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 - Effective 12/16/23
Acthar Gel (repository corticotropin injection) C8373-A – Effective 1/10/24
Adakveo (crizanlizumab-tmca) C17920-A – Effective 11/19/23
Adcetris (brentuximab vedotin) C15428-A - Effective 9/11/23
Adcetris (brentuximab vedotin) C15428-A – Effective 5/1/24
Aduhelm (aducanumab-avwa) MNR C21304-A – Effective 1/10/24
ADZYNMA (ADAMTS13, recombinant-krhn) C27325-A – Effective 4/12/24
Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A - Effective 11/20/23
Amondys 45 C21154-A - Effective 11/20/23
Amvuttra (vutrisiran) C24213-A – Effective 11/19/23
Antiemetics C20780-A – Effective 3/6/24
Antiemetics C20780-A – Effective 5/1/24
Aphexda (motixafortide) C27171-A – Effective 4/12/24
Azactam (aztreonam) C10143-A - Effective 9/11/23
Benlysta (belimumab) C2722-A – Effective 1/10/24
Beovu (brolucizumab) C17923-A – Effective 1/10/24
Botulinum Toxin C8755-A - Effective 4/12/24
Brineura (cerliponase alfa) C11526-A - Effective 10/21/23
Briumvi ublituximab-xiiy C25204-A - Effective 10/21/23
Cablivi (caplacizumab-yhdp) C19481-A – Effective 11/19/23
Calcitonin Gene-Related Peptide (CGRP) Antagonist C15443-C - Effective 11/20/23
Cancidas (caspofungin) C17928-A - Effective 9/11/23
Cimzia (certolizumab pegol) C10269-A - Effective 12/16/23
Cinqair (reslizumab) C9761-A – Effective 1/15/24
Copaxone_Glatopa (glatiramer acetate) C10270-A - Effective 9/11/23
Cosela (trilaciclib) C21205-A - Effective 9/16/23
Cosela (trilaciclib) C21205-A - Effective 5/1/24
Cosentyx (secukinumab) C10410-A - Effective 2/3/24
Cosentyx (secukinumab) C10410-A - Effective 5/1/24
Crysvita (burosumab-twza) C14517-A - Effective 10/21/23
Cubicin (daptomycin) C10467-A - Effective 9/11/23
Cubicin (daptomycin) C10467-A - Effective 5/1/24
Cytogam (cytomegalovirus immune globulin) C9970-A – Effective 4/12/24
Dalvance (dalbavancin) C9351-A – Effective 4/12/24
Durysta (bimatoprost implant) C19830-A – Effective 1/15/24
Elaprase (idursulfase) C2720-A – Effective 11/19/23
Enjaymo (sutimlimab) C22996-A - Effective 9/11/23
Enjaymo (sutimlimab) C22996-A - Effective 5/1/24
Entyvio (vedolizumab) C6773-A – Effective 1/10/24
Enzyme Replacement Therapy for Lysosomal Storage Disorders C9997-A – Effective 11/19/23
Erythropoiesis-stimulating agents (ESAs) C15389-A - Effective 10/21/23
Evenity (romosozumab-aqqg) C17324-A – Effective 11/19/23
Evkeeza (evinacumab_dgnb) C21101-A – Effective 11/27/23
Evkeeza (evinacumab_dgnb) C21101-A – Effective 5/1/24
Exondys 51 (eteplirsen) C18464-A - Effective 11/20/23
Eylea (aflibercept) C5674-A – Effective 1/10/24
Fabrazyme (agalsidase beta) C4865-A – Effective 11/19/23
Fasenra (benralizumab) C13643-A - Effective 1/10/24
Filgrastim C2437-A – Effective 11/19/23
Furoscix (furosemide on-body infusor) C24669– A - Effective 10/6/23
Furoscix (furosemide injection) C24669-A - Effective 4/22/24
Gamifant (emapalumab-lzsg) C15970-A – Effective 11/19/23
Givlaari (givosiran) C17924-A – Effective 11/19/23
Hemophilia and Blood Factor Products C15607-A – Effective 11/19/23
Hepatitis B Immune Globulin C9971-A – Effective 4/12/24
Hereditary Angioedema Agents C21463-A – Effective 11/19/23
Hyaluronic Acid Injections C14676-A - Effective 1/10/24
