Clinical & Payment Policies
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
All policies found in the PA Health & Wellness Clinical Policy Manual apply to PA Health & Wellness members. Policies in the PA Health & Wellness Clinical Policy Manual may have either a PA Health & Wellness or a “Centene” heading. PA Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a PA Health & Wellness clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling PA Health & Wellness. In addition, PA Health & Wellness may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by PA Health & Wellness.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
| Policy # | Policy Name | Last Review Date | Purpose |
|---|---|---|---|
| CP.CPC.01 | Clinical Policy Committee | 7/31/2018 | Clinical Policy Committee Process |
| CP.CPC.02 | Clinical Policy Web Posting | 8/24/2018 | Corporate and health plan responsibilities for initial posting and maintenance of clinical, payment, and specialty drug policies to public heatlh plan websites. |
| CP.CPC.03 | Preventive Health and Clinical Practice Guideline Policy | 9/19/18 | The process by which the Plan adopts/develops and distributes preventive health and clinical practice guidelines to assist practitioners and members make decisions about appropriate health care for specific clinical circumstances. |
| CP.MP.100 | Allergy Testing and Therapy | 1/31/18 | Medical necessity guidelines for allergy testing and treatment |
| CP.MP.101 | Donor lymphocyte infusion | 10/31/18 | Medical necessity guidelines for donor lymphocyte infusion |
| CP.MP.102 | Pancreas transplant | 2/28/18 | Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant. |
| CP.MP.103 | Fractional exhaled nitric oxide | 12/29/17 | Medical necessity guidelines for use of fractional exhaled nitric oxide (FeNO) in asthma diagnosis and care |
| CP.MP.104 | Applied Behavioral Analysis for Autism | 1/31/18 | Medical necessity guidelines for applied behavioral analysis for autism |
| CP.MP.105 | Digital electroencephalography spike analysis | 1/31/18 | Medical necessity guidelines for digital EEG spike analysis |
| CP.MP.106 | Endometrial ablation | 7/31/18 | Medical necessity guidelines for endometrial ablation |
| CP.MP.107 | Durable Medical Equipment (DME) | 7/31/18 | Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics |
| CP.MP.108 | Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia | 2/28/18 | Medical necessity guidelines for allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia |
| CP.MP.109 | Panniculectomy | 3/31/18 | Medical necessity guidelines for panniculectomy |
| CP.MP.110 | Bronchial Thermoplasty | 3/31/18 | Medical necessity guidelines for bronchial thermoplasty |
| CP.MP.111 | Zika Virus Testing | 5/31/18 | Medical necessity guidelines for diagnostic testing for Zika Virus with the rRT-PCR and MAC-ELISA tests |
| CP.MP.113 | Holter Monitors | 6/30/18 | Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring |
| CP.MP.114 | Disc Decompression Procedures | 5/31/18 | Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression |
| CP.MP.115 | Discography | 6/30/18 | Medical necessity guidelines for discography |
| CP.MP.116 | Lysis of Epidural Lesions | 5/31/18 | Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty |
| CP.MP.117 | Spinal Cord Stimulation | 9/30/18 | Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation |
| CP.MP.119 | Balloon sinus ostial dilation | 9/30/18 | Medical necessity guidelines for balloon sinus ostial dilation for chronic rhinosinusitus and recurrent acute rhinosinusitis |
| CP.MP.12 | Vagus Nerve Stimulation | 8/31/18 | Medical necessity guidelines for vagus nerve stimulation. |
| CP.MP.120 | Pediatric Liver Transplant | 4/30/18 | Medical necessity guidelines for pediatric liver transplant for end-stage liver disease |
| CP.MP.121 | Homocysteine testing | 5/31/18 | Medical necessity guidelines for homocysteine testing |
| CP.MP.123 | Laser therapy for skin conditions | 6/30/18 | Medical necessity guidelines for excimer laser based targeted phototherapy |
| CP.MP.124 | ADHD Assessment and Treatment | 5/31/18 | Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD) |
