Archived Medicaid Molina Clinical Policies

Below is a list of archived Medicaid Molina Clinical Policies. View the Molina Clinical Policy page to find the current Molina Clinical Polices for Ohio Medicaid.

Policy Effective End Date
MCP 132 Percutaneous Ventricular Assist Devices - Effective 3/1/23
3/15/2024
MCP 427 Microwave Tumor Ablation - Effective 3/1/23
3/6/2024
MCP 426 Stem Cell Therapy for Orthopedic Applications - Effective 3/1/23
3/6/2024
MCP 422 Neuromuscular Electrical Training for the Treatment of OSA or Snoring (eXciteOSA) – Effective 12/16/23
3/6/2024
MCP 408 Balloon Sinus Ostial Dilation_Balloon Sinuplasty - Effective 3/1/23
3/6/2024
MCP 389 XEN Gel Stent for Glaucoma - Effective 3/1/23
3/6/2024
MCP 386 Coolief Cooled Radiofrequency - Effective 3/1/23
3/6/2024
MCP 384 Water Vapor Thermal Therapy for BPH - Effective 3/1/23
3/6/2024
MCP 383 IB-Stim Device for Abdominal Pain in Adolescents - Effective 3/1/23
3/6/2024
MCP 357 Skin Substitutes - Effective 9/16/23
3/6/2024
MCP 352 IDEO Intrepid Dynamic Exoskeletal Orthosis - Effective 3/1/23
3/6/2024
MCP 351 MILD for Spinal Stenosis - Effective 3/1/23
3/6/2024
MCP 340 Implantable Neurostimulator for Central Sleep Apnea - Effective 3/1/23
3/6/2024
MCP 321 Category III CPT Codes - Effective 3/1/23
3/6/2024
MCP 145 EPAP for Obstructive Sleep Apnea - Effective 3/1/23
3/6/2024
Rolvedon, Neulasta and Related Biosimilars C10419-A - Effective 9/11/23
3/6/2024
Antiemetics C20780-A – Effective 10/6/23
3/6/2024
Tygacil (tigecycline) C14555-A - Effective 11/13/23
2/15/2024
Fuzeon (enfuvirtide) C9573– A - Effective 10/6/23
2/15/2024
Botulinum Toxin C8755-A - Effective 1/14/24
2/2/2024
Krystexxa (pegloticase) C2729-A – Effective 11/27/23
2/2/2024
Cosentyx (secukinumab) C10410-A - Effective 10/21/23
2/2/2024
MCP 282 Ozurdex (dexamethasone intravitreal implant) - Effective 7/26/23
2/2/2024
Cinqair (reslizumab) C9761-A – Effective 11/19/23
1/15/2024
Nulojix (belatacept) C9968-A – Effective 11/27/23
1/15/2024
Xipere (triamcinolone ocular inj) C22222-A – Effective 11/27/23
1/15/2024
MCP 370 Durysta (bimatoprost) Implant - Effective 7/26/23
1/14/2024
Syfovre (pegcetacoplan) C25311-A - Effective 11/26/23
1/14/2024
Ilumya (tildrakizumab) C15971-A - Effective 11/20/23
1/14/2024
Botulinum Toxin C8755-A - Effective 3/1/23
1/14/2024
UM CARDIO_1143 Non Invasive Programmed Stimulation of AICD_11282022 – Effective 3/1/23
1/10/24
UM CARDIO_1146 Implantation of Loop Recorder Systems – Effective 10/6/23
1/10/24
UM CARDIO_1268 Aorto-Renal Endarterectomy or Bypass Surgery_09302022
1/10/24
UM CARDIO_1293 Renal Angiography – Effective 10/6/23
1/10/24
UM CARDIO_1336 Automated Ambulatory Blood Pressure Monitoring_11282022 – Effective 3/1/23
1/10/24
UM CARDIO_1453 Ultrasound Guided Vascular Access - Effective 10/21/23
1/10/24
UM CARDIO_1113 Cardiac Magnetic Resonance Imaging_11282022 – Effective 3/1/23
1/10/24
Leqvio (inclisiran) C23141-A - Effective 12/7/23
1/10/24
Xolair (omalizumab) C5678-A - Effective 8/17/23
1/10/24
Vyvgart (efgartigimod alfa) C23127-A – Effective 3/1/23
1/10/24
Vabysmo (faricimab) C22795-A – Effective 3/1/23
1/10/24
Tezspire(tezepelumab) C23042-A – Effective 3/1/23
1/10/24
Tepezza (teprotumumab-trbw) C18462-A – Effective 11/27/23
1/10/24
Skyrizi (risankizumab-rzaa) C17336-A - Effective 11/13/23
1/10/24
Saphnelo (anifrolumab) C21970-A – Effective 11/27/23
1/10/24
Reblozyl (luspatercept-aamt) C18002-A - Effective 9/11/23
1/10/24
Acthar Gel (repository corticotropin injection) C8373-A – Effective 3/1/23
