Molina Clinical Policy
The Molina Clinical Policies accessible on this page are specific to Molina Healthcare of Ohio Medicaid only and can be used as a tool to guide you in your medical decisions.
Molina has established Molina Clinical Policies that function as one of the sets of guidelines for coverage decisions or determinations.
Please know that these Molina Clinical Policies do not constitute plan authorization, nor is it an explanation of benefits.
Note: For Medicare, MyCare Ohio, and Marketplace Clinical Policies, please visit the Molina Clinical Policy page.
Archived Medicaid Molina Clinical Policies can be found here.
- Buy and Bill Medications
Actemra (tocilizumab) C10265-A
Acthar Gel (repository corticotropin injection) C8373-A
Adakveo (crizanlizumab-tmca) C17920-A
Adcetris (brentuximab vedotin) C15428-A
Aduhelm (aducanumab-avwa) Medical Necessity Review C21304-A
Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A
Amondys 45 (casimersen) Medical Necessity Review C21154-A
Amvuttra (vutrisiran) C24213-A
Brineura (cerliponase alfa) C11526-A
Cablivi (caplacizumab-yhdp) C19481-A
Calcitonin Gene-Relaed Peptide (CGRP) antagonist C15443-C
Cancidas (caspofungin) C17928-A
Cimzia (certolizumab pegol) C10269-A
Copaxone_Glatopa (glatiramer acetate) C10270-A
Cosentyx (secukinumab) C10410-A
Crysvita (burosumab-twza) C14517-A
Cytogam (cytomegalovirus immune globulin) C9970-A
Dalvance (dalbavancin) C9351-A
Elaprase (idursulfase) C2720-A
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A
Enzyme Replacement Therapy for Lysosomal Storage Disorders C9997-A
Erythropoiesis-stimulating agents (ESAs) C15389-A
Evenity (romosozumab-aqqg) C17324-A
Evkeeza (evinacumab_dgnb) C21101-A
Exondys 51 (eteplirsen) Medical Necessity Review C18464-A
Fabrazyme (agalsidase beta) C4865-A
Fasenra (benralizumab) C13643-A
Gamifant (emapalumab-lzsg) C15970-A
Global J Code Criteria C11251-A
Hemophilia and Blood Factor Products C15607-A
Hepatitis B Immune Globulin C9971-A
Hereditary Angioedema Agents C21463-A
Hyaluronic Acid Injections_Viscosupplementation for Knee OA C14676-A
Igalmi (dexmedetomidine) C23724-A
Ilumya (tildrakizumab) C15971-A
Immunoglobulin (SCIg, IVIg) MHI C21554-A
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A
INPEN (Insulin Smart Pen) Non-Coverage C21865-A
Intravenous Bisphosphonates C16790-A
Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) C15214-A
Iron Deficiency Anemia Agents C14569-A
Kanuma (sebelipase alfa) C9974-A
Kesimpta (ofatumumab) C21104-A
Korsuva (difelikefalin) C23743-A
Krystexxa (pegloticase) C2729-A
Lemtrada (alemtuzumab) C6919-A
Leukine (sargramostim) C2439-A
Leuprolide long acting (Lupron Depot, Eligard, Lupron Depot Ped, Fensolvi, Camcevi) C8756-A
Lumizyme (alglucosidase alfa) C8716_A
Mepsevii (vestronidase alfa-vjbk) C17942-A
Mozobil (plerixafor injection) C9017-A
Multiple Sclerosis Agents - Interferons C10267-A
Nexviazyme (alglucosidase alfa-ngpt) C21948-A
Nulibry (fosdenopterin) C21306-A
Nuzyra (omadacycline tosylate) C15914-A
Ocrevus (ocrelizumab) C11250-A
Onpattro (patisiran)_Tegsedi_(inotersen) C17894-A
Parsabiv (etelcalcetide) C17883-A
Prevymis (letermovir) C15922-A
