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 and Wellness Clinical Policy Manual apply to PA Health and Wellness members. Policies in the PA Health and Wellness Clinical Policy Manual may have either a PA Health and Wellness or a “Centene” heading. PA Health and Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a PA Health and 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 and Wellness. In addition, PA Health and 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 and Wellness.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
A-H
- Acupuncture PA.CP.MP.92 July 2023 (PDF)
- AHC Transplants SCA Thalassemia PA.CP.MP.108 July 2023 (PDF)
- Allergy Testing and Therapy PA.CP.MP.100 July 2023 (PDF)
- Ambulatory Surgery Center Optimization PA.CP.MP.158 v3.2022 (PDF)
- Articular Cartilage Defect Repairs PA.CP.MP.26 v3.2022 (PDF)
- Bariatric Surgery PA.CP.MP.37 July 2023 (PDF)
- Biofeedback PA.CP.MP.168 v2.2022 (PDF)
- Bone-Anchored Hearing Aid PA.CP.MP.93 v2.2021 (PDF)
- Bronchial Thermoplasty PA.CP.MP.110 v1.2023 (PDF)
- Burn Surgery PA.CP.MP.186 v2.2022 (PDF)
- Cardiac Biomarker Testing PA.CP.MP.156 v3.2022 (PDF)
- Caudal or Interlaminar ESIs PA.CP.MP.164 v2.2022 (PDF)
- Clinical Trials PA.CP.MP.94 v2.2021 (PDF)
- Cochlear Implant Replacements PA.CP.MP.14 July 2023 (PDF)
- Cosmetic and Reconstructive Surgery PA.CP.MP.31 July 2023 (PDF)
- Dental Anesthesia PA.CP.MP.61 v2.2022 (PDF)
- Diaphragmatic Phernic Nerve Simulation PA.CP.MP.203 v2.2022 (PDF)
- Disc Decompression Procedures PA.CP.MP.114 v1. July 2023 (PDF)
- Discography PA.CP.MP.115 v2.2022 (PDF)
- Digital EEG Analysis PA.CP.MP.105 v2.2022 (PDF)
- DME Outpatient Criteria PA.CP.MP.107 v1. July 2023 (PDF)
- Donor Lymphocyte Infusion PA.CP.MP.101 v1. July 2023 (PDF)
- EEG Headache PA.CP.MP.155 v1. July 2023 (PDF)
- Electric Tumor Treatment Fields PA.CP.MP.145 v2.2022 (PDF)
- Endometrial Ablation PA.CP.MP.106 v1. July 2023 (PDF)
- Evoked Potentials PA.CP.MP.134 v1. July 2023 (PDF)
- Experimental Technologies PA.CP.MP.36 v2.2022 (PDF)
- Facet Joint Interventions PA.CP.MP.171 v1. July 2023 (PDF)
- Fecal Incontinence Treatments PA.CP.MP.137 v2.2022 (PDF)
- Ferriscan R2 MRI PA.CP.MP.53 July 2023 (PDF)
- Fertility Preservation PA.CP.MP.130 v2.2022 (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations PA.CP.MP.129 v1.July 2023 (PDF)
- Functional MRI PA.CP.MP.43 v2.2022 (PDF)
- Gastric Electrical Stimulation PA.CP.MP.40 v2.2022 (PDF)
- Gender Affirming Surgery PA.CP.MP.95 July 2023 (PDF)
- Heart Lung Transplant PA.CP.MP.132 v1. July 2023 (PDF)
- Holter Monitors PA.CP.MP.113 v1. July 2023 (PDF)
- Homocysteine Testing PA.CP.MP.121 v1. July 2023 (PDF)
- Hospice Service PA.CP.MP.54 v2.2022 (PDF)
- H Pylori Serology Testing PA.CP.MP.153 v1. July 2023 (PDF)
- Hyperhidrosis Treatments PA.CP.MP.62 July 2023 (PDF)
I-Q
- Implantable Intrathecal Pain Pump PA.CP.MP.173 v2.2022 (PDF)
- Implantable Loop Recorder PA.CP.MP.243 v1. July 2023 (PDF)
- Implantable Wireless PAP Monitoring PA.CP.MP.160 v1. July 2023 (PDF)
- Intensity-Modulated Radiotherapy PA.CP.MP.69 v2.2022 (PDF)
- Intestinal and Multivisceral Transplant PA.CP.MP.58 v2.2022 (PDF)
- Intradiscal Steroid Injections PA.CP.MP.167 v2.2022 (PDF)
- Laser Therapy for Skin Conditions PA.CP.MP.123 v1. July 2023 (PDF)
- Long Term Care Placement PA.CP.MP.71 July 2023 (PDF)
- Low Frequency US Therapy for Wound Management PA.CP.MP.139 v1. July 2023 (PDF)
- Lung Transplantation PA.CP.MP.57 July 2023 (PDF)
- Lysis of Epidural Lesions PA.CP.MP.116 v1. July 2023 (PDF)
- Measurement of Serum 1,25 dihydroxyvitamin D PA.CP.MP.152 v1. July 2023 (PDF)
- Mechanical Stretch Devices PA.CP.MP.144 v1. July 2023 (PDF)
- Multiple Sleep Latency Testing PA.CP.MP.24 July 2023 (PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) PA.CP.MP.48 July 2023 (PDF)
- Nerve Blocks PA.CP.MP.170 v1. July 2023 (PDF)
- Non-Invasive Home Ventilator PA.CP.MP.184 v2.2022 (PDF)
- Nonmyeloablative Allogenic Stem Cell Transplants PA.CP.MP.141 v1. July 2023 (PDF)
- Optic Nerve Decompression Surgery PA.CP.MP.128 v1. July 2023 (PDF)
- Outpatient Testing for DOA PA.CP.MP.50 v2.2022 (PDF)
- Pancreas Transplantation PA.CP.MP.102 v2.2022 (PDF)
- Panniculectomy PA.CP.MP.109 v1.July 2023 (PDF)