1/10/24
Benlysta (belimumab) C2722-A – Effective 11/19/23
1/10/24
Beovu (brolucizumab) C17923-A
1/10/24
Aduhelm (aducanumab-avwa) Medical Necessity Review C21304-A - Effective 9/11/23
1/10/24
Entyvio (vedolizumab) C6773-A – Effective 11/19/23
1/10/24
Eylea (aflibercept) C5674-A - Effective 8/17/23
1/10/24
Ilaris (canakinumab) C2435-A - Effective 11/20/23
1/10/24
Hyaluronic Acid Injections_Viscosupplementation for Knee OA C14676-A - Effective 10/21/23
1/10/24
Leqembi (lecanemab-irmb) MNR C25201-A - Effective 8/17/23
1/10/24
Stelara (usketinumab) C10424-A - Effective 11/13/23
1/10/24
Fasenra (benralizumab) C13643-A - Effective 10/21/23
1/10/24
Nucala (mepolizumab) C9704-A – Effective 11/27/23
1/10/24
Rituxan (rituximab) and Biosimilars C10423-A - Effective 11/13/23
1/10/24
MCP 372 Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain
1/10/24
MCP 428 Mobile Cardiac Outpatient Telemetry
1/8/2024
Physician Administered Drugs C11251-A - Effective 9/11/23
1/7/2024
MCP 329 Enclosed Bed Systems - Effective 3/1/23
1/7/2024
MCP 391 Radiofrequency Ablation of Primary or Metastatic Liver Tumors
1/1/2024
MCP 433 Roctavian (valoctocogene roxaparvovec) - Effective 10/21/23
1/1/2024
MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 9/16/23
12/15/2023
MCP 347 Autologous Chondrocyte Implantation for Knee
12/15/2023
MCP 301 Iluvien (fluocinolone acetonide) Intravitreal Implant
12/15/2023
MCP 244 Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
12/15/2023
MCP 422 Neuromuscular Electrical Training for the Treatment of OSA or Snoring (eXciteOSA)
12/15/2023
MCP 667 Xenoview_Xenon MRI - Effective 9/16/23
12/15/2023
UM CARDIO_1095 Aortic Valve Replacement_09302022
12/15/2023
UM CARDIO_1097 Ascending Aortic Graft Surgery_10282022
12/15/2023
UM CARDIO_1098 Descending Thoracic Aortic Graft Surgery_09302022
12/15/2023
UM CARDIO_1100 Tricuspid Valve Surgery_09302022
12/15/2023
UM CARDIO_1139 Electrophysiology Study with Arrhythmia Induction_09302022
12/15/2023
UM CARDIO_1152 Device Physiologic CV Data Element Interrogation_10282022
12/15/2023
UM CARDIO_1162 Endo Vascular Abdominal Aortic and Iliac Artery Aneurysm Repair_09302022
12/15/2023
UM CARDIO_1163 Carotid Endarterectomy_09302022
12/15/2023
UM CARDIO_1168 Inferior Vena Cava Filter Device_09302022
12/15/2023
UM CARDIO_1175 Perioperative Cardiovascular Evaluation Before Surgery_10282022
12/15/2023
UM CARDIO_1295 Trans Catheter Aortic Valve Replacement_09302022
12/15/2023
UM CARDIO_1320 Percutaneous Left Atrial Appendage Closure_09302022
12/15/2023
UM CARDIO_1337 Abdominal Aortic Aneurysm Open Repair_09302022
12/15/2023
UM CARDIO_1417 Percutaneous Closure of PFO_10282022
12/15/2023
Actemra (tocilizumab) C10265-A - Effective 10/21/23
12/15/2023
Cimzia (certolizumab pegol) C10269-A - Effective 10/21/23
12/15/2023
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A
12/15/2023
UM CARDIO_1370 Thoracentesis and Pleurodesis_09302022
12/15/2023
Orencia (abatacept) C10420-A - Effective 11/13/23
12/15/2023
Ranibizumab (Lucentis, Byooviz, Cimerli) MHI C10417-A – Effective 3/1/23
12/15/2023
Simponi_Simponi Aria (golimumab) C10422-A - Effective 11/13/23
12/15/2023
MCP 421 Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Parenteral Nutrition (IPN) – Effective 3/1/23
12/14/2023
MCP 414 Gastric Electrical Stimulation - Effective 9/11/23
12/14/2023
MCP 343 Intervertebral Stabilization Devices – Effective 3/1/23
12/14/2023
MCP 337 Gastroesophageal Reflux Disease GERD Treatment – Effective 3/1/23
