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:
Phone: (855) 866-5462
Fax: (855) 365-8112
Email: MHILPharmacy@molinahealthcare.com
Abecma (idecabtagene vicleucel) MCP
Abilify MyCite Kit (aripiprazole with biosensor)-(Medical Necessity) MHI
Actemra (tocilizumab) C10265-A
Acthar gel (repository corticotropin injection) C8373-A
Adakveo (crizanlizumab-tcma) C17920-A
Adcetris (brentuximab vedotin) C15428-A
Aduhelm (aducanumab-avwa) MNR
Aldara/Zyclara (imiquimod) MHI
Alpha-1 Antitrypsin Deficiency [Aralast NP, Glassia, Prolastin, Zemaira] MHI
Amitiza (lubiprostone) MHI
Amondys 45 (casimersen) MNR MHI
Ampyra (dalfampridine) MHI
Anticonvulsants Molina IL Medicaid Only C21453-A
Antidiabetic Agents IL Medicaid Only C21858-A
Antiemetics MHI
Antimalarial agents MHI
Apokyn, Kynmobi (apomorphine) MHI
Arcalyst (rilonacept) MHI
Atopic Dermatitis Eucrisa Elidel Protopic IL Medicaid Only C21052-A
Atypical Antipsychotics MHI
Austedo (deutetrabenazine) MHI
Azactam(aztreonam) MHI
Baxdela (delafloxacin) MHI
Belbuca (buprenorphine buccal film) Butrans (buprenorphine transdermal) MHI
Benlysta (belimumab) MHI
Beovu (brolucizumab-dbll) MHI
Botulinum Toxin MHI
Breyanzi MCP
Brineura (cerliponase alfa) MHI
Bylvay (odevixebant) MHI
Cabenuva IL Medicaid Only
Cablivi (caplacizumab) MHI
Calcitonin Gene-Related Peptide (CGRP) antagonist - IL Only C17186-A
Cancidas (caspofungin) MHI
Carisoprodol MHI
Cayston (aztreonam) MHI
Cerdelga (eliglustat) MHI
Cholbam (cholic acid) MHI
Cialis (tadalafil) BPH Coverage Only MHI
Cimzia (certolizumab pegol) MHI
Cinqair (reslizumab) MHI
CNS Stimulants IL Medicaid Only C21108-A
Colcrys, Mitigare, Gloperba (colchicine) MHI
Continous Glucose Monitoring (CGM) IL Medicaid Only
Copaxone/Glatopa (glatiramer acetate) MHI
Cosela (trilaciclib) MHI
Cosentyx (secukinumab) MHI
Crysvita (Burosumab-twza) MHI
Cubicin (daptomycin) MHI
Cuvposa (glycopyrrolate) oral solution MHI
Cystic Fibrosis Agents (Kalydeco, Orkambi, Symdeko, Trikafta) MHI
Cytogam (cytomegalovirus immune globulin) MHI
Dalvance (dalbavancin) MHI
Daraprim (pyrimethamine) MHI
Desmopressin Nasal and Oral (DDAVP) MHI
Dexycu (Dexamethasone intraocular suspension MCP
Diabetic Testing Supplies MHI
Diclofenac topical MHI
Direct Oral Anticoagulants MHI
Disposable Insulin Delivery Device MHI
Doptelet (avatrombopag) MHI
Doxylamine/Pyridoxine MHI
Dry Eye Therapies MHI
Dupixent IL Medicaid Only
Duplication of Therapy/High Risk Combination MHI
Durysta (bimatoprost implant) MCP
Egrifta (tesamorelin) MNR MHI
Elaprase (idursulfase) MHI
Eliquis apixaban IL Medicaid Only C18476-A
Emflaza (deflazacort) MNR MHI
Empaveli (pegcetacoplan) MHI
Enbrel (etanercept) MHI
Endari(L-glutamine) MNR MHI
Enspryng (satralizmab) MHI
Entyvio (vedolizumab) MHI
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] MHI
Enzyme Replacement Therapy for Lysosomal Storage Disorders (MPS I, VI) [Aldurazyme, Naglayzme] MHI
Erythropoiesis-stimulating agents (ESAs) MHI
Esbriet (pirfenidone) MHI
Evenity (romosozumab-aqqg) MHI
Evkeeza MHI
Evrysdi (risdiplam) MHI
Exondys 51 (eteplirsen) MNR MHI
Eylea (aflibercept) MHI
Fabrazyme (agalsidase beta) MHI
Fasenra IL Medicaid Only
Fentanyl patch MHI
Filgrastim MHI
Firdapse_Ruzurgi (Amifamipridine) MHI
Forteo (teriparatide) MHI
Fuzeon (enfuvirtide) MHI
Galafold (migalastat) MHI
Gamifant (Emapalumab-lzsg) MHI
Gattex (teduglutide [rDNA origin]) MHI
Gender Dysphoria Hormone Therapy MHI
Givlaari (givosiran) MHI
Global Compounded Product MHI
Global J Code Criteria MHI
Gocovri/Osmolex (amantadine ER caps/tabs) MHI