Igalmi (dexmedetomidine) C23724-A – Effective 11/19/23
Igalmi (dexmedetomidine) C23724-A – Effective 5/1/24
Ilaris (canakinumab) C2435-A - Effective 1/10/24
Ilumya (tildrakizumab) C15971-A - Effective 1/14/24
Immunoglobulin (SCIg, IVIg) MHI C21554-A – Effective 11/27/23
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A – Effective 12/16/23
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A – Effective 5/1/24
Intravenous Bisphosphonates C16790-A - Effective 11/20/23
Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) C15214-A - Effective 11/13/23
Iron Deficiency Anemia Agents C14569-A - Effective 11/13/23
Izervay (avacincaptad intravitreal) C26436-A – Effective 1/10/24
Kanuma (sebelipase alfa) C9974-A - Effective 11/20/23
Kesimpta (ofatumumab) C21104-A – Effective 11/27/23
Korsuva (difelikefalin) C23743-A – Effective 11/27/23
Krystexxa (pegloticase) C2729-A – Effective 4/12/24
Lemtrada (alemtuzumab) C6919-A - Effective 8/17/23
Leqembi (lecanemab-irmb) C25201-A – Effective 1/10/24
Leqvio (inclisiran) C23141-A - Effective 1/10/24
Leqvio (inclisiran) C23141-A - Effective 5/1/24
Leukine (sargramostim) C2439-A - Effective 4/12/24
Lumizyme (alglucosidase alfa) C8716_A - Effective 10/21/23
Mepsevii (vestronidase alfa-vjbk) C17942-A - Effective 11/13/23
Mozobil (plerixafor injection) C9017-A - Effective 4/12/24
Multiple Sclerosis Agents - Interferons C10267-A - Effective 9/11/23
Mycamine (micafungin) C9347-A – Effective 11/27/23
NexoBrid anacaulase-bcdb C25200-A - Effective 8/17/23
Nexviazyme (alglucosidase alfa-ngpt) C21948-A – Effective 11/27/23
Nplate (romiplostim) C6662-A – Effective 11/27/23
Nucala (mepolizumab) C9704-A – Effective 1/10/24
Nulibry (fosdenopterin) C21306-A – Effective 11/27/23
Nulojix (belatacept) C9968-A – Effective 1/15/24
Nuzyra (omadacycline tosylate) C15914-A - Effective 9/11/23
Nuzyra (omadacycline tosylate) C15914-A - Effective 5/1/24
Ocrevus (ocrelizumab) C11250-A - Effective 9/11/23
Octreotide C8839-A – Effective 11/27/23
Off-Label Use of Drugs and Biologic Agents C4141-A – Effective 1/10/24
Omvoh (mirikizumab) C27293-A - Effective 4/12/24
Onpattro (patisiran)_Tegsedi_(inotersen) C17894-A - Effective 11/13/23
Orencia (abatacept) C10420-A - Effective 4/12/24
Oxlumo (lumasiran) C21126-A – Effective 11/27/23
Ozurdex (dexamethasone intravitreal implant) C9975-A – Effective 2/3/24
Parsabiv (etelcalcetide) C17883-A - Effective 11/13/23
Physician Administered Drugs C11251-A - Effective 1/7/24
Pombiliti (cipaglucosidase alfa) C27242-A – Effective 4/12/24
Prevymis (letermovir) C15922-A - Effective 9/11/23
Prevymis (letermovir) C15922-A - Effective 5/1/24
Prolia (denosumab) C8848-A – Effective 11/27/23
Pulmonary Arterial Hypertension (PAH) C9837-A - Effective 4/12/24
Qutenza (capsaicin) C2809-A - Effective 8/17/23
Radicava (edaravone) C11528-A - Effective 8/17/23
Ranibizumab and Biosimilars (Lucentis, Byooviz, Cimerli) C10417-A – Effective 12/16/23
Reblozyl (luspatercept-aamt) C18002-A – Effective 1/10/24
Reblozyl (luspatercept-aamt) C18002-A – Effective 5/1/24
Rebyota (fecal microbiota, live-jslm) C25213-A - Effective 4/12/24
Revcovi (elapegademase) C16329-A - Effective 11/13/23
