23 Miss. Code. R. 203-4.23 - Gastric Electrical Stimulation (GES)
A. The Division of
Medicaid covers Gastric Electrical Stimulation (GES) when used for the
treatment of chronic intractable (drug-refractory) nausea and vomiting
secondary to gastroparesis of diabetic or idiopathic etiology. The Food and
Drug Administration has approved the GES device through a humanitarian
exemption.
B. The beneficiary's
medical record must contain documentation that the implanting facility's
institutional review board (IRB) or equivalent governing body has approved the
implantation of the GES for the specific indications listed in Rule 4.23
A.
C. GES is considered medically
necessary if a beneficiary has a diagnosis of gastroparesis and meets all of
the following criteria:
1. Is refractory or
intolerant of two (2) out of three (3) classes of prokinetic medications and
two (2) out of three (3) antiemetic medications,
2. Has significantly delayed gastric emptying
as documented by standard scintigraphic imaging of solid food,
3. Has a poor nutritional status and enteral
feedings or total parental nutrition (TPN) is medically necessary,
and
4. Is age eighteen (18) through
seventy (70).
D. All
other indications including, but not limited to, the treatment of obesity, are
considered investigational and not medically necessary.
E. GES is not covered for beneficiaries who
are:
1. Pregnant,
2. Suffering from chemical
dependency,
3. Undergoing
peritoneal dialysis, or
4. Terminal
with a limited life expectancy based on a diagnosis of cancer.
F. Prior authorization by the
UM/QIO is required.
Notes
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No prior version found.