| CP.MP.125 | DNA analysis of stool to screen for colorectal cancer | 7/31/18 | Medical necessity guidelines for DNA analysis of stool for colorectal cancer |
| CP.MP.126 | Sacroiliac joint fusion | 6/30/18 | Medical necessity guidelines for sacroiliac joint fusion |
| CP.MP.127 | Total artificial heart | 12/29/18 | Medical necessity guidelines for a total artificial heart (TAH) |
| CP.MP.128 | Optic nerve decompression surgery | 8/31/2018 | Medical necessity guidelines for optic nerve sheath decompression surgery |
| CP.MP.129 | Fetal surgery in utero for prenatally diagnosed malformations | 10/31/2018 | Medical necessity guidelines for performing fetal surgery in utero |
| CP.MP.130 | Fertility preservation | 9/30/2018 | Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility |
| CP.MP.131 | Essure Removal | 10/31/2018 | Medical necessity guidelines for removal of Essure®, a permanent birth control device |
| CP.MP.132 | Heart-Lung Transplant | 4/30/2018 | Medical necessity guidelines for heart-lung transplantation |
| CP.MP.133 | Posterior tibial nerve stimulation for voiding dysfunction | 8/31/2018 | Medical necessity guidelines for posterior tibial nerve stimulation for the treatment of overactive bladder |
| CP.MP.134 | Evoked Potential Testing | 10/31/2018 | Medical necessity guidelines for evoked potential testing |
| CP.MP.135 | Fecal calprotectin assay | 11/30/2017 | Medical necessity guidelines for fecal calprotectin assay for diagnosis and screening of inflammatory bowel disease (IBD) |
| CP.MP.136 | Home Birth | 10/31/2018 | Medical necessity guidelines for planned home birth |
| CP.MP.137 | Fecal incontinence treatments | 12/29/2017 | Medical necessity guidelines for fecal incontinence treatments |
| CP.MP.138 | Pediatric heart transplant | 1/31/2018 | Medical necessity guidelines for pediatric heart transplant |
| CP.MP.139 | Low-frequency ultrasound therapy for wound management | 1/31/2018 | Medical necessity guidelines for low-frequency ultrasound therapy for wound management |
| CP.MP.140 | EpiFix Wound Treatment | 3/31/2018 | Medical necessity guidelines for EpiFix® wound treatment |
| CP.MP.141 | Non-myeloablative allogeneic stem cell transplants | 2/28/2018 | Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants |
| CP.MP.142 | Urinary Incontinence Devices and Treatments | 9/24/2018 | Medical necessity guidelines for treatments and devices for urinary incontinence including sacral neuromodulation (sacral nerve stimulation) and urethral bulking agents |
| CP.MP.143 | Wireless Motility Capsule | 3/31/2018 | Medical necessity guidelines for wireless motility capsule |
| CP.MP.144 | Mechanical Stretching Devices for Joint Stiffness and Contracture | 3/31/2018 | Medical necessity guidelines for mechanical stretch devices, including low-load prolonged-duration stretch (LLPS) devices/dynamic stretch devices, static progressive (SP) stretch devices, and patient-actuated serial stretch devices. |
| CP.MP.145 | Electric Tumor Treating Fields | 3/31/2018 | Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM) |
| CP.MP.146 | Sclerotherapy for Varicose Veins | 4/30/2018 | Medical necessity guidelines for sclerotherapy for treatment of vericose veins |
| CP.MP.147 | Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention | 5/31/2018 | Medical necessity guidelines for left atrial appendage closure devices for stroke prevention. |
| CP.MP.148 | Radial Head Implant | 10/19/2018 | Medical necessity guidelines for radial head implant, also known as arthroplasty |
| CP.MP.149 | Testing for rupture of fetal membranes | 6/30/2018 | Medical necessity guidelines for testing for rupture of fetal membranes |
| CP.MP.150 | Home phototherapy for neonatal hyperbilirubinemia | 10/31/2018 | Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia |
| CP.MP.151 | Transcatheter closure of patent foramen ovale | 12/29/2017 | Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder. |
| CP.MP.152 | Measurement of serum 1,25-dihydroxyvitamin D | 12/29/2017 | Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D |
| CP.MP.153 | H. Pylori serology testing | 12/29/2017 | Medical necessity guidelines for H. pylori serology testing |
| CP.MP.154 | Thyroid hormones and insulin testing in pediatrics | 12/29/2017 | Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics |
