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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

Pharmacy Policies

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















PHW Supplemental Drug List Pharmacy Policies




Policy #Policy NameLast Review DatePurpose
CP.CPC.01Clinical Policy CommitteeJuly 31, 2018Clinical Policy Committee Process
CP.CPC.02Clinical Policy Web PostingAugust 24, 2018Corporate and health plan responsibilities for initial posting and maintenance of clinical, payment, and specialty drug policies to public heatlh plan websites.
CP.CPC.03Preventive Health and Clinical Practice Guideline PolicySeptember 19, 2018The 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.100Allergy Testing and TherapyJanuary 31, 2018Medical necessity guidelines for allergy testing and treatment
CP.MP.101Donor lymphocyte infusionOctober 31, 2018Medical necessity guidelines for donor lymphocyte infusion
CP.MP.102Pancreas transplant2/28/18Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant.
CP.MP.103Fractional exhaled nitric oxide12/29/17Medical necessity guidelines for use of fractional exhaled nitric oxide (FeNO) in asthma diagnosis and care
CP.MP.104Applied Behavioral Analysis for Autism1/31/18Medical necessity guidelines for applied behavioral analysis for autism
CP.MP.105Digital electroencephalography spike analysis1/31/18Medical necessity guidelines for digital EEG spike analysis
CP.MP.106Endometrial ablation7/31/18Medical necessity guidelines for endometrial ablation
CP.MP.107Durable Medical Equipment (DME)7/31/18Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics
CP.MP.108Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia2/28/18Medical necessity guidelines for allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia
CP.MP.109Panniculectomy3/31/18Medical necessity guidelines for panniculectomy
CP.MP.110Bronchial Thermoplasty3/31/18Medical necessity guidelines for bronchial thermoplasty
CP.MP.111Zika Virus Testing5/31/18Medical necessity guidelines for diagnostic testing for Zika Virus with the rRT-PCR and MAC-ELISA tests
CP.MP.113Holter Monitors6/30/18Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring
CP.MP.114Disc Decompression Procedures5/31/18Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression
CP.MP.115Discography6/30/18Medical necessity guidelines for discography
CP.MP.116Lysis of Epidural Lesions5/31/18Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty
CP.MP.117Spinal Cord Stimulation9/30/18Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation
CP.MP.119Balloon sinus ostial dilation9/30/18Medical necessity guidelines for balloon sinus ostial dilation for chronic rhinosinusitus and recurrent acute rhinosinusitis
CP.MP.12Vagus Nerve Stimulation8/31/18Medical necessity guidelines for vagus nerve stimulation.
CP.MP.120Pediatric Liver Transplant4/30/18Medical necessity guidelines for pediatric liver transplant for end-stage liver disease
CP.MP.121Homocysteine testing5/31/18Medical necessity guidelines for homocysteine testing
CP.MP.123Laser therapy for skin conditions6/30/18Medical necessity guidelines for excimer laser based targeted phototherapy
CP.MP.124ADHD Assessment and Treatment5/31/18Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD)
CP.MP.125DNA analysis of stool to screen for colorectal cancer7/31/18Medical necessity guidelines for DNA analysis of stool for colorectal cancer
CP.MP.126Sacroiliac joint fusion6/30/18Medical necessity guidelines for sacroiliac joint fusion
CP.MP.127Total artificial heart12/29/18Medical necessity guidelines for a total artificial heart (TAH)
CP.MP.128Optic nerve decompression surgery8/31/2018Medical necessity guidelines for optic nerve sheath decompression surgery
CP.MP.129Fetal surgery in utero for prenatally diagnosed malformations10/31/2018Medical necessity guidelines for performing fetal surgery in utero
CP.MP.130Fertility preservation9/30/2018Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility
CP.MP.131Essure Removal10/31/2018Medical necessity guidelines for removal of Essure®, a permanent birth control device
CP.MP.132Heart-Lung Transplant4/30/2018Medical necessity guidelines for heart-lung transplantation
CP.MP.133Posterior tibial nerve stimulation for voiding dysfunction8/31/2018Medical necessity guidelines for posterior tibial nerve stimulation for the treatment of overactive bladder
CP.MP.134Evoked Potential Testing10/31/2018Medical necessity guidelines for evoked potential testing
CP.MP.135Fecal calprotectin assay11/30/2017Medical necessity guidelines for fecal calprotectin assay for diagnosis and screening of inflammatory bowel disease (IBD)
CP.MP.136Home Birth10/31/2018Medical necessity guidelines for planned home birth