- Percutaneous LAA Device Stroke Prevention PA.CP.MP.147 v1. July 2023 (PDF)
- Physical Occupational and Speech Therapy Services PA.CP.MP.49 v2.2021 (PDF)
- Posterior Nerve Stimulation for Voiding Dysfunction PA.CP.MP.133 v2.2022 (PDF)
- Proton and Neutron Beam Therapy PA.CP.MP.70 v1. July 2023 (PDF)
- Pulmonary Function Testing PA.CP.MP.242 v1. July 2023 (PDF)
R-Z
- Radial Head Implant PA.CP.MP.148 v2.2022 (PDF)
- Reduction Mammoplasty Gynecomastia Surgery PA.CP.MP.51 v1. July 2023 (PDF)
- Sacroiliac Joint Fusion PA.CP.MP.126 v2.2022 (PDF)
- Sacroiliac Joint Interventions PA.CP.MP.166 v2.2022 (PDF)
- Sclerotherapy for Varicose Veins PA.CP.146 v1. July 2023 (PDF)
- Selective Dorsal Rhizotomy for Spasticity PA.CP.MP.174 v1. July 2023 (PDF)
- Selective Nerve Root Blocks and Transoraminal Epidural Steroid Injections PA.CP.MP.165 v2.2022 (PDF)
- Short Inpatient Hospital Stay PA.CP.MP.182 v2.2022 (PDF)
- Skin Substitutes for Chronic Wounds PA.CP.MP.185 v1. July 2023 (PDF)
- SNF Leveling PA.CP.MP.206 v2.2022 (PDF)
- Stereotactic Body Radiation Therapy PA.CP.MP.22 v3.2022 (PDF)
- Spinal Cord Stimulation PA.CP.MP.117 v2.2022 (PDF)
- Tandem Transplant PA.CP.MP.162 v3.2022 (PDF)
- Total Artificial Heart PA.CP.MP.127 v2.2022 (PDF)
- Total Par Nurtr Intradialytic PA.CP.MP.163 v1. July 2023 (PDF)
- Transcatheter Closure of Patent Foramen Ovale PA.CP.MP.151 v1. July 2023 (PDF)
- Trigger Point Injections PA.CP.MP.169 v3.2022 (PDF)
- Ultrasound in Pregancy PA.CP.MP.38 v1. July 2023 (PDF)
- Urinary Incontinence Devices Treatments PA.CP.MP.142 v2.2021 (PDF)
- Urodynamic Testing PA.CP.MP.98 v1. July 2023 (PDF)
- Vagus Nerve Stimulation PA.CP.MP.12 v1. July 2023 (PDF)
- Ventricular Assist Devices PA.CP.MP.46 v1. July 2023 (PDF)
- Wheelchair Seating PA.CP.MP.99 v1. July 2023 (PDF)
- Wireless Motility Capsule PA.CP.MP.143 v1. July 2023 (PDF)
A-H Policies
- 3 Day Payment Window Policy PA.CC.PP.500 (PDF)
- 30 Day Readmission PA.CC.PP.501 (PDF)
- Add on Policy PA.CC.PP.030 (PDF)
- Assistant Surgeon PA.CC.PP.029 (PDF)
- Bilateral Services PA.CC.PP.037 (PDF)
- Cerumen Removal PA.CC.PP.008 (PDF)
- Clean Claims PA.CC.PP.021 Clean Claims (PDF)
- CLIA PA.CC.PP.022 (PDF)
- Clinic Facility Charge PA.CC.PP.059 (PDF)
- Clinical Validation of Modifier 59 PA.CC.PP.014 (PDF)
- Code Editing PA.CC.PP.011 (PDF)
- Cosmetic Procedures PA.CC.PP.024 (PDF)
- Distinct Procedural Modifiers PA.CC.PP.020 (PDF)
- Duplicate Primary Code Billing PA.CC.PP.044 (PDF)
- ED Facility EM Policy PA.CC.PP.064 (PDF)
- EM Bundling with Labs and Radiology PA.CC.PP.010 (PDF)
- EM Medical Decision Making PA.CC.PP.051 (PDF)
- Hospital Visit Codes Billed with Labs PA.CC.PP.023 (PDF)
I-Q Policies
- Inpatient Consultation PA.CC.PP.038 (PDF)
- Inpatient Only Procedures PA.CC.PP.018 (PDF)
- Intravenous Hydration PA.CC.PP.012 (PDF)
- Laser Therapy for Skin Conditions PA.CP.MP.123 (PDF)
- Leveling of Care Evaluation and Management Overcoding (NEW) PA.CC.PP.066 (PDF)
- Leveling of Care Policy Professional PA.CC.PP.058 (PDF)
- Maximum Units of Service PA.CC.PP. 007 (PDF)
- Moderate Conscious Sedation PA.CC.PP.015 (PDF)
- Modifier 25 PA.CC.PP.013 (PDF)
- Modifier DOS Validation (PA.CC.PP.034) (PDF)
- Modifier to Procedure Code Validation PA.CC.PP.028 (PDF)
- Multiple CPT Codes Replacement PA.CC.PP.033 (PDF)
- Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (NEW) PA.CC.PP.065 (PDF)
- NCCI Unbundling PA.CC.PP.031 (PDF)
- Never Paid Events PA.CC.PP.017 (PDF)
- New Patient PA.CC.PP.036 (PDF)
- Not Medically Necessary Inpatient Professional Services (PDF)
- Outpatient Consulation PA.CC.PP.039 (PDF)
- Pelvic and Transabdominal Ultrasound (PDF)
- Physicians Consultation Services PA.CC.PP.054 (PDF)
- Physicians Office Laboratory Testing PA.CC.PP.055 (PDF)
- Place of Service Mismatch PA.CC.PP.063 (PDF)
- Postoperative Visits PA.CC.PP.042 (PDF)
- Preoperative Visits PA.CC.PP.041 (PDF)
- Problem Oriented Visits with Preventative Services PA.CC.PP.057 (PDF)
- Problem Oriented Visits with Surgical Procedures PA.CC.PP.052 (PDF)
- Professional Component Modifier PA.CC.PP.027 (PDF)
- Professional Services Billed with Labs PA.CC.PP.019 (PDF)
- Pulse Oximetry with Office Visits PA.CC.PP.025 (PDF)
