Molina Clinical Policy
- Behavioral Health Policies
- DME Policies
- Back Braces_MCR_067
- Bioness Foot Drop System_MCP_346
- Continuous Glucose Monitoring of the Interstitial Fluid_MCP_054
- Cranial Orthotic Devices_MCP_041
- Enclosed Bed Systems_MCP_329
- EPAP for Obstructive Sleep Apnea_MCP_145
- IDEO Intrepid Dynamic Exoskeletal Orthosis_MCP_352
- Lower Limb Robotic Exoskeleton (ReWalk) for Parapalegia_MCP_244
- MyoPro Orthosis_MCP_350
- Noninvasive Positive Pressure Ventilation_MCP_275
- Vendor Oversight for DME and Supplies_MCP_012
- Genetic Testing Policies
- Medical Policies
- Actigraphy_MCP_374
- Administrative Hospital Days_MCP_007
- Ambulatory and Video EEG Monitoring Outpatient Setting_MCP_133
- Autologous Chondrocyte Implantation Knee_MCP_347
- Back Braces MCR 067
- Bioimpedence Analysis for Lymphedema Assessment_MCP_234
- Back Braces MCR 067
- Administrative Hospital Days_MCP_007
- Administrative Hospital Days_MCP_007
- Bioness Foot Drop System_MCP_346
- Breast Implant Removal_MCP_315
- Bronchial Thermoplasty_MCP_17
- CART T cell Therapy_MCP_317
- CAR T-cell Yescarta MCP 396
- Category III CPT Codes_MCP_321
- Chimeric Antigen Receptor T cell Therapy (CAR-T Cell Therapy): Abecma MCP 403
- Chimeric Antigen Receptor T cell Therapy (CAR-T): Yescarta (axicabtagene ciloleucel)_MCP_317b
- Clinical Trials and Rare Disease Policy_MCP_183
- Cluneal Nerve Block for Low Back Pain_MCP_366
- Computer Aided Evaluation Malignancy Breast with MRI and Lung Radiology_MCP_261
- Consistency in Applying Criteria for Medical Necessity Review by Medical Directors and Pharmacists_IL_MA_376
- Continuous Glucose Monitoring of the Interstitial Fluid_MCP_054
- Coolief Cooled Radiofrequency_MCP_386
- COVID 19_MCP_364
- Deep Brain Stimulation for Epilepsy with the Activa® PC Neurostimulator_MCP_335
- Dexamethasone intraocular suspension (Dexycu)_MCP_342
- Donor Lymphocyte Infusion_MCP_210
- Durysta MCP 370
- Electric Tumor Treatment Fields for Glioblastoma_MCP_353
- Epidural Steroid Injections (ESI) for Back and Neck Pain_MCR_032
- Evaluation of New Technology UM 10_MCP_000
- Experimental and Investigational Services_MCP_184
- Eylea MCP 191
- Facet Joint Diagnostic Injections for Chronic Spinal Pain_MCR_030
- Functional Electrical Stimulation for Spinal Cord Injury_MCP_205
- Gastroesophageal Reflux Disease (GERD) Treatment_MCP_337
- Greater Occipital Nerve Block for Treatment of Migraine Headache_MCP_355.pdf
- Heart Transplantation_MCP_116
- High Intensity Focused Ultrasound for Prostate CA_MCP_295
- Hyperbaric Oxygen Therapy (HBOT)_MCR_050
- IB-Stim Device for Abdominal Pain in Adolescents_MCP_383
- Inhaled Nitric Oxide (iNO) for Neonatal Hypoxic Respiratory Failure_MCP_121
- Intensity Modulated Radiation Therapy (IMRT)_MCP_225
- Intravenous Immune Globulin for Solid Organ Transplant_MCP_237
- Intravenous Immunoglobulin (IVIg)_MCP_043
- Ketogenic Diet Induction for Treatment of Intractable Seizures in the Hospital Setting_MCP_344
- Kymriah_MCP_317a
- Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor_MCP_312
- Measurement of Carotid Artery Intima Thickness_MCP_235