Rezzayo (rezafungin) C26183-A - Effective 4/12/24
Rituxan (rituximab) and Biosimilars C10423-A - Effective 1/10/24
Rolvedon, Neulasta, and Related Biosimilars C10419-A – Effective 3/6/24
Ryplazim (plasminogen, human) C22238-A – Effective 11/27/23
Rystiggo (rozanolixizumab) C26210-A – Effective 1/10/24
Saphnelo (anifrolumab) C21970-A – Effective 1/10/24
Sexual Dysfunction Criteria - Non-Coverage C16658-A - Effective 9/11/23
Sexual Dysfunction Criteria - Non-Coverage C16658-A - Effective 5/1/24
Signifor (pasireotide diaspartate) C15367-A - Effective 11/13/23
Simponi_Simponi Aria (golimumab) C10422-A - Effective 12/16/23
Sivextro (tedizolid) C9353-A – Effective 4/12/24
Skyrizi (risankizumab-rzaa) C17336-A - Effective 1/10/24
Soliris_Ultomiris (eculizumab_ravulizumab) C4867-A – Effective 11/27/23
Standard Oncology Criteria C16154-A - Effective 9/11/23
Standard Oncology Criteria C16154-A - Effective 5/1/24
Stelara (usketinumab) C10424-A - Effective 1/10/24
Sunlenca (lenacapavir) C25206-A – Effective 4/12/24
Supprelin LA (histrelin acetate) Implant C20611-A – Effective 11/27/23Syfovre (pegcetacoplan intravitreal) C25311-A - Effective 1/14/24
Synagis (palivizumab) C6074-A – Effective 12/1/23
Tepezza (teprotumumab-trbw) C18462-A – Effective 1/10/24
Testosterone C2270-A – Effective 11/27/23
Tezspire(tezepelumab) C23042-A – Effective 1/10/24
Triptodur (triptorelin pamoate) C14649-A - Effective 11/13/23
Trogarzo (ibalizumab-uiyk) C14522-A - Effective 9/11/23
Trogarzo (ibalizumab-uiyk) C14522-A - Effective 5/1/24
Tysabri (natalizumab) C10276-A - Effective 9/11/23
Tzield teplizumab C24729-A - Effective 8/17/23
Uplizna (inebilizumab-cdon) C20171-A – Effective 11/27/23
Vabysmo (faricimab) C22795-A – Effective 1/10/24
Vabysmo (faricimab) C22795-A – Effective 5/1/24
Veopoz (pozelimab-bbfg) C26434-A – Effective 1/10/24
Veklury (remdesivir) C20763-A – Effective 11/27/23
Vibativ (telavancin) C14575-A - Effective 9/11/23
Vibativ (telavancin) C14575-A - Effective 5/1/24
Vimizim (elosulfase alfa) C7068-A – Effective 11/27/23
Vyondys 53 (golodirsen) C18466-A - Effective 11/20/23
Vyvgart (efgartigimod alfa) C23127-A – Effective 1/10/24
Xacduro (sulbactam and durlobactam) C26432-A – Effective 1/10/24
Xacduro (sulbactam and durlobactam) C26432-A – Effective 4/22/24
Xgeva (denosumab) C8849-A – Effective 4/12/24
Xipere (triamcinolone ocular inj) C22222-A – Effective 1/15/24
Xolair (omalizumab) C5678-A – Effective 1/10/24
Zinplava (bexlotoxumab) C14821-A - Effective 9/11/23
Zoladex (goserelin acetate) C8757-A - Effective 11/20/23
- Molina Clinical Policies
MCP 000 Evaluation of New Technology - Effective 9/16/23
MCP 006 Vagal Nerve Stimulation for Epilepsy - Effective 7/26/23
MCP 006 Vagal Nerve Stimulation for Epilepsy - Effective 5/1/24
MCP 011 Artificial Disc Replacement - Effective 7/26/23
MCP 011 Lumbar Artificial Intervertebral Disc Replacement - Effective 4/22/24
MCP 030 Facet Joint Diagnostic Injections for Chronic Back Pain - Effective 7/26/23
MCP 032 Epidural Steroid Injections for Back and Neck Pain - Effective 10/21/23
MCP 033 Sacroiliac Injections and RFA for SIJ Pain - Effective 7/26/23
MCP 050 Hyperbaric Oxygen Therapy and Topical Oxygen Therapy - Effective 9/16/23