R-Z Policies
- Reporting the Global Maternity Package PA.CC.PP.016 (PDF)
- Robotic Surgeries PA.CC.PP.050 (PDF)
- Same Day Visits PA.CC.PP.040 (PDF)
- Sleep Studies Place of Service Rev PA.CC.PP.035 (PDF)
- Status B Bundled Services PA.CC.PP.046 (PDF)
- Status P Bundled Services PA.CC.PP.049 (PDF)
- Supplies Same Day as Surgery PA.CC.PP.032 (PDF)
- Transgender Related Services PA.CC.PP.047 (PDF)
- Unbundled Professional Services PA.CC.PP.043 (PDF)
- Unbundled Surgical Procedures PA.CC.PP.045 (PDF)
- Unlisted Procedure Codes PA.CC.PP.009 (PDF)
- Urine Specimen Validity Testing PA.CC.PP.056 (PDF)
- Wheelchairs and Accessories (PDF)
Payment Policies
- PHW Provider Payment Policy Notification November 11, 2020 (PDF)
- PHW Provider Payment Policy Notification August 14, 2020 (PDF)
- PHW Provider Payment Policy Notification April 22, 2020 (PDF)
- PHW Provider Payment Policy Notification December 20, 2019 (PDF)
- PHW Provider Payment Policy Notification October 10, 2019 (PDF)
Pharmacy Policies
Pennsylvania Medical Assistance Program's Statewide Preferred Drug List (PDL) Pharmacy Policies
A
- Acne Agents, Oral v1.2023 (PDF)
- Acne Agents, Topical v1.2022 (PDF)
- Alcohol Use Disorder Agents v1.2023 (PDF)
- Alzheimers Agents v1.2022 (PDF)
- Analgesics Long-Acting Opioids v1. July 2023 (PDF)
- Analgesics Non-Opioid Barbiturate Combinations v1.2022 (PDF)
- Analgesics, Opioid Short-Acting v1. July 2023 (PDF)
- Androgenic Agents v1.2022 (PDF)
- Angiotensin Modulators v1.2022 (PDF)
- Angiotensin Modulator Combinations v2.2022 (PDF)
- Antianginal Agents v1.2023 (PDF)
- Antibiotics, Inhaled v1.2022 (PDF)
- Antibiotics, GI and Related Agents v1.2023 (PDF)
- Antibiotics, Topical v2.2022 (PDF)
- Anticoagulants v1.2022 (PDF)
- Anticonvulsants v2.2022 (PDF)
- Antidepressants, Other v1.2022 (PDF)
- Antidepressants, SSRIs (Selective Serotonin Reuptake Inhibitors) v1.2022 (PDF)
- Antiemetics Antivertigo Agents v1. July 2023 (PDF)
- Antifibrotics Respiratory Agents v1.2023 (PDF)
- Antifungals, Oral v1.2022 (PDF)
- Antifungals, Topical v1.2022 (PDF)
- Antihemophilia Agents v1.2023 (PDF)
- Antihistamines, Minimally Sedating v1.2022 (PDF)
- Antihypertensives, Sympatholytic v2.2022 (PDF)
- Antihyperuricemics v1.2022 (PDF)
- Antimalarials v1.2022 (PDF)
- Antimigraine Agents, Other v2.2020 (PDF)
- Antimigraine Agents, Triptans v2.2020 (PDF)
- Antiparasitics, Topical v1. July 2023 (PDF)
- Antiparkinson's Agents v2.2022 (PDF)
- Antipsoriatics, Oral v2.2022 (PDF)
- Antipsoriatics, Topical v1.2023 (PDF)
- Antipsychotics v1.2023 (PDF)
- Antivirals, CMV v1.2023 (PDF)
- Antivirals, Herpes v1.2022 (PDF)
- Antivirals, Influenza v1.2022 (PDF)
- Anxiolytics v1.2022 (PDF)
B
- Beta-Blockers v1.2021 (PDF)
- Bile Salts v1.2023 (PDF)
- Bladder Relaxant Preparations v1.2022 (PDF)
- Blood Glucose Meters (Glucometers) and Test Strips v1.2022 (PDF)
- Bone Density Regulators v1.2022 (PDF)
- Botulinum Toxins v1.2022 (PDF)
- BPH (Benign Prostatic Hyperplasia) Treatments v1.2022 (PDF)
- Bronchodilators, Beta Agonist v1.2022 (PDF)
C
- Calcium Channel Blockers v1.2022 (PDF)
- Cephalosporins v1.2022 (PDF)
- Chronic Obstructive Pulmonary Disease (COPD) Agents v1.2022 (PDF)
- Colony Stimulating Factors v1.2022 (PDF)
- Contraceptives, Oral v2.2022 (PDF)
- Contraceptives, Other v2.2022 (PDF)
- Cytokine and CAM Antagonists v1.2023 (PDF)
D
E
- Enzyme Replacements, Gaucher Disease v1.2022 (PDF)
- Epinephrine, Self-Injected v2.2022 (PDF)
- Erythropoiesis Stimulating Agents v1.2022 (PDF)
- Estrogens v1.2022 (PDF)
F
G
- GI Motility, Chronic Agents v1.2023 (PDF)
- Glucocortoids, Inhaled v1.2023 (PDF)
- Glucocortoids, Oral v1.2023 (PDF)
- Growth Hormones v1.2022 (PDF)
H
- Hematopoietic Mixtures v1.2022 (PDF)
- Hepatitis B Agents v2.2022 (PDF)
- Hepatitis C Agents v1. July 2023 (PDF)
- Hereditary Angiodema Treatments v1.2022 (PDF)
- Histamine 2 (H2) Receptor Blockers v1.2022 (PDF)
- HIV AIDS Antiretrovirals v1.2022 (PDF)
- H. Pylori Treatments v1.2022 (PDF)
- Hypoglycemia Treatments v1.2022 (PDF)
- Hypoglycemics, Alpha-Glucosidase Inhibitors v2.2022 (PDF)
- Hypglycemics, Incretin Mimetics, Enhancers v1.2023 (PDF)
- Hypoglycemics, Insulin and Related Agents v1.2023 (PDF)
- Hypoglycemics, Meglitinide v1.2022 (PDF)
