotics and Prosthetics Guidelines

CP.MP.107

CHIP and Ambetter

Policy revisions include:

• Added criteria for enclosed beds to “Other Equipment” section of policy
• Added references and codes E0316, E1399 and E0328 or E0329 (when combined with E0316 or E1399) for enclosed beds
• Replaced “investigational” with “not proven safe and effective” in the following sections: Pneumatic compression devices, neuromuscular stimulator, and peroneal nerve stimulators

Spinal Cord Stimulation

CP.MP.117

Medicaid (STAR,

STAR Health, STAR Kids, STAR+PLUS)

CHIP and Ambetter

Policy revisions include:

• Revised I.A.6&7, B.6&7, C.4&5, D.5&6, and E.8&9, to strengthen criteria for psychological evaluation and drug abuse

Enteral Nutrition TX.CP.MP.550

Medicaid (STAR,

STAR Health, STAR Kids, STAR+PLUS)

CHIP

Policy revisions include:

• In section III added F criteria for Immobilized Lipase Cartridges
• Added procedure code B4105 to the HCPCS chart
• Updated references

Transcranial Magnetic Stimulation

CP.BH.200

Ambetter

Policy revisions include:

• Annual review included a full literature review
• The following edits were made to the Policy/Criteria section I
  • Specified quantity of “20 sessions” in the section;
  • Removed “Failure of psychopharmacologic agents, both of the following”
  • Removed mono-or poly-drug therapy with antidepressants involving
  • Added c.  “at least two recognized augmentation treatments have been attempted such as Lithium, Thyroid Hormone, Second generation Antipsychotic augmentation, dual antidepressant approaches, etc”   
• Removed “this initial request can be reviewed for up to 20 TMS sessions in Section 1. Item 9
• Included new Section III. “Requests for TMS taper: For patients who demonstrated after 30 TMS sessions >50% reduction in baseline severity scores who are approaching PHQ-9 scores of 9 or for those who have a history of good response to TMS followed by relapse into depression within a 6 months period, authorization of up to 6 taper TMS additional sessions over a period 3 weeks will be considered”
• Removed from Section I
  •  For patients who demonstrated less than or equal to 50% reduction in baseline severity scores who are approaching PHQ-9 scores of 9 or for those who have a history of good responses to TMS followed by relapse into depression over a 6 month period, authorization of up to 6 taper TMS sessions over a period 3 weeks will be considered.  Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT, an accelerated, high-dose, iTBS protocol with fcMRI-guided targeting, was well tolerated and safe in a sample size of 21 patients with TRD who received fifty iTBS sessions (1,800 pulses per session, 50-minute intersession interval) delivered as 10 daily sessions over 5 consecutive days at 90% resting motor threshold (adjusted for cortical depth) (Eleanor J. Cole et al., 2020). Nineteen of 21 participants (90.5%) met remission criteria (defined as a score <11 on the MADRS). In the intent-to-treat analysis, 19 of 22 participants (86.4%) met remission criteria. Neuropsychological testing demonstrated no negative cognitive side effects to the background section
• Changed medical necessity statements to require review by a medical director