Growth Hormone hGH somatropin Therapy IL Medicaid Only
Hemangeol IL Medicaid Only Policy C21109-A
Hemophilia and Blood Factor Products MHI
Hemostatic Agents MHI
Hepatitis B Immune Globulin MHI
Hepatitis C Antiviral Therapy IL Medicaid Only C18433-A
Hereditary Angioedema Agents MHI
Hetlioz (tasimelteon) MHI
High-Cost Outlier Targeted (HOT) Drug Exception MHI
Humira (adalimumab) MHI
Hyaluronic Acid (HA) Injections_Viscosupplementation for Knee OsteoArthritis MHI
Ilaris (canakinumab) MHI
Ilumya (tildrakizumab) MHI
Iluvien (fluocinolone acetonide intravitreal implant) MCP
Immunoglobulin (SCIg, IVIg) MHI
Impetigo Agents- Altabax, Centany, Xepi MHI
Increlex (mecasermin) MHI
Infliximab (Remicade_Inflectra_Renflexis) MHI
Ingrezza (valbenazine) MHI
InPen (Insulin Smart Pen) NC MHI
Inrebic (fedratinib) MHI
Intravenous Bisphophonates MHI
Invega Sustenna IL Medicaid Only C18438-A
Invega Trinza IL Medicaid Only C21110-C
Iron chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) MHI
Iron Deficiency Anemia Agents MHI
Isotretinoin MHI
Isturisa (osilodrostat) MHI
Itraconazole (Sporanox,Tolsura) MHI
Juxtapid (lomitapide) MHI
Kanuma (sebelipase alfa) MHI
Kerendia (finerenone) MHI
Kesimpta (ofatumumab) MHI
Keveyis (dichlorphenamide) MHI
Kevzara (sarilumab) MHI
Kineret (anakinra) MHI
Korlym (mifepristone) MHI
Koselugo (selumetinib) MHI
Krystexxa (pegloticase) MHI
Kuvan (sapropterin dihydrochloride) MHI
Kymriah MCP
Lemtrada (alemtuzumab) MHI
Leukine (sagramostim) MHI
Leuprolide long acting (Lupron Depot, Eligard, Lupaneta, Lupron Depot Ped, Fensolvi) MHI
Lidocaine Patch MHI
Linezolid MHI
Linzess (linaclotide) MHI
Livmarli (maralixibant) MHI
Livtencity (maribavir) MHI
Lokelma (sodium zirconium cyclosilicate) MHI
Lucentis (ranibizumab) MHI
Lumizyme, Myozyme (Alglucosidase alfa) MHI
Lupkynis (voclosporin)
Lutathera (lutetium Lu 177 dotatate) MCP
Luxturna (Voretigene neparvovec-rzyl) for Inherited Retinal Dystrophy MCP
Lyrica.Lyrica CR (pregabalin.pregabalin ER) MHI
Makena IL Medicaid Only
Medical Necessity Review IL Medicaid Only
Mepron (atovaquone) MHI
Mepsevii (vestronidase alfa-vjbk) MHI
Methadone MHI
Motegrity (prucalopride) MHI
Mozobil (plerixafor injection) MHI
Mulpleta (lusutrombopag) MHI
Multiple Sclerosis Agents- Interferons MHI
Myalept (metreleptin) MHI
Mycamine (micafungin) MHI
Narcolepsy Agents MHI
Nasal Steroids MHI
Natpara (parathyroid hormone) MHI
Nexletol (bempedoic acid)_Nexlizet (bempedoic acid and ezetimibe) MHI
Nexviazyme (avalglucosidase alfa-ngpt) MHI
Northera (droxidopa) MHI
Nplate (romiplostim)_Chronic ITP MHI
Nucala (mepolizumab) MHI
Nuedexta (dextromethorphan/quinidine) MHI
Nulibry (fosdenopterin)
Nulojix (belatacept) MHI
Nuplazid (pimavanserin) MHI
Nuzyra (Omadacycline Tosylate) MHI
Ocaliva (obeticholic acid) MHI
Ocrevus (ocrelizumab) MHI
Octreotide MHI
Ofev (nintedanib) MHI
Off-Label Use of Drugs and Biologic Agents MHI
Olumiant (baricitinib) MHI
Omega-3 Fatty Acids MHI
Onpattro (patisiran) and Tegsedi (inotersen) MHI
Opioid Global Criteria MHI
Opioid Induced Constipation Agents MHI
Opzelura (ruxolitinib) MHI
Oral MS Disease-Modifying Therapies
Orencia (abatacept) MHI
Orgovyx (relugolix), Myfembree (relugolix, estradiol, and norethindrone) MHI
Orilissa (elagolix), Oriahn (elagolix, estradiol, and norethindrone acetate capsules) IL ONLY
Orladeyo (berotralstat) MHI
Otezla (apremilast) MHI
Otrexup_Rasuvo (methotrexate) MHI
Oxbryta (voxelotor) MHI
Oxervate (cenegermin) MHI
Oxlumo (lumasiran) MHI
Ozurdex (dexamethasone intravitreal implant) MCP
Palforzia [peanut (Arachis hypogaea) allergen powder-dnfp] MHI