- Hypoglycemics, Metformins v2.2022 (PDF)
- Hypoglycemics, SGLT2 Inhibitors v1.2023 (PDF)
- Hypoglycemics, Sulfonylureas v2.2022 (PDF)
- Hypoglycemics, TZD's v1.2023 (PDF)
I
- Immunomodulators, Atopic Dermatitis v1.2023 (PDF)
- Immunomodulators, Topical v2.2022 (PDF)
- Immunosuppresives, Oral v1.2022 (PDF)
- Inotuzumab Ozogamicin (Besponsa) v1.2022 (PDF)
- Intoseren (Tegsedi) v3.2022 (PDF)
- Intra-Articular Hyaluronates v1.2022 (PDF)
- Intranasal Rhinitis Agents v1.2022 (PDF)
- Iron Chelating Agents v1.2022 (PDF)
- Iron, Parenteral v1.2022 (PDF)
L
- Leukotriene Modifiers v2.2022 (PDF)
- Lipotropics, Other v1.2023 (PDF)
- Lipotropics, Statins v2.2022 (PDF)
- Local Anesthetics, Topical v1.2022 (PDF)
M
- Macrolides v1.2022 (PDF)
- Macular Degeneration Agents v1.2022 (PDF)
- Methotrexate v2.2022 (PDF)
- Migraine Acute Treatment Agents v1.2022 (PDF)
- Migraine Prevention Agents v1.2022 (PDF)
- Monoclonal Antibodies - Anti-II, ANti-IgE v1.2023 (PDF)
- Multiple Sclerosis Agents v1.2022 (PDF)
N
O
- Obesity Treatment Agents v1.2023 (PDF)
- Oncology Agents, Breast Cancer v1.2022 (PDF)
- Oncology Agents, Oral v1.2022 (PDF)
- Opiod Dependence Treatments v1.2022 (PDF)
- Opiod Overdose Agents v1.2022 (PDF)
- Opioid Use Disorder Treatments v1. July 2023 (PDF)
- Opthalmics, Allergic Conjunctivitis v1.2022 (PDF)
- Opthalmics, Antibiotics v1.2022 (PDF)
- Opthalmics, Antibiotic-Steroid Combination v1.2022 (PDF)
- Opthalmics, Anti-Inflammatories v1.2022 (PDF)
- Opthalmics, Glaucoma v1.2022 (PDF)
- Opthalmics, Immunomodulators v1.2022 (PDF)
- Otic Antibiotics v1.2022 (PDF)
- Ozanimod (Zeposia) v1.2022 (PDF)
P
- Pancreatic Enzymes v1.2022 (PDF)
- Penicillins v1.2022 (PDF)
- Phosphate Binders v2.2022 (PDF)
- Pituitary Suppressive Agents, LHRH v1.2023 (PDF)
- Platelet Aggregation Inhibitors v1.2023 (PDF)
- Potassium Removing Agents v1.2022 (PDF)
- Prenatal Vitamins v1.2022 (PDF)
- Progestational Agents v1. July 2023 (PDF)
- Proton Pump Inhibitors (PPI's) v1.2022 (PDF)
- Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled v1.2022 (PDF)
S
- Sedative Hypnotics v2.2022 (PDF)
- Sickle Cell Anemia Agents v1.2022 (PDF)
- Skeletal Muscle Relaxants v1.2022 (PDF)
- Smoking Cessation Products v2.2022 (PDF)
- Steroids, Topical v1.2022 (PDF)
- Stimulants and Related Agents v1.2023 (PDF)
T
- Tetracyclines v1.2022 (PDF)
- Thalidomide and Derivatives v1.2022 (PDF)
- Thrombopoietics v1.2022 (PDF)
- Thyroid Hormones v2.2022 (PDF)
- Tysabri (natalizumab) v1.2022 (PDF)
U
- Ulcerative Colitis Agents v1.2022 (PDF)
- Urea Cycle Disorder Agents v1.2022 (PDF)
- Urinary Anti-Infectives v1.2022 (PDF)
V
PHW Supplemental Drug List Pharmacy Policies
A
- Ado-Trastuzumab (Kadcyla) V1.2023 (PDF)
- Aducanumab (Aduhelm) v1.2023 (PDF)
- Afamelanotide (Scenesse) v1.2023 (PDF)
- Agalsidase Beta (Fabrazyme) v1.2023 (PDF)
- Alglucosidase alfa (Lumizyme) v1.2023 (PDF)
- Allogenic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat_StrataGraft v1.2023 (PDF)
- Allogenic Processed Thymus Tissue - agdc (Rethymic) v1.2023 (PDF)
- Alpelisib (Vijoice) v1. August 2023 (PDF)
- Alpha - 1 Proteinase Inhibitors (Aralast NP, Glassia, ProlastinC, Zemaira) v1.2023 (PDF)
- Amifampridine (Firdapse, Ruzurgi) v1.2023 (PDF)
- Amisulpride (Barhemsys) v1.August 2023 (PDF)
- Amivantamab-vmjw (Rybrevant) v1. August 2023
- Anifrolumab-fnia (Saphnelo) v1.2022 (PDF)
- Antithrombin III (ATryn, Thrombate III) v1.2023 (PDF)
- Antithymocyte Globulion (Atgam, Thymoglobulin) v1.2022 (PDF)
- Apomorphine (Apokyn, Kynmobi) v2.August 2023 (PDF)
- Aprepitant (Aponvie) v2. August 2023 (PDF)
- Asfotase Alfa (Strensiq) v1.2022 (PDF)
- Atezolizumab (Tecentriq) v1.2023 (PDF)
- Avacopan (Tavenos) v1.2023 (PDF)
- Avalglucosidase alfa-ngpt (Nexviazyme) v1.2023 (PDF)
- Avelumab (Bavencio) v1.2023 (PDF)
- Axicabtagene Ciloleucel (Yescarta) v1.2023 (PDF)
- Azacitidine (Vidaza) v1.2022 (PDF)
B
- Bedaquiline (Siruro) v1.2023 (PDF)
- Belantamab Mafodotin (Blenrep) v1.2023 (PDF)
- Belatacept (Nulojix) v1.2022 (PDF)
- Belimumab (Benlysta) v1.2023 (PDF)
- Belinostat (Beleodaq) v1.2022 (PDF)
- Bendamustine (Bendeka, Treanda) v1.2023 (PDF)
- Benznidazole v1.2023 (PDF)
- Beremagene geperpavec-svdt (Vyjuvek) v1. August 2023 (PDF)
