Preauthorization Information

This page contains the Molina internal screening criteria for preauthorization

The files below are in PDF format ( pdf icon )

Molina Clinical Review: 3D Interpretation and Reporting of Imaging Studies

Molina Clinical Review: Abdomen CT

Molina Clinical Review: Abdomen CTA

Molina Clinical Review: Abdomen CTA with runoff

Molina Clinical Review: Abdomen MRA

Molina Clinical Review: Abdomen MRI

Molina Clinical Review: Abdomen Pelvic CTA

Molina Clinical Review: AbdomenPelvis CT

Molina Clinical Policy: Ambulatory and Video EEG Monitoring Outpatient Setting

Molina Clinical Policy: Artificial Disc Replacement

Molina Clinical Policy: Autologous Chondrocyte Implantation Knee

Molina Clinical Review: Back Braces

Molina Clinical Policy: Balloon Sinus Ostial Dilation (Balloon Sinuplasty)

Molina Clinical Policy: Bioimpedence Analysis for Lymphedema Assessment

Molina Clinical Policy: Bioness Foot Drop System

Molina Clinical Review: Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair

Molina Clinical Review: Bone Density

Molina Clinical Review: Bone Marrow MRI

Molina Clinical Review: Brain CT

Molina Clinical Review: Brain MRI

Molina Clinical Review: Brain PET

Molina Clinical Review: Brain SPECT

Molina Clinical Policy: Breast Implant Removal

Molina Clinical Review: Breast MRI

Molina Clinical Policy: Bronchial Thermoplasty

Molina Clinical Policy: Category III CPT Codes

Molina Clinical Review: Cervical Spine CT

Molina Clinical Review: Cervical Spine MRI

Molina Clinical Review: Chest CT

Molina Clinical Review: Chest CTA

Molina Clinical Review: Chest MRA

Molina Clinical Review: Chest MRI

Molina Clinical Policy: Clinical Trials and Rare Disease Policy

Molina Clinical Policy: Computer Aided Evaluation Malignancy Breast with MRI and Lung Radiology

Molina Clinical Policy: Coolief Cooled Radiofrequency Ablation (CRFA) for the Management of Chronic Pain

Molina Clinical Policy: COVID-19 Co-Pays and Cost Share

Molina Clinical Policy: Cranial Orthotic Devices

Molina Clinical Review: CT (Computer Tomography) Heart with 3D Image

Molina Clinical Review: CT Angiography Brain

Molina Clinical Review: CT Angiography Heart with 3D Image CCTA _Coronary Computed Tomography Angiography

Molina Clinical Review: CT Heart Calcium Scoring

Molina Clinical Review: CT Sinus- Face

Molina Clinical Review: CT Soft Tissue Neck

Molina Clinical Policy: Deep Brain Stimulation for Epilepsy

Molina Clinical Review: Diagnostic CT Colonography

Molina Clinical Policy: Donor Lymphocyte Infusion

Molina Clinical Policy: Electric Tumor Treatment Fields for Glioblastoma

Molina Clinical Policy: Enclosed Bed Systems

Molina Clinical Policy: EPAP for Obstructive Sleep Apnea

Molina Clinical Review: Epidural Steroid Injections for Chronic Back Pain

Molina Clinical Policy: Evaluation of New Technology UM 10

Molina Clinical Policy: Experimental and Investigational Services

Molina Clinical Review: Facet Joint Diagnostic Injections for Chronic Back Pain

Molina Clinical Review: Fetal MRI

Molina Clinical Review: Functional Brain MRI

Molina Clinical Policy: Functional Electrical Stimulation for Spinal Cord Injury

Molina Clinical Policy: Gastroesophageal Reflux Disease GERD Treatment

Molina Clinical Policy: Gastrointestinal Electrical Stimulation _GES for Obesity

Molina Clinical Policy: Genetic Testing

Molina Clinical Policy: Genicular RFA for Chronic Knee Pain

Molina Clinical Policy: Haploidentical Allogeneic Hematopoietic Cell Transplantation in Blood Cancers