CP.MP.137Fecal incontinence treatments12/29/2017Medical necessity guidelines for fecal incontinence treatments
CP.MP.138Pediatric heart transplant1/31/2018Medical necessity guidelines for pediatric heart transplant
CP.MP.139Low-frequency ultrasound therapy for wound management1/31/2018Medical necessity guidelines for low-frequency ultrasound therapy for wound management
CP.MP.140EpiFix Wound Treatment3/31/2018Medical necessity guidelines for EpiFix® wound treatment
CP.MP.141Non-myeloablative allogeneic stem cell transplants2/28/2018Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants
CP.MP.142Urinary Incontinence Devices and Treatments9/24/2018Medical necessity guidelines for treatments and devices for urinary incontinence including sacral neuromodulation (sacral nerve stimulation) and urethral bulking agents
CP.MP.143Wireless Motility Capsule3/31/2018Medical necessity guidelines for wireless motility capsule
CP.MP.144Mechanical Stretching Devices for Joint Stiffness and Contracture3/31/2018Medical 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.145Electric Tumor Treating Fields3/31/2018Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM)
CP.MP.146Sclerotherapy for Varicose Veins4/30/2018Medical necessity guidelines for sclerotherapy for treatment of vericose veins
CP.MP.147Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention5/31/2018Medical necessity guidelines for left atrial appendage closure devices for stroke prevention.
CP.MP.148Radial Head Implant10/19/2018Medical necessity guidelines for radial head implant, also known as arthroplasty
CP.MP.149Testing for rupture of fetal membranes6/30/2018Medical necessity guidelines for testing for rupture of fetal membranes
CP.MP.150Home phototherapy for neonatal hyperbilirubinemia10/31/2018Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia
CP.MP.151Transcatheter closure of patent foramen ovale12/29/2017Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder.
CP.MP.152Measurement of serum 1,25-dihydroxyvitamin D12/29/2017Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D
CP.MP.153H. Pylori serology testing12/29/2017Medical necessity guidelines for H. pylori serology testing
CP.MP.154Thyroid hormones and insulin testing in pediatrics12/29/2017Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics
CP.MP.155Electroencephalography in the evaluation of headache12/29/2017Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches
CP.MP.156Cardiac biomarker testing3/30/2018Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction
CP.MP.15725-hydroxyvitamin D testing in children and adolescents12/29/2017Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents
CP.MP.158Ambulatory Surgery Center Optimization2/16/2018Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services
CP.MP.159Infusion Therapy Site of Care Optimization10/31/2018Medical necessity criteria for IV or injectable therapy services in an outpatient setting.
CP.MP.160Implantable Wireless Pulmonary Artery Pressure Monitoring4/30/2018Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring
CP.MP.161Monitored Anesthesia Care for Gastrointestinal Endoscopy5/31/2018Medical necessity guidelines for monitored anesthesia care (MAC) for gastrointestinal endoscopy
CP.MP.162Tandem Transplant7/31/2018Medical necessity guidelines for tandem transplant
CP.MP.163Total Parenteral Nutrition and Intradialytic Parenteral Nutrition4/30/2018Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN)
CP.MP.164Caudal or Interlaminar Epidural Steroid Injections for Pain Management8/31/2018Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management
CP.MP.165Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management8/31/2018Medical necessity criteria for selective nerve root blocks and transforaminal epidural injections for pain management
CP.MP.166Sacroiliac Joint Interventions for Pain Management8/31/2018Medical necessity criteria for sacroiliac joint interventions for pain management
CP.MP.167Intradiscal Steroid Injections for Pain Management8/31/2018Medical necessity criteria for intradiscal steroid injections for pain management
CP.MP.168Biofeedback5/31/2018Medical necessity guidelines for biofeedback therapy
CP.MP.169Trigger Point Injections for Pain Management8/31/2018Medical necessity criteria for trigger point injections for pain management
CP.MP.170Nerve Blocks for Pain Management8/31/2018Medical necessity criteria for nerve blocks for pain management
CP.MP.171Facet Joint Interventions for pain management9/14/2018Medical necessity guidelines for facet joint injections and facet joint radiofrequency neurotomy (ablation) for lumbar, thoracic, and cervical pain management