- Betaine (Cystadane) v1.2022 (PDF)
- Betibeglogene Autotemcel (Zynteglo) v2.August 2023 (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) v1.2023 (PDF)
- Bexarontene (Targretin Capsules, Gel) v1.2023 (PDF)
- Blinatumomab (Blincyto) v1.2023 (PDF)
- Bortezomib (Velcade) v1.2023 (PDF)
- Brand Name Override for Medications Not on the Statewide PDL v1.2023 (PDF)
- Brentuximab Vedotin (adcetris) v2.2023 (PDF)
- Brexanolone (Zulresso) v1.July 2023 (PDF)
- Brexucabtagene autoleucel (Tecartus) v1.2023 (PDF)
- Brimonidine (Mirvaso) v1.2023 (PDF)
- Burosumab-twza (Crysvita) v1. August 2023 (PDF)
C
- Cabazitaxel (Jevtana) v1.2023 (PDF)
- Caplacizumab-yhdp (Cablivi) v1.2023 (PDF)
- Carfilzomib (Kyprolis) v1.2022 (PDF)
- Carglumic Acid (Carbaglu) v1.2023 (PDF)
- Casimersen (Amondys 45) v1.2023 (PDF)
- Cemiplimab-rwlc (Libtayo) v1.2022 (PDF)
- Cenegermin-bkbj (Oxervate) v1.2023 (PDF)
- Cerliponase Alfa (Brineura) v1. August 2023 (PDF)
- Cetuximab (Eritux) v1.2021 (PDF)
- Chlorambucil (Leukeran) v1.2023 (PDF)
- Chloramphenicol v2. August 2023 (PDF)
- Ciltacabtagene Autoleucel (Carvykti) v2 July 2023 (PDF)
- Cinacalcet (Sensipar) v1. August 2023 (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) v1. August 2023 (PDF)
- Coumponded Prescriptions v1. August 2023 (PDF)
- Continuous Glucose Monitors v1.2022 (PDF)
- Copanlisib (Aliqopa) v1.2022 (PDF)
- Corticotropin Injection (H.P. Acthar Gel, Purified Cortophin Gel) v1.2023 (PDF)
- Cosyntropin (Cortrosyn) v1.2023 (PDF)
- Cysteamine (Cystagon, Procysbi) v1.2023 (PDF)
- Cytomegalovirus Immune Globulin (Cytogam) v1. August 2023 (PDF)
- Cysteamine Ophthalmic (Cystaran, Cystadrops) v1 July 2023 (PDF)
D
- Daptomycin (Cubicin Cubicin RF) v2.2023 (PDF)
- Daratumumab (Darzalex, Darzalex Faspro) v1. August 2023 (PDF)
- Daunorubicin Cytaribine (Vyxeos) v1.2022 (PDF)
- Decitabine-Cedazuridine (Inqovi) v1.2023 (PDF)
- Deferoxamine (Desferal) v2. August 2023 (PDF)
- Degarelix Acetate (Firmagon) v2.2022 (PDF)
- Desmopressin Acetate (DDAVP Injection ) v1.2023 (PDF)
- Dexrazoxane (Zinecard Totect) v1.2023 (PDF)
- Dextromethorphan-Quindine (Nuedexta) v1.2023 (PDF)
- Dichlorphenamide (Keveyis) v1.2023 (PDF)
- Dornase Alfa (Pulmozyme) v2. August 2023 (PDF)
- Dostarlimab-gxly (Jemperli) v2.2023 (PDF)
- Droxidopa (Northera) v1.2023 (PDF)
- Durvalumab (Imfinzi) v1.2023 (PDF)
E
- Eculizumab (Soliris) v2. August 2023 (PDF)
- Edaravone (Radicava) v1.2023 (PDF)
- Efgartigimod Alfa-fcab (Vyvgart) v2. August 2023 (PDF)
- Elapegademase-lvlr (Revcovi) v1.2023 (PDF)
- Elexacaftor ivacaftor tezacaftor (Trikafta) v.2 August 2023 (PDF)
- Elivaldogene Autotemcel (Skysona) v1.2023 (PDF)
- Elosulfase Alfa (Vimizim) v1.2023 (PDF)
- Eribulin Mesylate (Halaven ) v1.2021 (PDF)
- Elotuzumab (Empliciti) v1.2022 (PDF)
- Emapalumab-Izsg (Gamifant) v1.2023 (PDF)
- Enfortumab Vedotin-ejfv (Padcev) v2 July 2023 (PDF)
- Epcoritamab-bysp (Epkinly) v1. August 2023 (PDF)
- Epoprostenol Sodium (Flolan Veletri) v1.2023 (PDF)
- Eribulin Mesylate (Halaven) v1.2022 (PDF)
- Erwinia Asparaginase (Erwinaze) v1.2023 (PDF)
- Etelcalcetide (Parsabiv) v1. August 2023 (PDF)
- Eteplirsen (Exondys 51) v1.2023 (PDF)
- Etranacogene Dezaparvovec-drlb Hemgenix v1.2023 (PDF)
F
- Factor XIII A-Subunit (Recombinant Tretten) V1.2023 (PDF)
- Factor XIII (Human Corifact) v1.2023 (PDF)
- Fam-trastuzumab deruxtecan-nxki (Enhertu) v1.2023 (PDF)
- Fecal Microbiota Live-jslm (Rebyota) v1. August 2023 (PDF)
- Fecal Microbiota Spores Live-brpk (Vowst) v1. August 2023 (PDF)
- Ferric maltol (Accrufer) v1.2022 (PDF)
- Ferric Pyrophosphate (Triferic) v1 July 2023 (PDF)
- Fibrinogen Concentrate (human) (Fibryga, RiaSTAP) v1.2023 (PDF)
- Finerenone (Kerendia) v1.2022 (PDF)
- Fluorouracil Cream (Tolak) v1.2022 (PDF)
- Fosdenopterin (Nulibry) v1.2023 (PDF)
- Fulvestrant (Faslodex Injection) v1.2023 (PDF)
- Furosemide Furoscix v1.2023 (PDF)
G
- Galsulfase (Naglazyme) v1.2023 (PDF)
- Gemtuzumab (Mylotarg) v1.2022 (PDF)
- Givosiran (Givlaari) V1.2023 (PDF)
- Glofitamab-gxbm (Columvi) v1. 2023 (PDF)
- Glycopyrronium (Qbrexza) v1.2022 (PDF)
- Golodirsen (Vyondys 53) v1.2023 (PDF)
H
I
- Idecabtagene Vicleucel (Abecma) v1.July 2023 (PDF)
- Idursulfase (Elaprase) v1.2023 (PDF)