MCP 051 Genetic Testing - Effective 9/11/23
MCP 051 Genetic Testing - Effective 5/1/24
MCP 085 Radiofrequency Ablation for Chronic Back Pain - Effective 7/26/23
MCP 105 Provenge (sipuleucel-T) - Effective 9/16/23
MCP 105 Provenge (sipuleucel-T) – Effective 5/1/24
MCP 120 Transarterial Chemoembolization for Liver Tumors - Effective 7/26/23
MCP 121 Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure – Effective 12/15/23
MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 12/16/23
MCP 132 Percutaneous Ventricular Assist Devices - Effective 3/15/24
MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting - Effective 7/26/23
MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting - Effective 5/1/24
MCP 145 EPAP for Obstructive Sleep Apnea - Effective 3/6/24
MCP 148 Transcatheter Pulmonary Valve Replacement
MCP 161 Robotically Assisted Surgery - Effective 7/26/23
MCP 180 QEEG for ADHD with NEBA System - Effective 10/21/23
MCP 181 Radioembolization for Primary and Metastatic Tumors of the Liver - Effective 10/21/23
MCP 183 Clinical Trials and Rare Disease Policy - Effective 7/26/23
MCP 184 Experimental and Investigational Services - Effective 7/26/23
MCP 204 Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair - Effective 9/16/23
MCP 205 Functional Electrical Stimulation for Spinal Cord Injury - Effective 7/26/23
MCP 206 Virtual Bronchoscopy for Pulmonary Lesions - Effective 9/16/23
MCP 207 Platelet Rich Plasma_PRP - Effective 7/26/23
MCP 208 Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury - Effective 7/26/23
MCP 216a Gender Affirmation Treatment and Procedures_Medicaid - Effective 9/11/23
MCP 218 Recombinant Human Bone Morphogenetic Protein - Effective 7/26/23
MCP 222 Interspinous Decompression Devices for Spinal Stenosis - Effective 7/26/23
MCP 235 Measurement of Carotid Artery Intima Thickness – Effective 12/15/23
MCP 250 Prostatic Urethral Lift or UroLift for BPH - Effective 10/21/23
MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 10/21/23
MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 5/1/24
MCP 292 Phototherapy and Laser Therapy for Dermatological Conditions - Effective 7/26/23
MCP 293 Spinraza_nusinersen - Effective 10/21/23
MCP 301 Iluvien (fluocinolone acetonide) Intravitreal Implant – Effective 12/16/23
MCP 302 Retisert_Yutiq_fluocinolone acetonide_Intravitreal Implants - Effective 7/26/23
MCP 308 Visudyne_verteporfin_for Ocular Photodynamic Therapy - Effective 10/21/23
MCP 312 Magnetic Resonance Guided Focused Ultrasound_MRgFUS_for Essential Tremor - Effective 9/16/23
MCP 314 Genicular Radiofrequency Ablation RFA and Genicular Nerve Blocks for Chronic Knee Pain - Effective 7/26/23
MCP 315 Breast Implant Removal - Effective 9/16/23
MCP 318 Luxturna (voretigene neparvovec rzyl) - Effective 10/21/23
MCP 321 Category III CPT Codes - Effective 3/6/24
MCP 322 Lutathera (lutetium Lu 177 dotatate) - Effective 11/13/23
MCP 328 Corneal Collagen Cross Linking - Effective 10/21/23
MCP 329 Enclosed Bed Systems - Effective 1/7/24
MCP 332 Medically Necessary Services: Policy No. 332 - Effective 7/26/23
MCP 333 Steroid-Eluting Sinus Stents and Implants (PROPEL, SINUVA) - Effective 10/6/23