Palynziq (pegvaliase-pqpz) MHI
Parsabiv (etelcalcetide) MHI
PCSK9 Inhibitors MHI
Pegfilgrastrim MHI
Prevymis (letermovir) MHI
Procysbi_Cystagon (cysteamine bitartrate) MHI
Prolia (denosumab) MHI
Promacta (eltrombopag) MHI
Provenge (sipuleucel-T) MCP
Pulmicort Respules (budesonide) MHI
Pulmonary Arterial Hypertension IL Medicaid Only C17185-A
Pulmozyme (dornase alfa) MHI
Qutenza (capsaicin) MHI
Radicava (edaravone) MHI
Ravicti (glycerol phenylbutyrate) MHI
Reblozyl (luspatercept-aamt) MHI
Regranex (becaplermin) MHI
Relizorb (immobilized lipase cartridge) MEDICAID MEDICAL NECESSITY REVIEW
Retisert, Yutiq (fluocinolone acetonide intravitreal implants) MCP
Revcovi (elapegademase) Criteria MHI
Reyvow (lasmiditan) MHI
Rezurock (belumosudil) MHI
Riluzole (Rilutek_Tiglutik_Exservan) MHI
Rinvoq (Upadacitinib) MHI
Rituxan (rituximab) & Rituxan Hycela (rituximab and hyaluronidase human) MHI
Rozlytrek (entrectinib) MHI
Ryplazim (plasminogen, human) MHI
Santyl (collagenase) MHI
Saphnelo (anifrolumab) MHI
Savella (milnacipran) MHI
Scenesse (afamelanotide) MCP
Sensipar (cinacalcet) MHI
Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) MHI
Sexual Dysfunction Criteria- Non-Coverage MHI
Seysara (sarecyline) MHI
Signifor (pasireotide diaspartate) MHI
Siliq (brodalumab) MHI
Simponi/Simponi Aria (golimumab) MHI
Sinuva (mometasone furoate) Sinus Implant MCP
Sivextro (tedizolid) MHI
Skyrizi (risankizumab-rzaa) MHI
Soliris_Ultomiris (eculizumab_ravulizumab) MHI
Spinraza (nusinersen) MCP
Spiriva (tiotropium) MHI
Spravato (esketamine) MHI
Stadol (butorphanol tartrate) MHI
Standard Oncology Criteria MHI
Stelara (ustekinumab) MHI
Strensiq (asfotase alfa) MHI
Sunosi (solriamfetol) MHI
Supprelin (histrelin) MHI
Symlin (pramlintide) MHI
Synagis (palivizumab) MHI
Synarel (nafarelin acetate, nasal solution) MHI
Taltz (ixekizumab) MHI
Tavalisse (fostamatinib) MHI
Tavneos (avacopan) MHI
Tecartus (brexucabtagene autoleucel) MCP
Tepezza (teprotumumab-trbw) MHI
Testosterone MHI
Thiola (tiopronin) MHI
Tobramycin for inhalation MHI
Tolvaptan MHI
Topical Acne and Topical Rosacea IL Medicaid Only C21454-A
Tremfya (guselkumab) MHI
Triptodur (triptorelin pamoate) MHI
Trogarzo (ibalizumab-uiyk) MHI
Tygacil (tigecycline) MHI
Tymlos (abaloparatide) MHI
Tysabri (natalizumab) MHI
Uplizna (inebilizumab) MHI
Valcyte (valganciclovir) MHI
Veklury (remdesivir) MHI
Veltassa (patriomer) MHI
Verquvo IL Medicaid Only
Vibativ (telavancin) MHI
Viltepso (Viltolarsen) MNR MHI
Vimizim (elosulfase alfa)_Mucopolysaccharidosis type IV A MHI
Visudyne (verteporfin) Ocular Photodynamic Therapy MCP
Vitrakvi (larotrectinib) MHI
Voxzogo (vosoritide) MHI
Vyndaqel_Vyndamax (tafamidis) MHI
Vyondys 53 (golodirsen) MNR MHI
Wakix (pitolisant) MHI
Xeljanz_Xeljanz XR (tofacitinib) IL Medicaid Only C22209-A
Xenazine (tetrabenazine) MHI
Xermelo (telotristat ethyl) MHI
Xgeva (denosumab) MHI
Xiaflex (collagenase, clostridium histolyticum)_Dupuytren’s Contracture MCP
Xiaflex (collagenase, clostridium histolyticum)_Peyronie Disease MCP
Xifaxan (rifaximin)_Aemcolo (rifamycin) MHI
Xipere (triamcinolone acetonide ocular inj)
Xolair (Omalizumab) MHI
Xyrem (sodium oxybate), Xywav (calcium, magnesium, potassium, and sodium oxybates) MHI
Yescarta MCP
Zavesca (miglustat) MHI
Zemplar (paricalcitol) MHI
Zilretta (Triamcinolone ER Injection) MCP
Zinplava (bexlotoxumab) MHI
Zokinvy (lonafarnib) MHI
Zoladex (goserelin acetate) MHI
Zortress (everolimus) MHI
Zovirax (acyclovir) topical MHI
Zulresso (brexanolone) MHI - 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