12/14/2023
MCP 235 Measurement of Carotid Artery Intima Thickness – Effective 3/1/23
12/14/2023
MCP 121 Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure – Effective 3/1/23
12/14/2023
Leqvio (inclisiran) C23141-A - Effective 3/1/23
12/6/2023
Synagis (palivizumab) C6074-A – Effective 11/27/23
11/30/2023
Xgeva (denosumab) C8849-A
11/26/2023
Korsuva (difelikefalin) C23743-A
11/26/2023
Krystexxa (pegloticase) C2729-A
11/26/2023
Soliris_Ultomiris (eculizumab_ravulizumab) C4867-A
11/26/2023
Nplate (romiplostim) C6662-A
11/26/2023
Vimizim (elosulfase alfa) C7068-A
11/26/2023
Octreotide C8839-A
11/26/2023
Prolia (denosumab) C8848-A
11/26/2023
Mycamine (micafungin) C9347-A
11/26/2023
Sivextro (tedizolid) C9353-A
11/26/2023
Nucala (mepolizumab) C9704-A
11/26/2023
Nulojix (belatacept) C9968-A
11/26/2023
MCP 440 Pancreatic Islet Cell Transplantation - Effective 9/16/23
11/26/2023
Synagis (palivizumab) C6074-A
11/26/2023
Tepezza (teprotumumab-trbw) C18462-A
11/26/2023
Uplizna (inebilizumab-cdon) C20171-A
11/26/2023
Supprelin LA (histrelin acetate) Implant C20611-A
11/26/2023
Veklury (remdesivir) C20763-A
11/26/2023
Evkeeza (evinacumab_dgnb) C21101-A
11/26/2023
Kesimpta (ofatumumab) C21104-A
11/26/2023
Oxlumo (lumasiran) C21126-A
11/26/2023
Nulibry (fosdenopterin) C21306-A
11/26/2023
Immunoglobulin (SCIg, IVIg) MHI C21554-A
11/26/2023
Nexviazyme (alglucosidase alfa-ngpt) C21948-A
11/26/2023
Saphnelo (anifrolumab) C21970-A
11/26/2023
Xipere (triamcinolone ocular inj) C22222-A
11/26/2023
Ryplazim (plasminogen, human) C22238-A
11/26/2023
Testosterone C2270-A
11/26/2023
Zoladex (goserelin acetate) C8757-A - Effective 3/1/23
11/19/2023
Vyondys 53 (golodirsen) Medical Necessity Review C18466-A - Effective 3/1/23
11/19/2023
Leuprolide long acting (Lupron Depot, Eligard, Lupron Depot Ped, Fensolvi, Camcevi) C8756-A - Effective 3/1/23
11/19/2023
Kanuma (sebelipase alfa) C9974-A - Effective 3/1/23
11/19/2023
Intravenous Bisphosphonates C16790-A - Effective 3/1/23
11/19/2023
Ilumya (tildrakizumab) C15971-A - Effective 3/1/23
11/19/2023
Ilaris (canakinumab) C2435-A - Effective 3/1/23
11/19/2023
Exondys 51 (eteplirsen) Medical Necessity Review C18464-A - Effective 9/11/23
11/19/2023
Calcitonin Gene-Related Peptide (CGRP) antagonist C15443-C - Effective 9/16/23
11/19/2023
Amondys 45 (casimersen) Medical Necessity Review C21154-A - Effective 9/11/23
11/19/2023
Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A - Effective 3/1/23
11/19/2023 
Hepatitis B Immune Globulin C9971-A – Effective 3/1/23
11/18/2023 
Igalmi (dexmedetomidine) C23724-A – Effective 3/1/23
11/18/2023 
Hereditary Angioedema Agents C21463-A – Effective 3/1/23
11/18/2023 
Enzyme Replacement Therapy for Lysosomal Storage Disorders C9997-A – Effective 3/1/23
11/18/2023 
Cytogam (cytomegalovirus immune globulin) C9970-A – Effective 3/1/23
11/18/2023 
Cinqair (reslizumab) C9761-A – Effective 3/1/23
11/18/2023 
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A – Effective 3/1/23
11/18/2023 
Dalvance (dalbavancin) C9351-A – Effective 3/1/23
11/18/2023 
Entyvio (vedolizumab) C6773-A – Effective 3/1/23
11/18/2023 
Fabrazyme (agalsidase beta) C4865-A – Effective 3/1/23
11/18/2023 
Benlysta (belimumab) C2722-A – Effective 3/1/23
11/18/2023 
Elaprase (idursulfase) C2720-A – Effective 3/1/23
11/18/2023 
Filgrastim C2437-A – Effective 3/1/23
11/18/2023 
Amvuttra (vutrisiran) C24213-A – Effective 3/1/23
11/18/2023 
Cablivi (caplacizumab-yhdp) C19481-A – Effective 3/1/23
11/18/2023 