MCP 335 Deep Brain Stimulation DBS for Epilepsy - Effective 9/16/23
MCP 335 Deep Brain Stimulation DBS for Epilepsy - Effective 5/1/24
MCP 337 Gastroesophageal Reflux Disease GERD Treatment – Effective 12/15/23
MCP 338 Plantar Fasciitis Treatment - Effective 7/26/23
MCP 338 Plantar Fasciitis Treatment - Effective 5/1/24
MCP 339 Interspinous Process Fixation Devices for Spinal Fusion - Effective 7/26/23
MCP 339 Interspinous Process Fixation Devices for Spinal Fusion - Effective 5/1/24
MCP 340 Implantable Neurostimulator for Central Sleep Apnea - Effective 3/6/24
MCP 340 Implantable Neurostimulator for Central Sleep Apnea - Effective 5/1/24
MCP 342 Dexycu (dexamethasone intraocular suspension) - Effective 7/26/23
MCP 343 Intervertebral Stabilization Devices – Effective 12/15/23
MCP 344 Ketogenic Diet for Treatment of Intractable Seizures - Effective 7/26/23
MCP 344 Ketogenic Diet for Treatment of Intractable Seizures - Effective 5/1/24
MCP 347 Autologous Chondrocyte Implantation for Knee – Effective 12/16/23
MCP 350 MyoPro Orthosis - Effective 7/26/23
MCP 350 MyoPro Orthosis - Effective 5/1/24
MCP 351 Minimally Invasive Lumbar Decompression MILD for Spinal Stenosis - Effective 3/6/24
MCP 352 Dynamic Exoskeletal Orthoses for Lower Extremity Injuries - Effective 3/6/24
MCP 353 Electric Tumor Treatment Fields for Glioblastoma - Effective 7/26/23
MCP 353 Electric Tumor Treatment Fields for Glioblastoma - Effective 5/1/24
MCP 357 Skin Substitutes - Effective 3/6/24
MCP 361 Renal Autotransplantation - Effective 7/26/23
MCP 362 Haploididentical Transplantation - Effective 7/26/23
MCP 363 Hypoglossal Nerve Stimulation for the Treatment of OSA - Effective 9/16/23
MCP 366 Cluneal Nerve Block for LBP - Effective 11/13/23
MCP 367 Scenesse (afamelanotide) Implant - Effective 7/26/23
MCP 372 Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain – Effective 1/10/24
MCP 377 Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers - Effective 10/21/23
MCP 378 Tecartus (brexucabtagene autoleucel) - Effective 11/13/23
MCP 381 Focused Microwave Thermotherapy for Breast Cancer - Effective 10/21/23
MCP 383 IB-Stim Device for Abdominal Pain in Adolescents - Effective 3/6/24
MCP 384 Water Vapor Thermal Therapy for BPH - Effective 3/6/24
MCP 385 Peroral Endoscopic Myotomy for Esophageal Achalasia - Effective 7/26/23
MCP 386 Coolief Cooled Radiofrequency - Effective 3/6/24
MCP 389 XEN Gel Stent for Glaucoma - Effective 3/6/24
MCP 392 Monarch External Trigeminal Nerve Stimulation eTNS System
MCP 395 Kymriah (tisagenlecleucel) - Effective 9/16/23
MCP 396 Yescarta (axicabtagene ciloleucel) - Effective 11/13/23
MCP 397 Moleculight Wound Care Device - Effective 7/26/23
MCP 399 Electrostimulation and Electromagnetic Therapy for Wound Care - Effective 11/13/23
MCP 400 Breyanzi (lisocabtagene maraleucel) - Effective 11/13/23
MCP 402 Plantar Fasciitis Surgery - Effective 9/16/23
MCP 403 Abecma (idecabtagene vicleucel) - Effective 11/13/23
MCP 404 Shoulder Arthroscopy Guidelines - Effective 7/26/23
MCP 405 Dextenza (dexamethasone intracanalicular insert) - Effective 7/26/23
MCP 407 Wound Vac (NPWT) - Effective 9/11/23
MCP 407 Wound Vac (NPWT) - Effective 5/1/24
MCP 408 Balloon Sinus Ostial Dilation Balloon Sinuplasty - Effective 3/6/24
MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis - Effective 7/26/23
MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis - Effective 5/1/24
MCP 411 Susvimo_ranibizumab intravitreal_injection implant - Effective 7/26/23
MCP 411 Susvimo_ranibizumab intravitreal_injection implant - Effective 5/1/24
MCP 412 Prescription Digital Therapeutics - Effective 9/16/23
MCP 413 Carvykti (ciltacabtagene autoleucel) - Effective 11/13/23
MCP 414 Gastric Electrical Stimulation - Effective 12/15/23
MCP 415 Pluvicto (lutetium Lu 177 vipivotide tetraxetan) - Effective 9/16/23
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 10/21/23
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 5/1/24
MCP 417 Neutron and Proton Beam Radiation Therapy Policy – Effective 11/19/23
MCP 417 Neutron and Proton Beam Radiation Therapy Policy – Effective 5/1/24
MCP 423 Topical and Intralesional Therapies - Effective 9/16/23
MCP 425 Hydrogel Spacer for Prostate Radiotherapy (SpaceOAR) - Effective 8/17/23
MCP 425 Hydrogel Spacer for Prostate Radiotherapy (SpaceOAR) - Effective 5/1/24
MCP 426 Stem Cell Therapy for Orthopedic Applications - Effective 3/6/24
MCP 427 Microwave Ablation of Lung and Liver Tumors - Effective 3/6/24
MCP 432 Developmental Testing - Effective 10/21/23
MCP 435 OMISIRGE (omidubicel onlv) - Effective 9/16/23
MCP 438 Adstiladrin_nadofaragene firadenovec vncg - Effective 9/16/23
MCP 439 Vyjuvek (beremagene geperpavec) - Effective 9/16/23
MCP 440 Pancreatic Islet Cell Transplantation (Autologous) – Effective 11/27/23
MCP 441 Pancreatic Islet Cell Allotransplantation Lantidra (donislecel-jujn) - Effective 10/21/23
MCP 442 MISHA Knee Implant System - Effective 10/21/23
MCP 443 Fractional Laser Treatment of Traumatic and Burn Scars – Effective 12/16/23
MCP 444 Implantable Peripheral Nerve and Nerve Field Stimulators for Chronic Pain – Effective 5/1/24
MCP 447 Casgevy (exagamglogene autotemcel) for Sickle Cell Disease – Effective 5/1/24
MCP 448 Lyfgenia (lovotibeglogene autotemcel) – Effective 5/1/24
MCP 449 Casgevy (exagamglogene autotemcel) for Beta Thalassemia – Effective 5/1/24
MCP 662 Whole Body MRI and/or CT - Effective 11/13/23
MCP 667 Xenoview_Xenon MRI - Effective 12/16/23
MCP 700 Foot Surgery Bunionectomy - Effective 9/11/23
MCP 701 Foot Surgery Hallux Rigidus - Effective 9/11/23
MCP 702 Foot Surgery Lesser Toe Deformities Hammer Mallet and Claw Toe - Effective 9/11/23
- Evolent (formerly known as New Century Health) Policies
UM CARDIO_1076 Arterial Duplex – Effective 3/22/24
UM CARDIO_1077 Arterial PVR and Stress Arterial PVR – Effective 3/22/24
UM CARDIO_1078 Ankle Brachial Index – Effective 3/22/24
UM CARDIO_1079 Duplex Scan of Hemodialysis Access – Effective 3/22/24
UM CARDIO_1080 Automatic Implantable Cardioverter Defibrillator – Effective 3/22/24
UM CARDIO_1081 Carotid Duplex – Effective 3/22/24
UM CARDIO_1082 Ambulatory EKG Monitoring – Effective 3/22/24
UM CARDIO_1083 Vessel Mapping for Hemodialysis Access or CABG Surgery – Effective 3/22/24
UM CARDIO_1084 Myocardial Perfusion Imaging-Exercise Nuclear Stress Testing – Effective 3/22/24
UM CARDIO_1085 Patient Activated Event Recorder – Effective 3/22/24