- Medically Necessary_MCP_332
- Moleculight Wound Care Device MCP 397
- Monarch external Trigeminal Nerve Stimulation_eTNS_System_MCP_392
- Occipital Nerve Block Therapy for Headache and Occipital Neuralgia_MCP_355
- Optical Coherence Tomography of the Anterior Eye Segment_MCP_388
- Oral and Tube Fed Enteral Nutrition_MCR_070
- Ozudex MCP 282
- Phototherapy, Photochemotherapy and Laser Therapy for Dermatoligical Conditions_MCR_292
- \Plantar Fasciitis Treatments_MCP_338
- Plasmapheresis for Renal and Nonrenal Indications_MCP_134
- Platelet Enriched Plasma_MCP_20
- Prialt_ziconotide intrathecal infusion_MCP_387
- Proton Beam Radiation Therapy_MCP_226
- Radiofrequency Ablation for Chronic Back Pain Associated with the Facet Joint MCR 085
- Radiofrequency Ablation of Primary or Metastatic Liver Tumors_MCP 391
- Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension_MCP_390
- Retisert, Yutiq (fluocinolone acetonide intravitreal implants) MCP 302
- Rezum System For Benign Prostatic Hyperplasia_MCP_384
- Robotically Assisted Surgery_MCR_161
- Sacroiliac Injections and Radiofrequency Albation (RFA) for Sacroiliac Joint Pain_MCR_033
- Salpingectomy for Female Sterilization_MCP_311
- Sinuva Sinus Implant MCP 333
- Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation_MCP_341
- Speech Therapy_MCR_269
- Subcutaneous Immune Globulin (SCIg)_MCP_268
- Stereotactic Radiosurgery_MCP_224
- Thermography and BSGI Imaging for the Detection of Breast Lesions_MCP_127
- Vagal Nerve Stimulation (VNS)_MCR_006
- Virtual Bronchoscopy for Pulmonary Lesions_MCP_206
- Wireless Pulmonary Artery Pressure Monitoring_MCP_393
- XEN Gel Stent for Glaucoma _MCP_389
- Xiaflex for Dupuytren Contracture MCP 259
- Xiaflex for Peyronie Disease MCP 279
- Yescarta_MCP_317b
- Zilretta MCP 349
- Zolgensma_onasemnogene abeparvovec_ MCP_348
- Payment Policies
- Pharmacy Policies
For information about Molina pharmacy policies, contact the Pharmacy Department at:
Phone: (855) 866-5462
Fax: (855) 365-8112
Email: MHILPharmacy@molinahealthcare.com - Radiology MCR Policies
- 3D Interpretation and Reporting of Imaging Studies_MCR-124
- Abdomen CT_MCR-635
- Abdomen CTA with runoff_MCR-648
- Abdomen CTA_MCR-637
- Abdomen MRA_MCR-641
- Abdomen MRI_MCR-639
- Abdomen Pelvic CTA_MCR-636
- AbdomenPelvis CT_MCR-638
- Bone Density_MCR-650
- Bone Marrow MRI_MCR-651
- Brain CT_MCR-601
- Brain MRI_MCR-611
- Brain PET_MCR-655
- Brain SPECT MCR-661
- Breast MRI_MCR-649
- Cervical Spine CT_MCR-616
- Cervical Spine MRI_MCR-619
- Chest CT_MCR-612
- Chest CTA_MCR-613
- Chest MRA_MCR-615
- Chest MRI_MCR-614
- CT (Computer Tomography) Heart with 3D Image_MCR-646
- CT Angiography Brain_MCR-606
- CT Angiography Heart with 3D Image CCTA (Coronary Computed Tomography Angiography)_MCR-647
- CT Heart Calcium Scoring_MCR-645
- CT Sinus- Face_MCR-604
- CT Soft Tissue Neck_MCR-605
- Diagnostic CT Colonography_MCR-642a
- Fetal MRI_MCR-643
- Functional Brain MRI_MCR-657
- Heart MRI_MCR-644
- Low Dose CT Scan for Lung Cancer Screening_MCR-658
- Lower Extremity CT_MCR-631
- Lower Extremity CTA_MCR-632