Givlaari (givosiran) C17924-A – Effective 3/1/23
11/18/2023 
Adakveo (crizanlizumab-tmca) C17920-A – Effective 3/1/23
11/18/2023 
Evenity (romosozumab-aqqg) C17324-A – Effective 3/1/23
11/18/2023 
Gamifant (emapalumab-lzsg) C15970-A – Effective 3/1/23
11/18/2023 
Hemophilia and Blood Factor Products C15607-A – Effective 3/1/23
11/18/2023 
UM-2-4000-8 Anesthesia Services - Effective 9/1/23
11/18/2023 
MCP 417 Neutron and Proton Beam Radiation Therapy Policy – Effective 3/1/23
11/18/2023 
MCP 662 Whole Body MRI - Effective 7/26/23
11/12/2023
MCP 413 Carvykti (ciltacabtagene autoleucel) - Effective 3/1/23
11/12/2023
MCP 403 Abecma (idecabtagene vicleucel) - Effective 3/1/23
11/12/2023
MCP 400 Breyanzi (lisocabtagene maraleucel) - Effective 3/1/23
11/12/2023
MCP 399 Electrostimulation and Electromagnetic Therapy for Wound Care - Effective 3/1/23
11/12/2023
MCP 396 Yescarta (axicabtagene ciloleucel) - Effective 3/1/23
11/12/2023
MCP 378 Tecartus (brexucabtagene autoleucel) - Effective 3/1/23
11/12/2023
MCP 322 Lutathera (lutetium Lu 177 dotatate) - Effective 3/1/23
11/12/2023
MCP 366 Cluneal Nerve Block for LBP - Effective 3/1/23
11/12/2023
UM CARDIO_1418 Intervention on Adults with Congenital Heart Defects_07292022
11/12/2023
UM CARDIO_1358 Intra Cardiac Echocardiography_07292022
11/12/2023
UM CARDIO_1321 Temporal Artery Biopsy_07292022
11/12/2023
UM CARDIO_1318 Peripheral Arterial and Venous Ultrasound_07292022
11/12/2023
UM CARDIO_1291 Coronary Atherectomy_08262022
11/12/2023
UM CARDIO_1257 Device (PPM AICD CRT-D CRT-P Subcut-ICD ILR) Programming_07292022
11/12/2023
UM CARDIO_1256 Device Interrogation_07292022
11/12/2023
UM CARDIO_1159 Tilt Table Testing_07292022
11/12/2023
UM CARDIO_1158 Microvolt T-Wave Alternans_07292022
11/12/2023
UM CARDIO_1112 Cardiac Telemetry_07292022
11/12/2023
Tygacil (tigecycline) C14555-A - Effective 3/1/23
11/12/2023
Triptodur (triptorelin pamoate) C14649-A - Effective 3/1/23
11/12/2023
Stelara (usketinumab) C10424-A - Effective 3/1/23
11/12/2023
Skyrizi (risankizumab-rzaa) C17336-A - Effective 3/1/23
11/12/2023
Simponi_Simponi Aria (golimumab) C10422-A - Effective 3/1/23
11/12/2023
Signifor (pasireotide diaspartate) C15367-A - Effective 3/1/23
11/12/2023
Rituxan (rituximab) and Biosimilars C10423-A - Effective 3/1/23
11/12/2023
Revcovi (elapegademase) C16329-A - Effective 3/1/23
11/12/2023
Parsabiv (etelcalcetide) C17883-A - Effective 3/1/23
11/12/2023
Orencia (abatacept) C10420-A - Effective 3/1/23
11/12/2023
Onpattro (patisiran)_Tegsedi_(inotersen) C17894-A - Effective 3/1/23
11/12/2023
Mepsevii (vestronidase alfa-vjbk) C17942-A - Effective 3/1/23
11/12/2023
Iron Deficiency Anemia Agents C14569-A - Effective 3/1/23
11/12/2023
Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) C15214-A - Effective 3/1/23
11/12/2023
MCP 429 Hemgenix (etranacogene dezaparvovec-drlb) - Effective 9/16/23 11/8/2023
UM CARDIO_1427 Cardiac Surveillance Following COVID-19 Infection - Effective 10/21/23 11/8/2023
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 9/16/23
10/20/2023
MCP 393 Wireless Pulmonary Artery Pressure Monitoring_CardioMEMS_for Congestive Heart Failure - Effective 3/1/23
10/20/2023
MCP 381 Focused Microwave Thermotherapy for Breast Cancer - Effective 3/1/23
10/20/2023
MCP 377 Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers - Effective 3/1/23
10/20/2023
MCP 368 Transcatheter Tricuspid Valve Replacement - Effective 3/1/23
10/20/2023
MCP 328 Corneal Collagen Cross Linking - Effective 3/1/23
10/20/2023