- Immune Globulins v1. July 2023 (PDF)
- Immunization Coverage v1. August 2023 (PDF)
- Inebilizumab-cdon (Uplizna) v2. August 2023 (PDF)
- Injectable Antibiotics Not on the Statewide Preferred Drug List v1. August 2023
- Insulin Delivery Systems (V-Go Omnipod InPen) v2.2023 (PDF)
- Interferon Gamma - 1b (Actimmune) v1.2023 (PDF)
- Intrathecal Baclofen (Gablofen, Lioresal Intrathecal) v1.2022 (PDF)
- Inotersen (Tegsedi) v1.2023 (PDF)
- Inotuzumab Ozogamicin (Besponsa) v1.2022 (PDF)
- Iobenguane l 131 (Azedra) v1.2023 (PDF)
- Ipilimumab (Yervoy) v1. July 2023 (PDF)
- Irinotecan Liposome Injection (Onivyde) v1.2022 (PDF)
- Isatuximab-irfc (Sarclisa) v1.2023 (PDF)
- Ivabradine (Corlanor) v1.2023 (PDF)
- Ivacaftor (Kalydeco) v2. August 2023 (PDF)
L
- Lanreotide (Somatuline Depot) v1.2022 (PDF)
- Laronidase (Aldurazyme) v1.2023 (PDF)
- Lecanemab-irmb (Leqembi) v1.2023 (PDF)
- Lefamulin (Xenleta) v2. August 2023 (PDF)
- Leniolisib (Joenja) v1.2023 (PDF)
- Leucovorin Injection v1.2022 (PDF)
- Levoketoconazole (Recorlev) v1.2023 (PDF)
- Levoleucovorin (Fusilev) v1.2022 (PDF)
- Linezolid (Zyvox) v2. August 2023 (PDF)
- Lisocabtagene Maraleucel (Breyanzi) v1. July 2023 (PDF)
- Lomustine (Gleostine) v1.2022 (PDF)
- Lonafarnib (Zokinvy) v1.2023 (PDF)
- Loncastuximab Tesirine-Ipyl (Zynlonta) v1. August 2023 (PDF)
- Lumacaftor-Ivacaftor (Orkambi) v2. August 2023 (PDF)
- Lumasiran (Oxlumo) v1.2023 (PDF)
- Lurbinectedin (Zepzelca) v1. August 2023 (PDF)
- Luspatercept-aamt (Reblozyl) v1.2023 (PDF)
- Lutetium Lu 177 Dotatate (Lutathera) v1. August 2023 (PDF)
M
- Mannitol (Bronchitol) v2. August 2023 (PDF)
- Maralixibat (Livmarli) v1. July 2023 (PDF)
- Margetuximab-cmkb (Margenza) v1.2023 (PDF)
- Mavacamten (Camzyos) v2.2023
- Mecamylamine (Vecamyl) v1. July 2023 (PDF)
- Mecasermin (Increlex) v1. August 2023 (PDF)
- Mechlorethamine (Valchlor) v1.2023 (PDF)
- Megestrol Acetate Oral Suspension (Megace ES) v1.2022 (PDF)
- Melphalan Flufenamide (Pepaxto) v2.2023 (PDF)
- Metreleptin (Myalept) v1.2023 (PDF)
- Mercaptopurine (Purixan) v1.2023 (PDF)
- Migalastat (Galafold) v1.2022 (PDF)
- Mifepristone (Korlym) v1.2023 (PDF)
- Mitapivat (Pyrukynd) v1.2022 (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) v1. August 2023 (PDF)
- Mitoxantrone (Novantrone) v1.2022 (PDF)
- Mogamulizumab-kpkc (Poteligeo) v1.2022 (PDF)
- Moxetumomab Pasudotox-tdfk (Lumoxiti) v1.2022 (PDF)
N
- Nadofaragene Firadenovec-vncg (Adstiladrin) v1.2023 (PDF)
- Naxitamab-gqgk (Danyelza) v1.2023 (PDF)
- Necitumumab (Portrazza) v1.2022 (PDF)
- Nifurtimox (Lampit) v1.2022 (PDF)
- Nitisinone (Orfadin, Nityr) v1.2022 (PDF)
- Nivolumab (Opdivo) v2. August 2023 (PDF)
- Nivolumab and Relatlimab-rmbw (Opdualag) v1.2023 (PDF)
- No Coverage Criteria, Recent Label Changes Pending Update for Drug Not on Statewide PDL v1.2023 (PDF)
- Nusinersen (Spinraza) v1.2023 (PDF)
O
- Obinutuzumab (Gazyva) v1.2022 (PDF)
- Octreotide Acetate (Sandostatin Injection Sandostatin LAR Depot) v1.2023 (PDF)
- Odevixbat_Bylvay v1.2023 (PDF)
- Ofatumumab (Arzerra) v1.2023 (PDF)
- Off Label Use of Drug Not on the Statewide Preferred Drug List v2. July 2023 (PDF)
- Olaratumab (Lartruvo) v1.2022 (PDF)
- Olipudase Alfa-rpcp (Xenpozyme) v1. August 2023 (PDF)
- Omacetaxine (Synribo) v1.2023 (PDF)
- Omaveloxolone (Skyclarys) v1. August 2023 (PDF)
- Onasemnogene Abeparvovec (Zolgensma) v1. July 2023 (PDF)
- Ophthalmic Riboflavin (Photrexa Photrexa Viscous) v1. July 2023 (PDF)
- Osilodrostat (Isturisa) v1. August 2023 (PDF)
- Ospemifene (Osphena) v1.2022 (PDF)
- Oxymetazoline (Rhofade, Upneeq) v1. July 2023 (PDF)
P
- Paclitaxel Protein Bound (Abraxane) v1.2023 (PDF)
- Palivizumab (Synagis) v1.2023 (PDF)
- Panitumumab (Vectibix) v1.2022 (PDF)
- Parathyroid Hormone (Natpara) v1.2023 (PDF)
- Pasireotide (Signifor, Signifor LAR) v1.2022 (PDF)
- Patisiran (Onpattro) v1.2022 (PDF)
- Peanut Allergen Powder-dnfp_Palforzia v1.2023 (PDF)
- Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) v1.2022 (PDF)
- Pegcetacoplan (Empaveli) v2. August 2023 (PDF)
- Pegunigalsidase Alfa-iwxj (Elfabrio) v1. August 2023 (PDF)
- Pegvaliase-pqpz (Palynziq) v1.2022 (PDF)
- Pegvisomant (Somavert) v1.2022 (PDF)
- Pembrolizuman (Keytruda) v2. August 2023 (PDF)