Pulmonary Arterial Hypertension (PAH) C9837-A
Ranibizumab (Lucentis, Byooviz, Cimerli) MHI C10417-A
Reblozyl (luspatercept-aamt) C18002-A
Revcovi (elapegademase) C16329-A
Rituxan (rituximab) and Biosimilars C10423-A
Ryplazim (plasminogen, human) C22238-A
Saphnelo (anifrolumab) C21970-A
Sexual Dysfunction Criteria - Non-Coverage C16658-A
Signifor (pasireotide diaspartate) C15367-A
Simponi_Simponi Aria (golimumab) C10422-A
Skyrizi (risankizumab-rzaa) C17336-A
Soliris_Ultomiris (eculizumab_ravulizumab) C4867-A
Standard Oncology Criteria C16154-A
Stelara (usketinumab) C10424-A
Sublocade (buprenorphine extended-release inj.) C15161-A
Supprelin LA (histrelin acetate) Implant C20611-A
Tepezza (teprotumumab-trbw) C18462-A
Tezspire(tezepelumab) C23042-A
Triptodur (triptorelin pamoate) C14649-A
Trogarzo (ibalizumab-uiyk) C14522-A
Tygacil (tigecycline) C14555-A
Tysabri (natalizumab) C10276-A
Uplizna (inebilizumab-cdon) C20171-A
Viltepso (vitolarsen) Medical Necessity Review C20406-A
Vimizim (elosulfase alfa) C7068-A
Vyondys 53 (golodirsen) Medical Necessity Review C18466-A
Vyvgart (efgartigimod alfa) C23127-A
Xipere (triamcinolone ocular inj) C22222-A
Zinplava (bexlotoxumab) C14821-A
- Molina Clinical Policies
MCP 000 Evaluation of New Technology
MCP 006 Vagal Nerve Stimulation for Epilepsy
MCP 011 Artificial Disc Replacement
MCP 030 Facet Joint Diagnostic Injections for Chronic Back Pain
MCP 0311 Salpingectomy for Female Sterilization
MCP 032 Epidural Steroid Injections for Back and Neck Pain
MCP 033 Sacroiliac Injections and RFA for SIJ Pain
MCP 050 Hyperbaric Oxygen Therapy and Topical Oxygen Therapy
MCP 085 Radiofrequency Ablation for Chronic Back Pain
MCP 105 Provenge (sipuleucel-T)
MCP 120 Transarterial Chemoembolization for Liver Tumors
MCP 121 Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure
MCP 124 3D Interpretation and Reporting of Imaging Studies
MCP 127 Thermography and BSGI Imaging for the Detection of Breast Lesions
MCP 132 Percutaneous Ventricular Assist Devices
MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting
MCP 145 EPAP for Obstructive Sleep Apnea
MCP 148 Transcatheter Pulmonary Valve Replacement
MCP 161 Robotically Assisted Surgery
MCP 175 Transcatheter Aortic Valve Replacement
MCP 180 QEEG for ADHD with NEBA System
MCP 181 Radioembolization for Primary and Metastatic Tumors of the Liver
MCP 183 Clinical Trials and Rare Disease Policy
MCP 184 Experimental and Investigational Services
MCP 205 Functional Electrical Stimulation for Spinal Cord Injury
MCP 206 Virtual Bronchoscopy for Pulmonary Lesions
MCP 208 Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury
MCP 216a Gender Affirmation Treatment and Procedures_Medicaid
MCP 218 Recombinant Human Bone Morphogenetic Protein
MCP 222 Interspinous Decompression Devices for Spinal Stenosis
MCP 234 Bioimpedence Analysis for Lymphedema Assessment
MCP 235 Measurement of Carotid Artery Intima Thickness
MCP 243 Gastrointestinal Electrical Stimulation GES for Obesity
MCP 244 Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
MCP 250 Prostatic Urethral Lift or UroLift for BPH
MCP 257 Percutaneous Epidural Adhesiolysis
MCP 266 Minimally Invasive Sacroiliac Joint Fusion