MCP 318 Luxturna (voretigene neparvovec rzyl) - Effective 3/1/23
10/20/2023
MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 7/26/23
10/20/2023
MCP 308 Visudyne_verteporfin_for Ocular Photodynamic Therapy - Effective 3/1/23
10/20/2023
MCP 293 Spinraza_nusinersen - Effective 3/1/23
10/20/2023
MCP 250 Prostatic Urethral Lift or UroLift for BPH - Effective 3/1/23
10/20/2023
MCP 181 Radioembolization for Primary and Metastatic Tumors of the Liver - Effective 3/1/23
10/20/2023
MCP 180 QEEG for ADHD with NEBA System - Effective 3/1/23
10/20/2023
MCP 032 Epidural Steroid Injections for Back and Neck Pain - Effective 3/1/23
10/20/2023
Erythropoiesis-stimulating agents (ESAs) C15389-A - Effective 3/1/23
10/20/2023
Hyaluronic Acid Injections_Viscosupplementation for Knee OA C14676-A - Effective 3/1/23
10/20/2023
Crysvita (burosumab-twza) C14517-A - Effective 3/1/23
10/20/2023
Fasenra (benralizumab) C13643-A - Effective 3/1/23
10/20/2023
Brineura (cerliponase alfa) C11526-A - Effective 3/1/23
10/20/2023
Cosentyx (secukinumab) C10410-A - Effective 3/1/23
10/20/2023
Cimzia (certolizumab pegol) C10269-A - Effective 3/1/23
10/20/2023
Actemra (tocilizumab) C10265-A - Effective 3/1/23
10/20/2023
Pulmonary Arterial Hypertension (PAH) C9837-A - Effective 3/1/23
10/20/2023
Briumvi ublituximab-xiiy C25204-A - Effective 8/17/23
10/20/2023
Lumizyme (alglucosidase alfa) C8716_A - Effective 3/1/23
10/20/2023
UM CARDIO_1453 Ultrasound Guided Vascular Access_12312021
10/20/2023
UM CARDIO_1427 Cardiac Surveillance Following COVID-19 Infection_03252022
10/20/2023
UM CARDIO_1402 Wireless Pulmonary Artery Pressure Device Policy_08262022
10/20/2023
UM CARDIO_1389 Subcutaneous ICD Device Implantation_07292022
10/20/2023
UM CARDIO_1339 Hemodialysis Access Maintenance_01282022
10/20/2023
UM CARDIO_1319 Venogram Invasive Vein Mapping_03252022
10/20/2023
UM CARDIO_1296 Trans Catheter Mitral Valve Repair_09302022
10/20/2023
UM CARDIO_1294 Renal Artery Intervention_07292022
10/20/2023
UM CARDIO_1292 Coronary Intra Vascular Arterial Ultrasound_07292022
10/20/2023
UM CARDIO_1269 Coronary Fractional Flow Reserve_07292022
10/20/2023
UM CARDIO_1125 Renal_Retroperitoneal Vascular Duplex Ultrasound_12312021
10/20/2023
INPEN (Insulin Smart Pen) Non-Coverage C21865-A
10/19/2023
MCP 134 Therapeutic Apheresis 10/12/2023
MCP 234 Bioimpedence Analysis for Lymphedema Assessment 10/12/2023
MCP 243 Gastrointestinal Electrical Stimulation GES for Obesity 10/12/2023
Linezolid C8632-A 10/6/2023
UM CARDIO_1456 Vascular Embolization and Occlusion_01282022
10/5/2023
UM CARDIO_1390 Ventricular Assist Device (VAD) Percutaneous and Permanent_01282022
10/5/2023
UM CARDIO_1388 Endomyocardial Biopsy_01282022
10/5/2023 
UM CARDIO_1369 Pericardial Disease Interventions_01282022
10/5/2023 
UM CARDIO_1368 Percutaneous IlioCaval Intervention_01282022
10/5/2023 
UM CARDIO_1293 Renal Angiography_12312021
10/5/2023
UM CARDIO_1255 Lower Extremity Venous Stab Phlebectomy_04292022
10/5/2023 
UM CARDIO_1254 Lower Extremity Venous Sclerotherapy_04292022
10/5/2023 
UM CARDIO_1253 Lower Extremity Venous Stripping Ligation_07292022
10/5/2023 
UM CARDIO_1252 Endovascular Venous Laser-Radiofrequency Ablation_04292022
10/5/2023 
UM CARDIO_1174 Endovascular Tibioperoneal Interventions_10282022
10/5/2023 
UM CARDIO_1173 Endovascular Femoropopliteal Interventions_09302022
10/5/2023 
UM CARDIO_1172 Endovascular Iliac Interventions_10282022
10/5/2023 
UM CARDIO_1171 Carotid Artery Stenting_01282022
10/5/2023 