- Pemetrexed (Alimta Pemfexy) v1.2023 (PDF)
- Pentosan Polysulfate Sodium (Elmiron) v1.2023 (PDF)
- Pertuzumab (Perjeta) v2.2023 (PDF)
- Pertuzumab (Phesgo) v1. August 2023 (PDF)
- Pegvaliase-pqpz (Palynziq) v2.2020 (PDF)
- Pembrolizumab (Keytruda) v1.2021 (PDF)
- Plasminogen (Ryplazim) v2.2022 (PDF)
- Plerixafor (Mozobil) v1. August 2023 (PDF)
- Polatuzumab Vedotin-piiq (Polivy) v1.2023 (PDF)
- Pralatrexate (Folotyn) v1.2022 (PDF)
- Prasterone (Intrarosa) v1.2023 (PDF)
- Pretomanid v1.2023 (PDF)
- Protein C Concentrate, Human (Ceprotin) v1.2023 (PDF)
- Pyrimethamine (Daraprim) v1.2022 (PDF)
Q
R
- Ramucirumab (Cyramza) v1.2023 (PDF)
- Ravulizumab-cwvz (Ultomiris) v2.2023 (PDF)
- Request for Medically Necessary Drug Not on the Statewide Preferred Drug List v2. August 2023 (PDF)
- Retifanlimab dlwr (Zynyz) v1. July 2023 (PDF)
- Rifabutin (Mycobutin) v1.2023 (PDF)
- Rifapentine (Priftin) v1.2023 (PDF)
- Risdiplam (Evrysdi) v1.2023 (PDF)
- Rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela) v3. August 2023 (PDF)
- Romidepsin (Istodax) v1.2022 (PDF)
- Ropeginterferon alfa-2b-njft (Besremi) v1.2023 (PDF)
S
- Sacituzumab Govitecan-hziy (Trodelvy) v1.2023 (PDF)
- Sapropterin Dihydrochloride (Kuvan) v1.2023 (PDF)
- Satralizumab-mwge (Enspryng) v2.August 2023 (PDF)
- Sebelipase Alfa (Kanuma) v1.2023 (PDF)
- Setmelanotide (Imcivree) v1.2023 (PDF)
- Siltuximab (Sylvant) v1.2022 (PDF)
- Sipuleucel-T (Provenge) v1.2023 (PDF)
- Sirolimus Protein-Bound Particles (Fayarr, Topical Gel, Hyftor) v1.2023 (PDF)
- Sodium Oxybate (Xyrem) (Xywav) v2. August 2023 (PDF)
- Sparsentan (Filspari) v1. July 2023 (PDF)
T
- Tafamidis (Vyndaqel, Vyndamax) v1.2022 (PDF)
- Tafasitamab-cxix (Monjuvi) v1.2022 (PDF)
- Talimogene Iaherparepvec (Imlygic) v2. August 2022 (PDF)
- Tebentafusp-tebn (Kimmtrak) v2.2023 (PDF)
- Teclistamab-cqyv (Tecvayli) v1.2023 (PDF)
- Tedizolid (Sivextro) v2. August 2023 (PDF)
- Teduglutide (Gattex) v1.2023 (PDF)
- Telotristat Ethyl (Xermelo) v1. July 2023 (PDF)
- Temsirolimus (Torisel) v1.2022 (PDF)
- Teplizumab-mzwv (Tzield) v1.2023 (PDF)
- Teprotumumab (Tepezza) v1.2023 (PDF)
- Tesamorelin (Egrifta SV) v1. August 2023 (PDF)
- Tezepelumab-ekko Tezspire v1.2022 (PDF)
- Tezacaftor-Ivacaftor (Symdeko) v2.2023 (PDF)
- Thioguanine (Tabloid) v1.2022 (PDF)
- Thyrotropin Alfa (Thyrogen) v1.2023 (PDF)
- Tisagenlecleucel (Kymriah) v1.2023 (PDF)
- Tisotumab Vedotin-tfv (Tivdak) v1.2022 (PDF)
- Tofersen Qalsody v1. August 2023 (PDF)
- Tolvaptan (Jynarque, Samsca) v1. August 2023 (PDF)
- Topotecan (Hycamtin) v1.2023 (PDF)
- Trabectedin (Yondelis) v1.2023 (PDF)
- Tralokinumab-Idrm Adbry v1.2022 (PDF)
- Tremelimbumab-actl (Imjudo) v1.2023 (PDF)
- Trastuzumab, Biosimilars, Trastuzumab-Hyaluronidase v1. July 2023 (PDF)
- Treprostinil (Remodulin) v1.2022 (PDF)
- Triamcinolone ER Injection (Zilretta) v1.2023 (PDF)
- Triheptanoin (Dojolvi) v1.2022 (PDF)
- Triclabendazole (Egaten) v1. August 2023 (PDF)
- Trientine (Syprine) v1.2022 (PDF)
- Trofineatide (Daybue) v1. July 2023 (PDF)
V
- Valrubicin (Valstar) v1.2022 (PDF)
- Varenicline (Tyravayaa) v1.2022 (PDF)
- Velmanase Alfa tycv (Lamzede) v1. July 2023 (PDF)
- Vestronidase Alfa-vjbk (Mepsevii) v1.2023 (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) v1.2022 (PDF)
- Vitolarsen (Viltepso) v1.2023 (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) v1.2023 (PDF)
- Vosoritide (Voxzogo) v1.2023 (PDF)
- Vutrisiran (Amvuttra) v1.2023 (PDF)
Z
Policy # | Policy Name | Last Review Date | Purpose |
---|---|---|---|
CP.CPC.01 | Clinical Policy Committee | July 31, 2018 | Clinical Policy Committee Process |
CP.CPC.02 | Clinical Policy Web Posting | August 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 | September 19, 2018 | 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 | January 31, 2018 | Medical necessity guidelines for allergy testing and treatment |
CP.MP.101 | Donor lymphocyte infusion | October 31, 2018 | 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 |
Archived Policies
- Tiludronate (Skelid) (CP.PM.106) (PDF)
- Mesalamine Oral Therapy (CP.PST.19) (PDF)
- Dipeptidyl Peptidase 4 (DPP 4) Inhibitors (CP.PST.18) (PDF)
- Daclizumab (Zinbryta) (CP.PHAR.269) (PDF)
