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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 Policies I-Q Policies R-Z Policies
Acupuncture (PDF) Intestinal and Multivisceral Transplant (PDF) Radial Head Implant (PDF)
ADHD Assessment and Treatment (PDF) Implantable Intrathecal Pain Pump (PDF) Reduction Mammoplasty and Gynecomastia Surgery (PDF)
AHC Transplants SCA Thalassemia (PDF) Implantable Wireless PAP Monitoring (PDF) Sacroiliac Joint Fusion (PDF)
Allergy Testing and Therapy (PDF) Intensity-modulated Radiotherapy (PDF) Scroiliac Joint Interventions (PDF)
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) Injections and Radiofrequency Neurotomy for Pain Management (PDF) Sclerotherapy for Vericose Veins (PDF)
Ambulatory EEG (PDF) Intradiscal Steroid Injections for Pain Management (PDF) Selective Nerve Root Blocks (PDF)
Ambulatory Surgery Center Optimization (PDF) Laser Therapy for Skin Conditions (PDF) Sickle Cell Observation (PDF)
Articular Cartilage Defect Repairs (PDF) Long Term Care Placement (PDF) Stereotactic Body Radiation Therapy (PDF)
Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis (PDF) Low Frequency US Therapy for Wound Management (PDF) Spinal Cord Stimulation (PDF)
Bariatric Surgery (PDF) Lung Transplantation (PDF) Tandem Transplant (PDF)
Biofeedback (PDF) Lysis of Epidural Lesions (PDF) Testing for Rupture of Fetal Membranes (PDF)
Bone-anchored Hearing Aid (PDF) Nerve Blocks for Pain Management (PDF)

Total Artificial Heart (PDF)
Bronchial Thermoplasty (PDF) Non-Myeloablative Allogeneic Stem Cell Transplants (PDF) Total Parental Nutrition and Intradialytic Parental Nutrition (PDF)
Cardiac Biomarker Testing (PDF) Measurement of Serum 1,25 dihydroxyvitamin D (PDF) Transcatheter Closure of Patent Foramen Ovale (PDF)
Carrier Screening in Pregnancy (PDF) Medical Necessity Guidelines (PDF) Trigger Point Injections for Pain Management (PDF)
Caudal or Interlaminar Epidural Steroid Injections (PDF) Multiple Sleep Latency Testing (PDF) Ultrasound in Pregnancy (PDF)
Cell-free Fetal DNA Testing (PDF) OB Home Health Programs (PDF) Urinary Incontinence Devices and Treatments (PDF)
Clinical Trials (PDF) Optic Nerve Decompression Surgery (PDF) Urodynamic Testing (PDF)
Cochlear Implant Replacements (PDF) Outpatient Testing for Drugs of Abuse (PDF) Vagus Nerve Stimulation (PDF)
Cosmetic and Reconstructive Surgery (PDF) Panniculectomy (PDF) Ventricular Assist Devices (PDF)
Dental Anesthesia (PDF) Pancreas Transplantation (PDF) Ventriculectomy and Cardiomyoplasty (PDF)
Digital EEG Spike Analysis (PDF) Pediatric Heart Transplant (PDF) Wheelchair Seating (PDF)
Disc Decompression Procedures (PDF) Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) Wireless Motility Capsule (PDF)
Discography (PDF) Physical, Occupational and Speech Therapy Services (PDF) Zika Virus Testing (PDF)
DNA Analysis of Stool (PDF) Posterior Nerve Stimulation for Voiding Dysfunction (PDF) Selective Dorsal Rhizotomy for Spasticity in CP (PDF)
Donor Lymphocyte Infusion (PDF) Proton and Neutron Beam Therapy (PDF) Video EEG Monitoring (PDF)
EEG in the Evaluation of Headache (PDF)   Transcranial Magnetic Stimulation (PDF)
Electric Tumor Treating Fields (Optune) (PDF)    
Endometrial Ablation (PDF)    
EpiFix Wound Treatment (PDF)    
Essure Removal (PDF)    
Evoked Potential Testing (PDF)    
Facet Joint Interventions (PDF)    
Fecal Calprotectin Assay (PDF)    
Fecal Incontinence Treatments (PDF)    
Ferriscan R2 MRI (PDF)    
Fertility Preservation (PDF)    
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)    
Fractional Exhaled Nitric Oxide (PDF)    
Functional MRI (PDF)    
Gastric Electrical Stimulation (PDF)    
Gender Confirmation Surgery (PDF)    
Genetic Testing (PDF)    
H Pylori Serology Testing (PDF)    
Heart-Lung Transplant (PDF)    
Helicobacter Pylori Serology Testing (PDF)    
Holter Monitors (PDF)    
Home Sleep Testing (PDF)    
Homocysteine Testing (PDF)    
Hospice Services (PDF)    
Hyperbaric Oxygen Therapy (PDF)    
Hyperemesis Gravidarum Treatment (PDF)

 
Hyperhidrosis Treatments (PDF)    
Antithrombin III (Atryn, Thrombate) (PDF)    
A-H Policies

I-Q Policies

R-Z Policies

Pharmacy Policies

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

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PHW Supplemental Drug List Pharmacy Policies

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Quantity Limit Override v2.2020 (PDF)

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Ubrogepant (Ubrelvy) v1.2020 (PDF)

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Ziv-Afibercept (Zaltrap) v2.2020 (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

Archived Policies