UM CARDIO_1170 Abd Aortography Plus Bilateral Iliofemoral Extremity Runoff_10282022
10/5/2023 
UM CARDIO_1169 Catheter Based Carotid Artery Digital Angio_01282022
10/5/2023 
UM CARDIO_1166 Central Venous Access Procedures_11282022
10/5/2023 
UM CARDIO_1165 Hemodialysis Access Creation_02252022
10/5/2023 
UM CARDIO_1164 Femoral Popliteal Bypass Surgery_03252022
10/5/2023 
UM CARDIO_1149 Cardiac Resynchronization Therapy Implantation_07292022
10/5/2023 
UM CARDIO_1148 Synchronized Electrical Cardioversion_01282022
10/5/2023 
UM CARDIO_1147 Pacemaker Implantation_01282022
10/5/2023 
UM CARDIO_1146 Implantation of Loop Recorder Systems_02252022
10/5/2023 
UM CARDIO_1145 Pacemaker Battery and Lead(s) Replacement_07292022
10/5/2023 
UM CARDIO_1144 Defibrillator Battery Replacement_02252022
10/5/2023 
UM CARDIO_1142 EPS with AI and AFib AVN and AP Ablation_07292022
10/5/2023 
UM CARDIO_1141 EPS with AI_Pacing after DI and Atrial or SVT and AP Ablation_07292022
10/5/2023 
UM CARDIO_1140 EPS with Transseptal Left Heart Cath with Arrhythmia Induction and VT Ablation_07292022
10/5/2023 
UM CARDIO_1127 Diagnostic Heart Catheterization_02252022
10/5/2023 
UM CARDIO_1126 Abdominal Aortic Ultrasound_08262022
10/5/2023 
UM CARDIO_1124 Positron Emission Tomography PET Myocardial Imaging_07292022
10/5/2023 
UM CARDIO_1123 Stress Echocardiography_07292022
10/5/2023 
UM CARDIO_1122 Transesophageal Echocardiography_02252022
10/5/2023 
UM CARDIO_1121 Transthoracic Echocardiography_03252022
10/5/2023 
UM CARDIO_1120 Radionuclide Angiogram (MUGA)_07292022
10/5/2023 
UM CARDIO_1119 Pharmacological Nuclear Stress Test-Myocardial Perfusion Imaging_07292022
10/5/2023 
UM CARDIO_1117 Enhanced External Counterpulsation (EECP)_01282022
10/5/2023 
UM CARDIO_1115 Coronary Computed Tomographic Angiography_09302022
10/5/2023 
UM CARDIO_1114 Cardiovascular Stress Test_09302022
10/5/2023 
UM CARDIO_1101 Cardiac Electrophysiology Study without Arrhythmia Induction_07292022
10/5/2023 
UM CARDIO_1099 Mitral Valve Surgery_09302022
10/5/2023 
UM CARDIO_1096 Aorta Coronary Bypass Surgery_10282022
10/5/2023 
UM CARDIO_1094 Percutaneous Coronary Intervention_10282022
10/5/2023 
UM CARDIO_1093 Venous Duplex_07292022
10/5/2023 
UM CARDIO_1085 Patient Activated Event Recorder_07292022
10/5/2023 
UM CARDIO_1084 Myocardial Perfusion Imaging-Exercise Nuclear Stress Testing_07292022
10/5/2023 
UM CARDIO_1083 Vessel Mapping for Hemodialysis Access or CABG Surgery_11282022
10/5/2023 
UM CARDIO_1082 Ambulatory EKG Monitoring_07292022
10/5/2023 
UM CARDIO_1081 Carotid Duplex_02252022
10/5/2023 
UM CARDIO_1080 Automatic Implantable Cardioverter Defibrillator_10282022
10/5/2023 
UM CARDIO_1079 Duplex Scan of Hemodialysis Access_07292022
10/5/2023 
UM CARDIO_1078 Ankle Brachial Index_02252022
10/5/2023 
UM CARDIO_1077 Arterial PVR and Stress Arterial PVR_07292022
10/5/2023
UM CARDIO_1076 Arterial Duplex)-7292022
10/5/2023 
MCP 333 Steroid-Eluting Sinus Stents and Implants (PROPEL, SINUVA) - Effective 7/26/23
10/5/2023 
Antiemetics C20780-A – Effective 3/1/23
10/5/2023 
Cosela (trilaciclib) C21205-A - Effective 3/1/23
9/15/2023
Calcitonin Gene-Related Peptide (CGRP) Antagonist C15443-C - Effective 3/1/23
9/15/2023
MCP 423 Topical and Intralesional Therapies - Effective 3/1/23
9/15/2023
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 3/1/23 9/15/2023
MCP 415 Pluvicto (lutetium Lu 177 vipivotide tetraxetan) - Effective 3/1/23
9/15/2023
MCP 412 Prescription Digital Therapeutics - Effective 3/1/23