UM CARDIO_1093 Venous Duplex – Effective 3/22/24
UM CARDIO_1094 Percutaneous Coronary Intervention – Effective 3/22/24
UM CARDIO_1095 Aortic Valve Replacement – Effective 12/16/23
UM CARDIO_1096 Aorta Coronary Bypass Surgery – Effective 10/6/23
UM CARDIO_1097 Ascending Aortic Graft Surgery – Effective 12/16/23
UM CARDIO_1098 Descending Thoracic Aortic Graft Surgery – Effective 12/16/23
UM CARDIO_1099 Mitral Valve Surgery – Effective 10/6/23
UM CARDIO_1100 Tricuspid Valve Surgery – Effective 12/16/23
UM CARDIO_1101 Cardiac Electrophysiology Study without Arrhythmia Induction – Effective 10/6/23
UM CARDIO_1112 Cardiac Telemetry - Effective 3/22/24
UM CARDIO 1113 Cardiac Magnetic Resonance Imaging – Effective 3/22/24
UM CARDIO_1114 Cardiovascular Stress Test – Effective 3/22/24
UM CARDIO_1115 Coronary Computed Tomographic Angiography – Effective 3/22/24
UM CARDIO_1117 Enhanced External Counterpulsation (EECP) – Effective 3/22/24
UM CARDIO_1119 Pharmacological Nuclear Stress Test-Myocardial Perfusion Imaging – Effective 3/22/24
UM CARDIO_1120 Radionuclide Angiogram (MUGA) – Effective 3/22/24
UM CARDIO_1121 Transthoracic Echocardiography – Effective 3/22/24
UM CARDIO_1122 Transesophageal Echocardiography – Effective 3/22/24
UM CARDIO_1123 Stress Echocardiography – Effective 3/22/24
UM CARDIO_1124 Positron Emission Tomography PET Myocardial Imaging – Effective 3/22/24
UM CARDIO_1125 Renal_Retroperitoneal Vascular Duplex Ultrasound - Effective 3/22/24
UM CARDIO_1126 Abdominal Aortic Ultrasound – Effective 3/22/24
UM CARDIO_1127 Left Heart Catheterization – Effective 3/22/24
UM CARDIO_1139 Electrophysiology Study with Arrhythmia Induction – Effective 12/16/23
UM CARDIO_1141 EPS with AI_Pacing after DI and Atrial or SVT and AP Ablation – Effective 10/6/23
UM CARDIO_1142 EPS with AI and AFib AVN and AP Ablation – Effective 10/6/23
UM CARDIO 1143 Non Invasive Programmed Stimulation of AICD – Effective 1/10/24
UM CARDIO_1144 Defibrillator Battery Replacement – Effective 10/6/23
UM CARDIO_1145 Pacemaker Battery and Lead(s) Replacement – Effective 10/6/23
UM CARDIO 1146 Implantation of Loop Recorder Systems – Effective 3/22/24
UM CARDIO_1147 Pacemaker Implantation – Effective 3/22/24
UM CARDIO_1148 Synchronized Electrical Cardioversion – Effective 10/6/23
UM CARDIO_1149 Cardiac Resynchronization Therapy Implantation – Effective 3/22/24
UM CARDIO_1152 Device Physiologic CV Data Element Interrogation – Effective 12/16/23
UM CARDIO_1158 Microvolt T-Wave Alternans - Effective 3/22/24
UM CARDIO_1159 Tilt Table Testing - Effective 11/13/23
UM CARDIO_1162 Endo Vascular Abdominal Aortic and Iliac Artery Aneurysm Repair – effective 12/16/23
UM CARDIO_1163 Carotid Endarterectomy – Effective 12/16/23
UM CARDIO_1164 Femoral Popliteal Bypass Surgery – Effective 10/6/23
UM CARDIO_1165 Hemodialysis Access Creation – Effective 10/6/23
UM CARDIO_1166 Central Venous Access Procedures – Effective 10/6/23
UM CARDIO_1168 Inferior Vena Cava Filter Device – Effective 12/16/23
UM CARDIO_1169 Catheter Based Carotid Artery Digital Angio – Effective 3/22/24
UM CARDIO_1170 Abd Aortography Plus Bilateral Iliofemoral Extremity Runoff – Effective 3/22/24