MCP 282 Ozurdex_dexamethasone intravitreal implant
MCP 292 Phototherapy and Laser Therapy for Dermatological Conditions
MCP 295 High Intensity Focused Ultrasound for Prostate Cancer
MCP 301 Iluvien (fluocinolone acetonide) Intravitreal Implant
MCP 302 Retisert_Yutiq_fluocinolone acetonide_Intravitreal Implants
MCP 308 Visudyne_verteporfin_for Ocular Photodynamic Therapy
MCP 312 Magnetic Resonance Guided Focused Ultrasound_MRgFUS_for Essential Tremor
MCP 314 Genicular Radiofrequency Ablation RFA and Genicular Nerve Blocks for Chronic Knee Pain
MCP 315 Breast Implant Removal
MCP 318 Luxturna (voretigene neparvovec rzyl)
MCP 321 Category III CPT Codes
MCP 322 Lutathera (lutetium Lu 177 dotatate)
MCP 328 Corneal Collagen Cross Linking
MCP 333 Steroid Eluting Sinus Stents and Implants_PROPEL SINUVA
MCP 335 Deep Brain Stimulation DBS for Epilepsy
MCP 337 Gastroesophageal Reflux Disease GERD Treatment
MCP 338 Plantar Fasciitis Treatment
MCP 339 Interspinous Process Fixation Devices for Spinal Fusion
MCP 340 Implantable Neurostimulator for Central Sleep Apnea
MCP 341 Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation
MCP 342 Dexycu_dexamethasone intraocular suspension
MCP 343 Intervertebral Stabilization Devices
MCP 344 Ketogenic Diet for Treatment of Intractable Seizures
MCP 347 Autologous Chondrocyte Implantation for Knee
MCP 349 Zilretta_triamcinolone ER injection
MCP 351 MILD for Spinal Stenosis
MCP 352 IDEO Intrepid Dynamic Exoskeletal Orthosis
MCP 353 Electric Tumor Treatment Fields for Glioblastoma
MCP 357 Skin Substitutes for Chronic Wound Healing Outpatient
MCP 361 Renal Autotransplantation
MCP 362 Haploididentical Transplantation
MCP 363 Hypoglossal Nerve Stimulation for the Treatment of OSA
MCP 364b COVID-19 CoPays and Cost Share Medicaid
MCP 366 Cluneal Nerve Block for LBP
MCP 367 Scenesse (afamelanotide) Implant
MCP 368 Transcatheter Tricuspid Valve Replacement
MCP 370 Durysta (bimatoprost) Implant
MCP 371 Myocardial Strain Imaging
MCP 372 Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain
MCP 377 Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers
MCP 378 Tecartus (brexucabtagene autoleucel)
MCP 381 Focused Microwave Thermotherapy for Breast Cancer
MCP 382 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
MCP 383 IB-Stim Device for Abdominal Pain in Adolescents
MCP 384 Water Vapor Thermal Therapy for BPH
MCP 385 Peroral Endoscopic Myotomy for Esophageal Achalasia
MCP 386 Coolief Cooled Radiofrequency
MCP 389 XEN Gel Stent for Glaucoma
MCP 391 Radiofrequency Ablation of Primary or Metastatic Liver Tumors
MCP 392 Monarch External Trigeminal Nerve Stimulation eTNS System
MCP 393 Wireless Pulmonary Artery Pressure Monitoring_CardioMEMS_for Congestive Heart Failure
MCP 395 Kymriah (tisagenlecleucel)
MCP 396 Yescarta (axicabtagene ciloleucel)
MCP 397 Moleculight Wound Care Device
MCP 399 Electrostimulation and Electromagnetic Therapy for Wound Care
MCP 400 Breyanzi (lisocabtagene maraleucel)
MCP 401 Foot Surgery Guidelines
MCP 402 Plantar Fasciitis Surgery
MCP 403 Abecma (idecabtagene vicleucel)
MCP 404 Shoulder Arthroscopy Guidelines
MCP 405 Dextenza_dexamethasone intracanalicular ophthalmic insert