| CP.MP.155 | Electroencephalography in the evaluation of headache | 12/29/2017 | Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches |
| CP.MP.156 | Cardiac biomarker testing | 3/30/2018 | Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction |
| CP.MP.157 | 25-hydroxyvitamin D testing in children and adolescents | 12/29/2017 | Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents |
| CP.MP.158 | Ambulatory Surgery Center Optimization | 2/16/2018 | Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services |
| CP.MP.159 | Infusion Therapy Site of Care Optimization | 10/31/2018 | Medical necessity criteria for IV or injectable therapy services in an outpatient setting. |
| CP.MP.160 | Implantable Wireless Pulmonary Artery Pressure Monitoring | 4/30/2018 | Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring |
| CP.MP.161 | Monitored Anesthesia Care for Gastrointestinal Endoscopy | 5/31/2018 | Medical necessity guidelines for monitored anesthesia care (MAC) for gastrointestinal endoscopy |
| CP.MP.162 | Tandem Transplant | 7/31/2018 | Medical necessity guidelines for tandem transplant |
| CP.MP.163 | Total Parenteral Nutrition and Intradialytic Parenteral Nutrition | 4/30/2018 | Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN) |
| CP.MP.164 | Caudal or Interlaminar Epidural Steroid Injections for Pain Management | 8/31/2018 | Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management |
| CP.MP.165 | Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management | 8/31/2018 | Medical necessity criteria for selective nerve root blocks and transforaminal epidural injections for pain management |
| CP.MP.166 | Sacroiliac Joint Interventions for Pain Management | 8/31/2018 | Medical necessity criteria for sacroiliac joint interventions for pain management |
| CP.MP.167 | Intradiscal Steroid Injections for Pain Management | 8/31/2018 | Medical necessity criteria for intradiscal steroid injections for pain management |
| CP.MP.168 | Biofeedback | 5/31/2018 | Medical necessity guidelines for biofeedback therapy |
| CP.MP.169 | Trigger Point Injections for Pain Management | 8/31/2018 | Medical necessity criteria for trigger point injections for pain management |
| CP.MP.170 | Nerve Blocks for Pain Management | 8/31/2018 | Medical necessity criteria for nerve blocks for pain management |
| CP.MP.171 | Facet Joint Interventions for pain management | 9/14/2018 | Medical necessity guidelines for facet joint injections and facet joint radiofrequency neurotomy (ablation) for lumbar, thoracic, and cervical pain management |
| CP.MP.22 | Stereotactic Body Radiation Therapy | 1/31/2018 | Medical necessity guidelines for stereotactic body radiation therapy |
| CP.MP.24 | Multiple Sleep Latency Testing | 4/30/2018 | Medical necessity criteria for multiple sleep latency testing (MSLT) |
| CP.MP.26 | Articular Cartilage Defect Repairs | 4/30/2018 | Medical necessity guidelines for articular cartilage defect repairs |
| CP.MP.27 | Hyperbaric Oxygen Therapy | 10/31/2018 | Medical necessity guidelines for hyperbaric oxygen therapy |
| CP.MP.31 | Cosmetic and Reconstructive Surgery | 3/31/2018 | Medical necessity guidelines for cosmetic and reconstructive surgery |
| CP.MP.34 | Hyperemesis gravidarum treatment | 3/30/2018 | Medical necessity guidelines for the treatment of hyperemesis gravidarum, including intravenous and subcutaneous infusions of ondansetron and metoclopramide, enteral therapy, and total parenteral nutrition (TPN) |
| CP.MP.36 | Experimental Technologies | 6/30/2018 | General medical necessity guidelines to use in determining coverage of experimental or investigational or potentially experimental or investigational medical and behavioral health technologies. These guidlines are to be used only when there is no other policy, criteria, or coverage statement available. |
| CP.MP.38 | Ultrasound in Pregnancy | 6/30/2018 | Medical necessity guidelines for ultrasound use in pregnancy. |
| CP.MP.40 | Gastric electrical stimulation | 9/30/2018 | Medical necessity guidelines for gastric electrical stimulation |
| CP.MP.43 | Functional MRI | 9/30/2018 | Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI). |