UM CARDIO_1171 Carotid Artery Stenting – Effective 3/22/24
UM CARDIO_1172 Endovascular Iliac Interventions – Effective 3/22/24
UM CARDIO_1173 Endovascular Femoropopliteal Interventions Effective 3/22/24
UM CARDIO_1174 Endovascular Tibioperoneal Interventions – Effective 3/22/24
UM CARDIO_1175 Perioperative Cardiovascular Evaluation Before Surgery – Effective 12/16/23
UM CARDIO_1252 Endovascular Venous Laser-Radiofrequency Ablation – Effective 3/22/24
UM CARDIO_1253 Lower Extremity Venous Stripping Ligation – Effective 3/22/24
UM CARDIO_1254 Lower Extremity Venous Sclerotherapy – Effective 3/22/24
UM CARDIO_1255 Lower Extremity Venous Stab Phlebectomy – Effective 3/22/24
UM CARDIO_1256 Device Interrogation - Effective 3/22/24
UM CARDIO_1257 Device (PPM AICD CRT-D CRT-P Subcut-ICD ILR) Programming - Effective 11/13/23
UM CARDIO 1268 Aorto-Renal Endarterectomy or Bypass Surgery – Effective 1/10/24
UM CARDIO_1269 Coronary Fractional Flow Reserve - Effective 3/22/24
UM CARDIO_1291 Coronary Atherectomy - Effective 11/13/23
UM CARDIO_1292 Coronary Intra Vascular Arterial Ultrasound - Effective 3/22/24
UM CARDIO 1293 Renal Angiography – Effective 3/22/24
UM CARDIO_1294 Renal Artery Intervention - Effective 3/22/24
UM CARDIO_1295 Trans Catheter Aortic Valve Replacement – Effective 3/22/24
UM CARDIO_1296 Trans Catheter Mitral Valve Repair - Effective 3/22/24
UM CARDIO_1318 Peripheral Arterial and Venous Ultrasound - Effective 11/13/23
UM CARDIO_1319 Venogram Invasive Vein Mapping - Effective 10/21/23
UM CARDIO_1320 Percutaneous Left Atrial Appendage Closure – Effective 3/22/24
UM CARDIO_1321 Temporal Artery Biopsy - Effective 11/13/23
UM CARDIO 1336 Automated Ambulatory Blood Pressure Monitoring – Effective 3/22/24
UM CARDIO_1337 Abdominal Aortic Aneurysm Open Repair – Effective 12/16/23
UM CARDIO_1339 Hemodialysis Access Maintenance - Effective 3/22/24
UM CARDIO_1358 Intra Cardiac Echocardiography - Effective 11/13/23
UM CARDIO_1368 Percutaneous IlioCaval Intervention – Effective 3/22/24
UM CARDIO_1369 Pericardial Disease Interventions – Effective 10/6/23
UM CARDIO_1370 Thoracentesis and Pleurodesis – Effective 12/16/23
UM CARDIO_1388 Endomyocardial Biopsy – Effective 10/6/23
UM CARDIO_1389 Subcutaneous ICD Device Implantation - Effective 3/22/24
UM CARDIO_1390 Ventricular Assist Device (VAD) Percutaneous and Permanent – Effective 3/22/24
UM CARDIO_1402 Wireless Pulmonary Artery Pressure Device Policy - Effective 10/21/23
UM CARDIO_1417 Percutaneous Closure of PFO – Effective 12/16/23
UM CARDIO_1418 Intervention on Adults with Congenital Heart Defects - Effective 11/13/23
UM CARDIO 1453 Ultrasound Guided Vascular Access – Effective 1/10/24
UM CARDIO_1456 Vascular Embolization and Occlusion – Effective 10/6/23
- SKYGEN Policies
UM-2-4000-D Utilization Review Criteria
UM-2-4000-1 Diagnostic Services - Effective 9/1/23
UM-2-4000-2 Preventive Services - Effective 9/1/23
UM-2-4000-3 Restorative Services - Effective 9/1/23
UM-2-4000-4 Periodontic Services - Effective 9/1/23
UM-2-4000-5 Prosthodontic Services - Effective 9/1/23
UM-2-4000-6 Oral Surgery Services - Effective 9/1/23
UM-2-4000-7 Orthodontic Services - Effective 9/1/23
UM-2-4000-8 Anesthesia Services - Effective 11/19/23