MCP 408 Balloon Sinus Ostial Dilation_Balloon Sinuplasty
MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis
MCP 411 Susvimo_ranibizumab intravitreal_injection implant
MCP 412 Prescription Digital Therapeutics
MCP 413 Carvykti (ciltacabtagene autoleucel)
MCP 415 Pluvicto (lutetium Lu 177 vipivotide tetraxetan)
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT
MCP 417 Neutron and Proton Beam Radiation Therapy Policy
MCP 421 Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Parenteral Nutrition (IPN)
MCP 422 Neuromuscular Electrical Training for the Treatment of OSA or Snoring (eXciteOSA)
MCP 423 Topical and Intralesional Therapies
MCP 426 Stem Cell Therapy for Orthopedic Applications
MCP 427 Microwave Tumor Ablation
- New Century Policies
UM CARDIO_1076 Arterial Duplex_09302022
UM CARDIO_1077 Arterial PVR and Stress Arterial PVR_0729202
UM CARDIO_1078 Ankle Brachial Index_02252022
UM CARDIO_1079 Duplex Scan of Hemodialysis Access_07292022
UM CARDIO_1080 Automatic Implantable Cardioverter Defibrillator_10282022
UM CARDIO_1081 Carotid Duplex_02252022
UM CARDIO_1082 Ambulatory EKG Monitoring_07292022
UM CARDIO_1083 Vessel Mapping for Hemodialysis Access or CABG Surgery_11282022
UM CARDIO_1084 Myocardial Perfusion Imaging-Exercise Nuclear Stress Testing_07292022
UM CARDIO_1085 Patient Activated Event Recorder_07292022
UM CARDIO_1093 Venous Duplex_07292022
UM CARDIO_1094 Percutaneous Coronary Intervention_10282022
UM CARDIO_1095 Aortic Valve Replacement_09302022
UM CARDIO_1096 Aorta Coronary Bypass Surgery_10282022
UM CARDIO_1097 Ascending Aortic Graft Surgery_10282022
UM CARDIO_1098 Descending Thoracic Aortic Graft Surgery_09302022
UM CARDIO_1099 Mitral Valve Surgery_09302022
UM CARDIO_1100 Tricuspid Valve Surgery_09302022
UM CARDIO_1101 Cardiac Electrophysiology Study without Arrhythmia Induction_07292022
UM CARDIO_1112 Cardiac Telemetry_07292022
UM CARDIO_1113 Cardiac Magnetic Resonance Imaging_11282022
UM CARDIO_1114 Cardiovascular Stress Test_09302022
UM CARDIO_1115 Coronary Computed Tomographic Angiography_09302022
UM CARDIO_1117 Enhanced External Counterpulsation (EECP)_01282022
UM CARDIO_1119 Pharmacological Nuclear Stress Test-Myocardial Perfusion Imaging_07292022
UM CARDIO_1120 Radionuclide Angiogram (MUGA)_07292022
UM CARDIO_1121 Transthoracic Echocardiography_03252022
UM CARDIO_1122 Transesophageal Echocardiography_02252022
UM CARDIO_1123 Stress Echocardiography_07292022
UM CARDIO_1124 Positron Emission Tomography PET Myocardial Imaging_07292022
UM CARDIO_1125 Renal_Retroperitoneal Vascular Duplex Ultrasound_12312021
UM CARDIO_1126 Abdominal Aortic Ultrasound_08262022
UM CARDIO_1127 Diagnostic Heart Catheterization_02252022
UM CARDIO_1139 Electrophysiology Study with Arrhythmia Induction_09302022
UM CARDIO_1141 EPS with AI_Pacing after DI and Atrial or SVT and AP Ablation_07292022
UM CARDIO_1142 EPS with AI and AFib AVN and AP Ablation_07292022
UM CARDIO_1143 Non Invasive Programmed Stimulation of AICD_11282022
UM CARDIO_1144 Defibrillator Battery Replacement_02252022
UM CARDIO_1145 Pacemaker Battery and Lead(s) Replacement_07292022
