Molina has established Molina Clinical Policy that function as one of the sets of guidelines for coverage decisions or determinations. In this site, the Molina Clinical Policy is made accessible to you to guide you in your medical decisions. Please know that these Clinical Policies do not constitute plan authorization, nor is it an explanation of benefits.
*The files below are in PDF format (
).
- Behavioral Health Policies
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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
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Medical Policies
Actigraphy_MCP_374
Administrative Hospital Days_MCP_007
Ambulatory and Video EEG Monitoring Outpatient Setting_MCP_133
Bioimpedence Analysis for Lymphedema Assessment_MCP_234
Breast Implant Removal_MCP_315
Bronchial Thermoplasty_MCP_171
CART T cell Therapy_MCP_317
Category III CPT Codes_MCP_321
Chimeric Antigen Receptor T cell Therapy (CAR-T Cell Therapy): Kymriah (Tisagenlecleucel)_MCP_317a
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
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
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
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
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
Ketogenic Diet Induction for Treatment of Intractable Seizures in the Hospital Setting_MCP_344
Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor_MCP_312
Measurement of Carotid Artery Intima Thickness_MCP_235
Medically Necessary_MCP_332
Oral and Tube Fed Enteral Nutrition_MCR_070
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_207
Proton Beam Radiation Therapy_MCP_226
Proton Beam Therapy for Prostate Cancer_MCP_153
Robotically Assisted Surgery_MCR_161
Sacroiliac Injections and Radiofrequency Albation (RFA) for Sacroiliac Joint Pain_MCR_033
Salpingectomy for Female Sterilization_MCP_311
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 -
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
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 -
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
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 (remedē System) 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
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_MCP_254
Transarterial Chemoembolization for Primary Liver Hepatocellular Cancer_MCP_120
Transcatheter Aortic Valve Replacment_MCP_175
Transcatheter Pulmonary Valve Replacement_MCP_148
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