ADMINISTRATIVE POLICY STATEMENT
OHIO MEDICAID
Policy Name
Policy Number
Date Effective
Impacted Cerumen Removal
AD-1059
11/01/2021
Policy Type
Medical
ADMINISTRATIVE
Pharmacy
Reimbursement
Administrative Policy Statements prepared by CareSource and its affiliates are derived from literature based on and supported by
clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y
standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those
health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and
without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of
a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local
area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically
necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements,
Provider Manuals, Member Handbooks, and/or other policies and procedures.
Administrative Policy Statements prepared by CareSource and its affili ates do not ensure an authorization or payment of
services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the
Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e.,
Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the
determination.
According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a
behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical
conditions as covered under this policy.
Table of Contents
Administrative Policy Statement ................................................................................................. 1
A. Subject ................................................................................................................................ 2
B. Background ......................................................................................................................... 2
C. Definitions ........................................................................................................................... 2
D. Policy .................................................................................................................................. 2
E. Conditions of Coverage ....................................................................................................... 3
F. Related Policies/Rules ........................................................................................................ 3
G. Review/Revision History ..................................................................................................... 3
H. References ......................................................................................................................... 3