UM CARDIO_1146 Implantation of Loop Recorder Systems_02252022
UM CARDIO_1147 Pacemaker Implantation_01282022
UM CARDIO_1148 Synchronized Electrical Cardioversion_01282022
UM CARDIO_1149 Cardiac Resynchronization Therapy Implantation_07292022
UM CARDIO_1152 Device Physiologic CV Data Element Interrogation_10282022
UM CARDIO_1158 Microvolt T-Wave Alternans_07292022
UM CARDIO_1159 Tilt Table Testing_07292022
UM CARDIO_1162 Endo Vascular Abdominal Aortic and Iliac Artery Aneurysm Repair_09302022
UM CARDIO_1163 Carotid Endarterectomy_09302022
UM CARDIO_1164 Femoral Popliteal Bypass Surgery_03252022
UM CARDIO_1165 Hemodialysis Access Creation_02252022
UM CARDIO_1166 Central Venous Access Procedures_11282022
UM CARDIO_1168 Inferior Vena Cava Filter Device_09302022
UM CARDIO_1169 Catheter Based Carotid Artery Digital Angio_01282022
UM CARDIO_1170 Abd Aortography Plus Bilateral Iliofemoral Extremity Runoff_10282022
UM CARDIO_1171 Carotid Artery Stenting_01282022
UM CARDIO_1172 Endovascular Iliac Interventions_10282022
UM CARDIO_1173 Endovascular Femoropopliteal Interventions_09302022
UM CARDIO_1174 Endovascular Tibioperoneal Interventions_10282022
UM CARDIO_1175 Perioperative Cardiovascular Evaluation Before Surgery_10282022
UM CARDIO_1252 Endovascular Venous Laser-Radiofrequency Ablation_04292022
UM CARDIO_1253 Lower Extremity Venous Stripping Ligation_07292022
UM CARDIO_1254 Lower Extremity Venous Sclerotherapy_04292022
UM CARDIO_1255 Lower Extremity Venous Stab Phlebectomy_04292022
UM CARDIO_1256 Device Interrogation_07292022
UM CARDIO_1257 Device (PPM AICD CRT-D CRT-P Subcut-ICD ILR) Programming_07292022
UM CARDIO_1268 Aorto-Renal Endarterectomy or Bypass Surgery_09302022
UM CARDIO_1269 Coronary Fractional Flow Reserve_07292022
UM CARDIO_1291 Coronary Atherectomy_08262022
UM CARDIO_1292 Coronary Intra Vascular Arterial Ultrasound_07292022
UM CARDIO_1293 Renal Angiography_12312021
UM CARDIO_1294 Renal Artery Intervention_07292022
UM CARDIO_1295 Trans Catheter Aortic Valve Replacement_09302022
UM CARDIO_1296 Trans Catheter Mitral Valve Repair_09302022
UM CARDIO_1318 Peripheral Arterial and Venous Ultrasound_07292022
UM CARDIO_1319 Venogram Invasive Vein Mapping_03252022
UM CARDIO_1320 Percutaneous Left Atrial Appendage Closure_09302022
UM CARDIO_1321 Temporal Artery Biopsy_07292022
UM CARDIO_1336 Automated Ambulatory Blood Pressure Monitoring_11282022
UM CARDIO_1337 Abdominal Aortic Aneurysm Open Repair_09302022
UM CARDIO_1339 Hemodialysis Access Maintenance_01282022
UM CARDIO_1358 Intra Cardiac Echocardiography_07292022
UM CARDIO_1368 Percutaneous IlioCaval Intervention_01282022
UM CARDIO_1369 Pericardial Disease Interventions_01282022
UM CARDIO_1370 Thoracentesis and Pleurodesis_09302022
UM CARDIO_1388 Endomyocardial Biopsy_01282022
UM CARDIO_1389 Subcutaneous ICD Device Implantation_07292022
UM CARDIO_1390 Ventricular Assist Device (VAD) Percutaneous and Permanent_01282022
UM CARDIO_1402 Wireless Pulmonary Artery Pressure Device Policy_08262022
UM-CARDIO-1417-Percutaneous-Closure-of-PFO-10282022
UM CARDIO_1418 Intervention on Adults with Congenital Heart Defects_07292022
UM CARDIO_1427 Cardiac Surveillance Following COVID-19 Infection_03252022