Tennessee Code Title 71. Welfare § 71-5-172

(a) As used in this section, “managed care organization” or “MCO” means a health maintenance organization, behavioral health organization, or managed health insurance issuer that participates in the TennCare program.

(b) The division of TennCare may require every group health insurance contract, and every group hospital or medical expense insurance policy, plan, and group policy delivered, issued for delivery, amended, or renewed in this state by an MCO on or after January 1, 2026, to provide coverage for physician prescribed treatment, deemed medically necessary pursuant to § 71-5-144, of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS).  Such treatment may include antibiotics, medication, behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.  Benefits provided under this section are not subject to a greater co-payment, deductible, or coinsurance than another similar benefit provided by the MCO.  Coverage authorization must be provided in a timely manner consistent with department of commerce and insurance rules for urgent treatments adopted pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.

(c) A group or individual policy of accident and health insurance or managed care must not deny or delay coverage for medically necessary treatment under this section solely because the recipient previously received treatment, including the same or similar treatment, for PANDAS or PANS, or because the recipient has been diagnosed with or received treatment for their condition under a different diagnostic name, such as autoimmune encephalopathy.  For the purposes of this section, when medically necessary pursuant to § 71-5-144, coverage of PANDAS and PANS may take into consideration the treatment recommendations developed by a medical professional consortium convened for the purposes of researching, identifying, and publishing best practice standards for diagnosis and treatment of such disorders that are accessible for medical professionals and are based on evidence of positive patient outcomes.  This section does not prevent an MCO from requesting treatment notes and anticipated duration of treatment and outcomes.

(d) For billing and diagnosis purposes, PANDAS and PANS must be coded as autoimmune encephalitis until the American Medical Association and the centers for medicare and medicaid services create and assign a specific code for PANDAS and PANS.  Thereafter, PANDAS and PANS may be coded as autoimmune encephalitis, PANDAS, or PANS.  If a new common name or code is utilized for PANDAS and PANS, then this section applies to patients with conditions under that new common name or code.