- Glucagon-like Peptide 1 (GLP-1) Receptor Agents (CP.PST.14) (PDF)
- Sodium-Glucose-Co-Transporter 2 (SGLT2) Inhibitors (CP.PST.19) (PDF)
- Celecoxib (Celebrex) (CP.PPA.01) (PDF)
- Lisdexamfetamine (Vyvanse) (CP.PPA.03) (PDF)
- Itraconazole (Sporanox) (CP.PPA.07) (PDF)
- Colchicine (Colcrys) (CP.PPA.11) (PDF)
- Methylphenidate (CP.PMN.10) (PDF)
- Naltrexone (CP.PHAR.96) (PDF)
- Atomoxetine Strattera (CP.PMN.01) (PDF)
- Topical Immunomodulators (CP.PPA.05) (PDF)
- Glucagon-like Peptide 1 RA (CPPPA.21) (PDF)
- Rivastigmine (Exelon) (CP.PPA.22) (PDF)
- SGLT2 Inhibitors (CP.PPA.24) (PDF)
- Infertility and Fertilitiy Preservation (PA.CP.PHAR.131) (PDF)
- TPB IDPN (PA.CP.PHAR.205) (PDF)
- Aripiprazole LA Injections (Abilify Maintena, Aristada) (PA.CP.PHAR.205) (PDF)
- Paliperidone Injection (Invega Sustenna, Invega Trinza) (PA.CP.PHAR.291) (PDF)
- Olanzapine LA Injection (Zyprexa Relprevv) (PA.CP.PHAR.292) (PDF)
- Risperidone LA Injection (Risperdal Consta) (PA.CP.PHAR.293) (PDF)
- Gefitnib (Iressa) (PA.CP.PHAR.299) (PDF)
- Oral Antimetics (PA.CP.PMN.11) (PDF)
- Famciclovir (Famvir) (PA.CP.PMN.26) (PDF)
- Dexmethylphenidate ER (Focalin XR) (PA.CP.PMN.63) (PDF)
- Inhaled Combination LAA-LABA (PA.CP.PMN.69) (PDF)
- Ragweed Pollen (Ragwitek) (PA.CP.PMN.83) (PDF)
- Timothy Grass Pollen (Grastek) (PA.CP.PMN.84) (PDF)
- House Dust Mite (Odactra) (PA.CP.PMN. 111) (PDF)
- Betrixaban (Bevyxxa) (PA.CP.PMN.114) (PDF)
- Naloxone (Evzio) (PA.CP.PMN.139) (PDF)
- Epinephrine (Epipen Epipen JR) (PA.CP.PPA.09) (PDF)
- Toremifene (Fareston) (PA.CP.PPA.10) (PDF)
- Milnacipran (Savella) (PA.CP.PPA.15) (PDF)
- Vilazodone (Viibryd) (PA.CP.PPA.16) (PDF)
- Pimavanserin (Nuplazid) (PA.CP.PPA.19) (PDF)
- Anti-Allergy Ophthalmics (PA.CP.PST.03) (PDF)
- Exemestane (Aromasin) (PA.CP.PST.05) (PDF)
- Isotretinoin (PA.CP.PST.13) (PDF)
- Pramlintide (Symlin) (PA.CP.PST.13) (PDF)
- Sedative Hypnotics (PA.CP.PST.16) (PDF)
- Pediatric Heart Transplant (PA.CP.MP.1380 (PDF)
- Hyperbaric Oxygen Therapy Rev (PA.CP.MP.27) (PDF)
- Fecal Calprotectin Assay (PA.CP.MP.135) (PDF)
- EpiFix Wound Treatment (PA.CP.MP.140) (PDF)
- 2019 Novel Coronavirus Testing (PA.CP.MP.183) (PDF)
- NICU Apnea Bradycardia Guidelines (PA.CP.MP.82) (PDF)
- OB Home Health Programs (PA.CP.MP.91) (PDF)
- Neonatal Abstinence Syndrome Guidelines (PA.CP.MP.86) (PDF)
- Transcranial Magnetic Stimulaiton (PA.CP.MP.172) (PDF)
- Medical Necessity Criteria (PA.CP.MP.68) (PDF)
- Inhale Nitric Oxide (PA.CP.MP.87) (PDF)
- Injections for Pain Management (PA.CP.MP.118) (PDF)
- Home Sleep Testing (PA.CP.MP.75) (PDF)
- Zika Virus Testing (PA.CP.MP.111) (PDF)
- Monitored Anesthesia Care (PA.CP.MP.161) (PDF)
- Ventriculectomy Cardiomyoplasty (PA.CP.MP.56) (PDF)
- FeNo (PA.CP.MP.103) (PDF)
- DNA Analysis of Stool (PA.CP.MP.125) (PDF)
- Iron, Oral v2.2020 (PDF)
- Becaplermin (Regranex) v1.2021 (PDF)
- Continuous Insulin Delivery Systems (V-Go, Omnipod) v2.2020 (PDF)
- Crizanlizumab-tmca (Adakveo) v1.2020 (PDF)
- Hydroxyurea (Siklos) v2.2020 (PDF)
- Insulin Infusion Pump (Omnipod, Omnipod DASH) v1.2020 (PDF)
- L-glutamine (Endari) v2.2020 (PDF)
- Lasmiditan (Reyvow) v1.2020 (PDF)
- Moxidectin v1.2020 (PDF)
- Omadacycline (Nuzyra) v1.2020 (PDF)
- Ozenoxacin (Xepi) v1.2020 (PDF)
- Pegademase Bovine (Adagen) v2.2020 (PDF)
- Rifabutin (Mycobutin), Rifabutin, Omeprazole, Amoxicillin (Talicia) v1.2020 (PDF)
- Rituximab (Pituxan) v1.2020 (PDF)
- Ubrogepant (Ubrelvy) v1.2020 (PDF)
- Voxelotor (Oxbryta) v1.2020 (PDF)
- Carrier Screening in Pregnancy PA.CP.MP.83 v1.2021 (PDF)
- Cell-free Fetal DNA Testing PA.CP.MP.84 v2.2022 (PDF)
- Ambulatory EEG PA.CP.MP.96 v1.2021 (PDF)
- Balloon Sinus Ostial Dilation PA.CP.MP.119 v1.2021 (PDF)
- Testing for Rupture of Fetal Membranes PA.CP.MP.149 v1.2021 (PDF)
- Antithrombin III Atryn Thrombate PA.CP.MP.179 v1.2021 (PDF)
- PCR Respiratory Viral Panel Testing PA.CP.MP.181 v1.2021 (PDF)
- Sickle Cell Observation PA.CP.MP.88 v1.2021 (PDF)
- Genetic and Pharmacogenetic Testing PA.CP.MP.89 v1.2021 (PDF)
- Video EEG Monitoring PA.CP.MP.177 v1.2021 (PDF)
- ADHD Assessment and Treatment PA.CP.MP.124 v3.2022 (PDF)
- Essure Removal PA.CP.MP.131 v3.2023 (PDF)
- Hyperemesis Gravidarum Treatment PA.CP.MP.34 v2.2021 (PDF)