- Lower Extremity MRA_MCR-634
- Lower Extremity MRI_MCR-633
- Lumbar Spine CT_MCR-618
- Lumbar Spine MRI_MCR-621
- Magnetic Resonance Neurography_MCR-659
- Magnetic Resonance Spectroscopy_MCR-660
- MRA Angiography Brain_MCR-609
- MRI Angiography Spinal Canal_MCR-622
- MUGA Scan_MCR-654
- Neck CTA_MCR-607
- Neck MRA_MCR-610
- NuclearStress_MCR-652
- Orbit-Sella-Temporal Bone IAC including Mastoid-Posterior Fossa MRI_MCR-608
- Orbit-Sella-Temporal Bone IAC Mastoid-Posterior Fossa CT_MCR-602
- Pelvic CT_MCR-624
- Pelvic MRI_MCR-625
- Pelvis CTA_MCR-623
- Pelvis MRA_MCR-626
- PET Scan With or Without CT Attenuation_MCR-656
- PET Scan, Heart (Cardiac)_MCR-653
- Screening CT Colonography_MCR-642b
- Thoracic Spine CT_MCR-617
- Thoracic Spine MRI_MCR-620
- TMJ MRI_MCR-600
- Upper extremity CT_MCR-627
- Upper Extremity CTA_MCR-628
- Upper Extremity MRI_MCR-629
- Upper Extremity MRI MCR 630
- Radiology Medical Policies
- Computer Aided Evaluation Malignancy Breast with MRI and Lung Radiology_MCP_261
- Digital Breast Tomosynthesis_MCP_270
- Low Dose Helical (Spiral) Computed Tomography for Lung Cancer Screening MCR 658
- Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor_MCP_312
- Proton Beam Radiation Therapy_MCP_226
- Proton Beam Therapy for Prostate Cancer_MCP_153
- Stereotactic Radiosurgery_MCP_224
- Thermography and BSGI Imaging for the Detection of Breast Lesions_MCP_127
- Transarterial Chemoembolization for Primary Liver Hepatocellular Cancer_MCP_120
- Surgical Medical Policies
- Artificial Disc Replacement_MCP_011
- Autologous Chondrocyte Implantation Knee_MCP_347
- Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair MCR 204
- Breast Implant Removal_MCP_315
- Epifix and Skin Substitutes_IL_MCP_357
- Facet Joint Allograft_MCP_369
- Foot Surgery Guidelines MCP 401
- Gastrointestinal Electrical Stimulation (GES) for Obesity_MCP_243
- Genicular RFA for Chronic Knee Pain_MCP_314
- Heart Transplantation with a Total Artificial Heart_MCP_245
- Hypoglossal Nerve Stimulation for OSA_MCP_363
- iFuse Implant for Sacroiliac Joint Fusion_MCP_266
- Implantable Neurostimulator for Central Sleep Apnea_MCP_340
- Implantable Neurostimulator for Urinary and Fecal Incontinence_MCP_182
- Implanted Intrathecal Pain Pumps Chronic Pain_MCP_160
- Interspinous Decompression Devices for Spinal Stenosis_MCP_222
- Interspinous Process Fixation Devices for Spinal Fusion_MCP_339
- Intervertebral Stabilization Devices_MCP_343
- MILD for Spinal Stenosis_MCP_351
- Pediatric Bariatric Surgery_MCP_091
- Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain Racz Procedure_MCP_257
- Percutaneous Ventricular Assist Devices_MCP_132
- Peroral Endoscopic Myotomy for Esophageal Achalasia_MCP_385
- Plantar Fasciitis Release Surgery MCP 402
- Prostatic Urethral Lift or UroLift for BPH_MCP_250
- Radioactive Microspheres for Liver Cancer_MCP_181
- Radiofrequency Ablation (RFA) for chronic back pain associated with the facet joint MCR 085
- Recombinant Human Bone Morphogenetic Protein_MCP_21
- Renal Autotransplantation MCP 361
- Robotically Assisted Surgery MCR 161
- Shoulder Arthroscopy Guidelines MCP 404
