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.

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A-H Policies

I-Q Policies

R-Z Policies

Payment Policies

Pharmacy Policies

Pennsylvania Medical Assistance Program's Statewide Preferred Drug List (PDL) Pharmacy Policies

Dupixent v1.2022 (PDF)

Fluoroquinolones, Oral v1.2021 (PDF)

PHW Supplemental Drug List Pharmacy Policies

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Quantity Limit Override v1.2021 (PDF)

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Ubrogepant (Ubrelvy) v1.2020 (PDF)

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Ziv-Afibercept (Zaltrap) v1.2021 (PDF)

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

Clinical & Payment Policies

Clinical Policies

Clinical Policies