9/15/2023
MCP 402 Plantar Fasciitis Surgery - Effective 3/1/23 9/15/2023
MCP 395 Kymriah (tisagenlecleucel) - Effective 3/1/23
9/15/2023
MCP 363 Hypoglossal Nerve Stimulation for OSA - Effective 3/1/23
9/15/2023
MCP 357 Skin Substitutes for Chronic Wound Healing Outpatient - Effective 3/1/23
9/15/2023
MCP 335 Deep Brain Stimulation DBS for Epilepsy - Effective 3/1/23
9/15/2023
MCP 315 Breast Implant Removal - Effective 3/1/23
9/15/2023
MCP 312 Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor - Effective 3/1/23 9/15/2023
MCP 206 Virtual Bronchoscopy for Pulmonary Lesions - Effective 3/1/23 9/15/2023
MCP 204 Blepharoplasty - Effective 3/1/23 9/15/2023
MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 3/1/23 9/15/2023
MCP 105 Provenge (sipuleucel-T) - Effective 3/1/23
9/15/2023
MCP 050 Hyperbaric Oxygen Therapy and Topical Oxygen Therapy - Effective 3/1/23
9/15/2023
MCP 000 Evaluation of New Technology - Effective 3/1/23
9/15/2023
MCP 127 Thermography and BSGI Imaging for the Detection of Breast Lesions 9/15/2023
MCP 371 Myocardial Strain Imaging 9/15/2023
MCP 374 Actigraphy 9/15/2023
MCP 382 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders 9/15/2023
Pegfilgrastim C10419-A
9/11/2023
Global J Code Criteria C11251-A
9/11/2023
MCP 051 Genetic Testing - Effective 3/1/23 9/10/2023
MCP 216a Gender Affirmation Treatment and Procedures_Medicaid - Effective 3/1/23 9/10/2023
Adcetris (brentuximab vedotin) C15428-A - Effective 3/1/23 9/10/2023
Aduhelm (aducanumab-avwa) Medical Necessity Review C21304-A - Effective 3/1/23 9/10/2023
Amondys 45 (casimersen) Medical Necessity Review C21154-A - Effective 3/1/23 9/10/2023
Azactam (aztreonam) C10143-A - Effective 3/1/23 9/10/2023
Cancidas (caspofungin) C17928-A - Effective 3/1/23 9/10/2023
Copaxone_Glatopa (glatiramer acetate) C10270-A - Effective 3/1/23 9/10/2023
Cubicin (daptomycin) C10467-A - Effective 3/1/23 9/10/2023
Enjaymo (sutimlimab) C22996-A - Effective 3/1/23 9/10/2023
Exondys 51 (eteplirsen) Medical Necessity Review C18464-A - Effective 3/1/23 9/10/2023
Multiple Sclerosis Agents - Interferons C10267-A - Effective 3/1/23 9/10/2023
Nuzyra (omadacycline tosylate) C15914-A - Effective 3/1/23 9/10/2023
Ocrevus (ocrelizumab) C11250-A - Effective 3/1/23 9/10/2023
Prevymis (letermovir) C15922-A - Effective 3/1/23 9/10/2023
Reblozyl (luspatercept-aamt) C18002-A - Effective 3/1/23 9/10/2023
Sexual Dysfunction Criteria - Non-Coverage C16658-A - Effective 3/1/23 9/10/2023
Standard Oncology Criteria C16154-A - Effective 3/1/23 9/10/2023
Trogarzo (ibalizumab-uiyk) C14522-A - Effective 3/1/23 9/10/2023
Tysabri (natalizumab) C10276-A - Effective 3/1/23 9/10/2023
Vibativ (telavancin) C14575-A - Effective 3/1/23 9/10/2023
Zinplava (bexlotoxumab) C14821-A - Effective 3/1/23 9/10/2023
Zulresso (brexanolone) C16319-A - Effective 3/1/23 9/10/2023
MCP 369 Facet Joint Allograft
9/6/2023
MCP 175 Transcatheter Aortic Valve Replacement
9/6/2023
UM-2-4010-D Clinical Criteria - Effective 3/1/23
9/1/2023 
UM-2-4400-D Criteria for Medical Necessity - Effective 3/1/23  9/1/2023 
UM-2-5200-D Criteria for Procedures that may Require Prior Authorization or Retrospective Review - Effective 3/1/23  9/1/2023 
UM-2-5235-D Criteria for Radiographs - Effective 3/1/23  9/1/2023 
UM-2-5245-D Criteria for Non-Restorable Tooth - Effective 3/1/23  9/1/2023 
Xolair (omalizumab) C5678-A
8/17/2023
Radicava (edaravone) C11528-A
8/17/2023
Qutenza (capsaicin) C2809-A
8/17/2023
Mozobil (plerixafor injection) C9017-A