Molina Clinical Review: Heart MRI

Molina Clinical Policy: Heart Transplantation

Molina Clinical Policy: Heart Transplantation with a Total Artificial Heart

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation Aplastic Anemia

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation Ewing's Sarcoma

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Acute Myelogenous Leukemia

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Chronic Lymphoblastic Leukemia _CLL

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Chronic Myelogenous Leukemia _CML

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Germ Cell Tumors

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Immunodeficiency Disorders

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for MPS

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndromes _MDS

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Neuroblastoma

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Primary Myelofibrosis

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Sickle Cell Anemia

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Wilm's Tumor

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation Hodgkins and NonHodgkins Lymphoma

Molina Clinical Policy: Hematopoietic Stem Cell Transplantation Multiple Myeloma

Molina Clinical Policy: High Intensity Focused Ultrasound for Prostate CA

Molina Clinical Review: Hyperbaric Oxygen Therapy

Molina Clinical Policy: IDEO (Intrepid Dynamic Exoskeletal Orthosis) for Lower Extremity Injuries

Molina Clinical Policy: iFuse Implant for Sacroiliac Joint Fusion

Molina Clinical Policy: Implantable Neurostimulator for Central Sleep Apnea

Molina Clinical Policy: Implantable Neurostimulator for Urinary and Fecal Incontinence

Molina Clinical Policy: Implanted Intrathecal Pain Pumps Chronic Pain

Molina Clinical Policy: Inhaled Nitric Oxide _iNO for Neonatal Hypoxic Respiratory Failure

Molina Clinical Policy: Intensity Modulated Radiation Therapy _IMRT

Molina Clinical Policy: Interspinous Decompression Devices for Spinal Stenosis

Molina Clinical Policy: Interspinous Process Fixation Devices for Spinal Fusion

Molina Clinical Policy: Intervertebral Stabilization Devices

Molina Clinical Policy: Ketogenic Diet for Treatment of Intractable Seizures

Molina Clinical Policy: Kidney Transplantation

Molina Clinical Policy: Kymriah _tisagenlecleucel Chimeric Antigen Receptor T cell Therapy

Molina Clinical Policy: Liver Transplantation Adult Pediatric

Molina Clinical Review: Low Dose CT Scan for Lung Cancer Screening

Molina Clinical Review: Lower Extremity

Molina Clinical Review: Lower Extremity CTA

Molina Clinical Review: Lower Extremity MRA

Molina Clinical Review: Lower Extremity MRI

Molina Clinical Policy: Lower Limb Robotic Exoskeleton _ReWalk for Parapalegia

Molina Clinical Review: Lumbar Spine CT

Molina Clinical Review: Lumbar Spine MRI

Molina Clinical Policy: Lung Transplantation

Molina Clinical Policy: Magnetic Resonance Guided Focused Ultrasound _MRgFUS for Essential Tremor

Molina Clinical Review: Magnetic Resonance Neurography

Molina Clinical Review: Magnetic Resonance Spectroscopy

Molina Clinical Policy: Measurement of Carotid Artery Intima Thickness

Molina Clinical Policy: Medically Necessary

Molina Clinical Policy: Minimally Invasive Lumbar Decompression _Mild for Treatment of Lumbar Spinal Stenosis

Molina Clinical Policy: Monarch Trigeminal Nerve Stimulation (eTNS) System

Molina Clinical Review: MRA Angiography Brain

Molina Clinical Review: MRI Angiography Spinal Canal

Molina Clinical Review: MRI Temporomandibular Joint _TMJ

Molina Clinical Review: MUGA Scan

Molina Clinical Policy: MyoPro Orthosis _Myomo, Inc. for Upper Extremity Paralysis/Paresis

Molina Clinical Review: Neck CTA

Molina Clinical Review: Neck MRA

Molina Clinical Policy: Noninvasive Positive Pressure Ventilation

Molina Clinical Policy: Noninvasive Prenatal Testing

Molina Clinical Review: NuclearStress

Molina Clinical Policy: Occipital Nerve Block for Treatment of Migraine Headache

Molina Clinical Policy: Optical Coherence Tomography (OCT) of the Anterior Eye Segment

Molina Clinical Review: Oral and Tube Fed Enteral Nutrition

Molina Clinical Review: Orbit-Sella-Neck-Temporal Bone IAC including Mastoid-Posterior Fossa MRI