CP.MP.22Stereotactic Body Radiation Therapy1/31/2018Medical necessity guidelines for stereotactic body radiation therapy
CP.MP.24Multiple Sleep Latency Testing4/30/2018Medical necessity criteria for multiple sleep latency testing (MSLT)
CP.MP.26Articular Cartilage Defect Repairs4/30/2018Medical necessity guidelines for articular cartilage defect repairs
CP.MP.27Hyperbaric Oxygen Therapy10/31/2018Medical necessity guidelines for hyperbaric oxygen therapy
CP.MP.31Cosmetic and Reconstructive Surgery3/31/2018Medical necessity guidelines for cosmetic and reconstructive surgery
CP.MP.34Hyperemesis gravidarum treatment3/30/2018Medical 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.36Experimental Technologies6/30/2018General 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.38Ultrasound in Pregnancy6/30/2018Medical necessity guidelines for ultrasound use in pregnancy. 
CP.MP.40Gastric electrical stimulation9/30/2018Medical necessity guidelines for gastric electrical stimulation
CP.MP.43Functional MRI9/30/2018Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI).
CP.MP.46Ventricular Assist Devices2/28/2018Medical necessity guidelines for ventricular assist devices.
CP.MP.49Therapy Services (PT/OT/ST)6/22/2018Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment.
CP.MP.50Outpatient testing for drugs of abuse7/31/2018Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. 
CP.MP.51Reduction mammoplasty and gynecomastia surgery7/31/2018Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men
CP.MP.53Ferriscan R2-MRI10/31/2018Medical necessity guidelines for use of the FerriScan R2-MRI
CP.MP.54Hospice Services4/30/2018Medical necessity guidelines for hospice services
CP.MP.55Assisted Reproductive Technology3/31/2018Medical necessity guidelines for assisted reproductive technology
CP.MP.56Ventriculectomy and cardiomyoplasty2/28/2018Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures
CP.MP.57Lung Transplantation10/31/2018Medical necessity guidelines for review of lung transplantation requests
CP.MP.58Intestinal and multivisceral transplant6/30/2018Medical necessity guidelines for the review of intestinal and multivisceral transplant requests.
CP.MP.61Dental Anesthesia4/30/2018Medical necessity guidelines for dental anesthesia
CP.MP.62Hyperhidrosis treatments2/28/2018Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands
CP.MP.68Medical Necessity Criteria6/30/2018This policy identifies the medical necessity guidelines used by the health plan and related definitions
CP.MP.69Intensity-Modulated Radiotherapy2/28/2018Medical necessity guidelines for intensity-modulated radiotherapy (IMRT)
CP.MP.70Proton and neutron beam therapy9/24/2018Medical necessity guidelines for proton beam and neutron beam radiation therapy
CP.MP.71Long Term Care Placement Criteria4/30/2018Medical necessity guidelines for long term care (LTC) placement
CP.MP.81NICU discharge guidelines8/31/2018Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home.
CP.MP.82NICU Apnea Bradycardia Guidelines5/31/2018Medical 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.83Carrier Screening in Pregnancy5/31/2018Medical necessity guidelines for carrier screening in pregnancy
CP.MP.84Cell-free Fetal DNA Testing4/30/2018Medical necessity guidelines for cell-free fetal DNA testing
CP.MP.85Neonatal sepsis management7/31/2018Medical necessity guidelines for neonates requiring comprehensive assessment, treatment, and discharge planning for neonatal intensive care unit (NICU) stays related to sepsis management
CP.MP.86Neonatal abstinence syndrome guidelines9/30/2018Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU)
CP.MP.87Inhaled nitric oxide9/30/2018Medical necessity guidelines for the use of inhaled nitric oxide (iNO)
CP.MP.88Sickle cell disease observation7/31/2018Medical necessity criteria for observation stay for sickle cell disease
CP.MP.89Genetic Testing4/30/2018Medical necessity criteria for genetic testing
CP.MP.91Obstetrical Home Health Care Programs1/31/2018Medical necessity guidelines for OB home health programs
CP.MP.94Clinical Trials10/31/2018Medical necessity guidelines for routine costs of clinical trials
CP.MP.95Gender reassignment surgery10/31/2018Medical necessity guidelines for surgery for the treatment of gender dysphoria
CP.MP.96Ambulatory EEG8/31/2018Medical necessity guidelines for the use of ambulatory electroencephalogram (EEG) testing in the outpatient setting
CP.MP.97Testing for select genitourinary conditions8/31/2018Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis
CP.MP.98Urodynamic testing9/30/2018Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction
CP.MP.99Wheelchair seating9/30/2018Medical necessity guidelines for special wheelchair seating and cushions

Archived Policies