- Skin Substitutes MCP 357
- Transcatheter Aortic Valve Replacment_MCP_175
- Transcatheter Pulmonary Valve Replacement_MCP_148
- Transcatheter Tricuspid Valve Replacement_MCP_368
- Recombinant Human Bone Morphogenetic Protein_MCP_218
- Intervertebral Stabilization Devices_MCP_343
- MILD for Spinal Stenosis_MCP_351
- Pediatric Bariatric Surgery_MCP_091
- Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain Racz Procedure_MCP_257
- Percutaneous Ventricular Assist Devices_MCP_132
- Prostatic Urethral Lift or UroLift for BPH_MCP_250
- Radioactive Microspheres for Liver Cancer_MCP_181
- Radiofrequency Ablation (RFA) for chronic back pain associated with the facet joint MCR 085
- Recombinant Human Bone Morphogenetic Protein_MCP_218
- Renal Autotransplantation MCP 361
- Robotically Assisted Surgery MCR 161
- Surgical Repair of Pectus Carinatum & Pectus Excavatum Chest Wall Deformity MCP-254
- Transarterial Chemoembolization for Primary Liver Hepatocellular Cancer_MCP_120
- Transcatheter Aortic Valve Replacment_MCP_175
- Transcatheter Pulmonary Valve Replacement_MCP_1
- Transcatheter Tricuspid Valve Replacement_MCP_368
- Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury_MCP_208
- Transplant Medical Policies
- Dexamethasone intraocular suspension (Dexycu)_MCP_342
- Donor Lymphocyte Infusion_MCP_210
- Haploididentical Transplantation_MCP_362
- Heart Transplantation_MCP_116
- Hematopoietic Stem Cell Transplantation Aplastic Anemia_MCP_143
- Hematopoietic Stem Cell Transplantation Ewing's Sarcoma_MCP_272
- Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia_MCP_118
- Hematopoietic Stem Cell Transplantation for Acute Myelogenous Leukemia_MCP_119
- Hematopoietic Stem Cell Transplantation for Chronic Lymphoblastic Leukemia (CLL)_MCP_188
- Hematopoietic Stem Cell Transplantation for Chronic Myelogenous Leukemia (CML)_MCP_187
- Hematopoietic Stem Cell Transplantation for Germ Cell Tumors_MCP_194
- Hematopoietic Stem Cell Transplantation for Immunodeficiency Disorders_MCP_265
- Hematopoietic Stem Cell Transplantation for MPS_MCP_256
- Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndromes (MDS)_MCP_309
- Hematopoietic Stem Cell Transplantation for Neuroblastoma_MCP_193
- Hematopoietic Stem Cell Transplantation for Primary Myelofibrosis (Myeloproliferative Neoplasms MPS)_MCP_324
- Hematopoietic Stem Cell Transplantation for Sickle Cell Anemia_MCP_209
- Hematopoietic Stem Cell Transplantation for Wilm's Tumor_MCP_283
- Hematopoietic Stem Cell Transplantation Hodgkins and NonHodgkins Lymphoma_MCP_125
- Hematopoietic Stem Cell Transplantation Multiple Myeloma_MCP_122
- Intravenous Immune Globulin for Solid Organ Transplant_MCP_237
- Ketogenic Diet Induction for Treatment of Intractable Seizures in the Hospital Setting_MCP_344
- Kidney Transplantation_MCP_045
- Liver Transplantation Adult Pediatric_MCP_114
- Lung Transplantation_MCP_115
- Pancreas Transplant Procedures_MCP_017
- Pre-Transplant Evaluation_MCP_323
- Small Bowel Multivisceral Transplantation_MCP_117
- Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation_MCP_341