| CP.MP.46 | Ventricular Assist Devices | 2/28/2018 | Medical necessity guidelines for ventricular assist devices. |
| CP.MP.49 | Therapy Services (PT/OT/ST) | 6/22/2018 | Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment. |
| CP.MP.50 | Outpatient testing for drugs of abuse | 7/31/2018 | Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. |
| CP.MP.51 | Reduction mammoplasty and gynecomastia surgery | 7/31/2018 | Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men |
| CP.MP.53 | Ferriscan R2-MRI | 10/31/2018 | Medical necessity guidelines for use of the FerriScan R2-MRI |
| CP.MP.54 | Hospice Services | 4/30/2018 | Medical necessity guidelines for hospice services |
| CP.MP.55 | Assisted Reproductive Technology | 3/31/2018 | Medical necessity guidelines for assisted reproductive technology |
| CP.MP.56 | Ventriculectomy and cardiomyoplasty | 2/28/2018 | Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures |
| CP.MP.57 | Lung Transplantation | 10/31/2018 | Medical necessity guidelines for review of lung transplantation requests |
| CP.MP.58 | Intestinal and multivisceral transplant | 6/30/2018 | Medical necessity guidelines for the review of intestinal and multivisceral transplant requests. |
| CP.MP.61 | Dental Anesthesia | 4/30/2018 | Medical necessity guidelines for dental anesthesia |
| CP.MP.62 | Hyperhidrosis treatments | 2/28/2018 | Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands |
| CP.MP.68 | Medical Necessity Criteria | 6/30/2018 | This policy identifies the medical necessity guidelines used by the health plan and related definitions |
| CP.MP.69 | Intensity-Modulated Radiotherapy | 2/28/2018 | Medical necessity guidelines for intensity-modulated radiotherapy (IMRT) |
| CP.MP.70 | Proton and neutron beam therapy | 9/24/2018 | Medical necessity guidelines for proton beam and neutron beam radiation therapy |
| CP.MP.71 | Long Term Care Placement Criteria | 4/30/2018 | Medical necessity guidelines for long term care (LTC) placement |
| CP.MP.81 | NICU discharge guidelines | 8/31/2018 | Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home. |
| CP.MP.82 | NICU Apnea Bradycardia Guidelines | 5/31/2018 | Medical necessity guidelines to assist with continuing care, discharge planning, and the transition to outpatient and home care of babies affected by ongoing neonatal apnea and bradycardia events |
| CP.MP.83 | Carrier Screening in Pregnancy | 5/31/2018 | Medical necessity guidelines for carrier screening in pregnancy |
| CP.MP.84 | Cell-free Fetal DNA Testing | 4/30/2018 | Medical necessity guidelines for cell-free fetal DNA testing |
| CP.MP.85 | Neonatal sepsis management | 7/31/2018 | Medical necessity guidelines for neonates requiring comprehensive assessment, treatment, and discharge planning for neonatal intensive care unit (NICU) stays related to sepsis management |
| CP.MP.86 | Neonatal abstinence syndrome guidelines | 9/30/2018 | Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU) |
| CP.MP.87 | Inhaled nitric oxide | 9/30/2018 | Medical necessity guidelines for the use of inhaled nitric oxide (iNO) |
| CP.MP.88 | Sickle cell disease observation | 7/31/2018 | Medical necessity criteria for observation stay for sickle cell disease |
| CP.MP.89 | Genetic Testing | 4/30/2018 | Medical necessity criteria for genetic testing |
| CP.MP.91 | Obstetrical Home Health Care Programs | 1/31/2018 | Medical necessity guidelines for OB home health programs |
| CP.MP.94 | Clinical Trials | 10/31/2018 | Medical necessity guidelines for routine costs of clinical trials |
| CP.MP.95 | Gender reassignment surgery | 10/31/2018 | Medical necessity guidelines for surgery for the treatment of gender dysphoria |
| CP.MP.96 | Ambulatory EEG | 8/31/2018 | Medical necessity guidelines for the use of ambulatory electroencephalogram (EEG) testing in the outpatient setting |
| CP.MP.97 | Testing for select genitourinary conditions | 8/31/2018 | Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis |
| CP.MP.98 | Urodynamic testing | 9/30/2018 | Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction |
| CP.MP.99 | Wheelchair seating | 9/30/2018 | Medical necessity guidelines for special wheelchair seating and cushions |