8/17/2023
Leukine (sargramostim) C2439-A
8/17/2023
Lemtrada (alemtuzumab) C6919-A
8/17/2023
Eylea (aflibercept) C5674-A
8/17/2023
MCP 0311 Salpingectomy for Female Sterilization 8/10/2023
Viltepso (vitolarsen) Medical Necessity Review C20406-A
8/1/2023
Sublocade (buprenorphine extended-release inj.) C15161-A
7/31/2023
MCP 120 Transarterial Chemoembolization (TACE) and Transarterial Embolization (TAE) for Liver Tumors
7/26/2023
MCP 208 Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury
7/26/2023
MCP 222 Interspinous Decompression Devices for Spinal Stenosis
7/26/2023
MCP 257 Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain (RACZ Procedure)
7/26/2023
MCP 266 Minimally Invasive Sacroiliac Joint Fusion
7/26/2023
MCP 282 Ozurdex (dexamethasone intravitreal implant)
7/26/2023
MCP 292 Phototherapy and Laser Therapy for Dermatological Conditions
7/26/2023
MCP 302 Retisert_Yutiq_fluocinolone acetonide_Intravitreal Implants
7/26/2023
MCP 314 Genicular Radiofrequency Ablation RFA and Genicular Nerve Blocks for Chronic Knee Pain
7/26/2023
MCP 332 Medically Necessary Services: Policy No. 332
7/26/2023
MCP 333 Steroid-Eluting Sinus Stents and Implants (PROPEL, SINUVA)
7/26/2023
MCP 338 Plantar Fasciitis Treatment
7/26/2023
MCP 339 Interspinous Process Fixation Devices for Spinal Fusion
7/26/2023
MCP 341 Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation
7/26/2023
MCP 342 Dexycu (dexamethasone intraocular suspension)
7/26/2023
MCP 344 Ketogenic Diet for Treatment of Intractable Seizures
7/26/2023
MCP 350 MyoPro Orthosis
7/26/2023
MCP 353 Electric Tumor Treatment Fields for Glioblastoma 7/26/2023
MCP 361 Renal Autotransplantation
7/26/2023
MCP 362 Haploidentical Transplantation
7/26/2023
MCP 367 Scenesse (afamelanotide) Implant
7/26/2023
MCP 370 Durysta (bimatoprost) Implant
7/26/2023
MCP 385 Peroral Endoscopic Myotomy for Esophageal Achalasia
7/26/2023
MCP 397 Moleculight Wound Care Device 7/26/2023
MCP 404 Shoulder Arthroscopy
7/26/2023
MCP 405 Dextenza (dexamethasone intracanalicular insert)
7/26/2023
MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis
7/26/2023
MCP 411 Susvimo_ranibizumab intravitreal_injection implant
7/26/2023
MCP 662 Whole Body MRI
7/26/2023
MCP 218 Recombinant Human Bone Morphogenetic Protein
7/25/2023
MCP 207 Platelet Rich Plasma
7/25/2023
MCP 205 Functional Electrical Stimulation for Spinal Cord Injury
7/25/2023
MCP 184 Experimental and Investigational Services
7/25/2023
MCP 183 Clinical Trials and Rare Disease Policy
7/25/2023
MCP 161 Robotically Assisted Surgery
7/25/2023
MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting
7/25/2023
MCP 085 Radiofrequency Ablation for Chronic Back Pain
7/25/2023
MCP 033 Sacroiliac Injections and RFA for SIJ Pain
7/25/2023
MCP 030 Facet Joint Diagnostic Injections for Chronic Back Pain
7/25/2023
MCP 011 Artificial Disc Replacement
7/25/2023
MCP 006 Vagal Nerve Stimulation for Epilepsy
7/25/2023
MCP 295 High Intensity Focused Ultrasound for Prostate Cancer
7/6/2023
MCP 349 Zilretta_triamcinolone ER injection
7/6/2023
MCP 364b COVID-19 CoPays and Cost Share Medicaid
7/6/2023
MCP 401 Foot Surgery Guidelines
7/6/2023
MCP 649 Breast MRI
7/6/2023
MCP 357 Skin Substitutes for Chronic Wound Healing Outpatient
5/1/2023
Pulmonary Arterial Hypertension (PAH) C9837-A 4/17/2023
Insulin Patch NC C24238-A 3/28/2023
MCP 045 Kidney Transplantation 2/27/2023
MCP 413 Carvykti (ciltacabtagene autoleucel) 2/10/2023
UM CARDIO_1121 Transthoracic Echocardiography 2/1/2023