Molina Clinical Review: Orbit-Sella-Temporal Bone IAC Mastoid-Posterior Fossa CT

Molina Clinical Policy: Pancreas Transplant Procedures

Molina Clinical Policy: Pediatric Bariatric Surgery

Molina Clinical Review: Pelvic CT

Molina Clinical Review: Pelvic MRI

Molina Clinical Review: Pelvis CTA

Molina Clinical Review: Pelvis MRA

Molina Clinical Policy: Percutaneous Electrical Nerve Field Stimulator (PENFS) [IB-Stim Device] for Functional Abdominal Pain in Adolescents

Molina Clinical Policy: Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain Racz Procedure

Molina Clinical Policy: Percutaneous Ventricular Assist Devices

Molina Clinical Policy: Peroral endoscopic myotomy (POEM) for Esophageal Achalasiac

Molina Clinical Review: PET Scan Heart _Cardiac

Molina Clinical Review: PET Scan With or Without CT Attenuation

Molina Clinical Review: Phototherapy and Laser Therapy for Dermatological Conditions

Molina Clinical Policy: Plantar Fasciitis Treatment

Molina Clinical Policy: Plasmapheresis for Renal and Nonrenal Indications

Molina Clinical Policy: Platelet Enriched Plasma

Molina Clinical Policy: Pretransplant Evaluation

Molina Clinical Policy: Prialt (ziconotide intrathecal infusion)

Molina Clinical Policy: Prostatic Urethral Lift or UroLift for BPH

Molina Clinical Policy: Proton Beam Radiation Therapy

Molina Clinical Policy: QEEG for ADHD with NEBA System

Molina Clinical Policy: Radioactive Microspheres for Liver Cancer

Molina Clinical Review: Radiofrequency Ablation for chronic back pain

Molina Clinical Policy: Radiofrequency Ablation (RFA) of Primary or Metastatic Liver Tumors

Molina Clinical Policy: Radiofrequency Ablation (RFA) of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension

Molina Clinical Policy: Recombinant Human Bone Morphogenetic Protein

Molina Clinical Policy: Renal Autotransplantation

Molina Clinical Review: Sacroiliac Injections and RFA for SIJ Pain

Molina Clinical Policy: Salpingectomy for Female Sterilization

Molina Clinical Review: Screening CT Colonography

Molina Clinical Policy: Shoulder Arthroscopy Guidelines

Molina Clinical Policy: Skin Substitutes for Chronic Wound Healing in the Out-Patient Setting

Molina Clinical Policy: Small Bowel Multivisceral Transplantation

Molina Clinical Policy: Smart Watch for Detection of AF

Molina Clinical Review: Speech Therapy

Molina Clinical Policy: Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

Molina Clinical Policy: Thermography and BSGI Imaging for the Detection of Breast Lesions

Molina Clinical Review: Thoracic Spine CT

Molina Clinical Review: Thoracic Spine MRI

Molina Clinical Policy: Transarterial Chemoembolization for Primary Liver Hepatocellular Cancer

Molina Clinical Policy: Transcatheter Aortic Valve Replacment

Molina Clinical Policy: Transcatheter Pulmonary Valve Replacement Melody

Molina Clinical Policy: Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury

Molina Clinical Review: Upper extremity CT

Molina Clinical Review: Upper Extremity CTA

Molina Clinical Review: Upper Extremity MRA

Molina Clinical Review: Upper extremity MRI

Molina Clinical Review: Vagal Nerve Stimulation

Molina Clinical Policy: Vagus Nerve Stimulation for Depression

Molina Clinical Policy: Virtual Bronchoscopy for Pulmonary Lesions

Molina Clinical Policy: Water Vapor Thermal Therapy for BPH (formerly Rezum System for BPH)

Molina Clinical Policy: Wireless Pulmonary Artery Pressure Monitoring (CardioMEMS) for Congestive Heart Failure

Molina Clinical Policy: XEN Glaucoma Treatment System

Molina Clinical Policy: Yescarta Chimeric Antigen Receptor T cell Therapy

Molina Clinical Policy: ZOLGENSMA (onasemnogene abeparvovec)

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