Molina has established Molina Clinical Policy (MCP) that functions as one of the sets of guidelines for coverage decisions or determinations. Please know that these MCPs do not constitute plan authorization, nor is it an explanation of benefits. The MCPs are applicable to all lines of business Apple Health (Medicaid), Marketplace, and Medicare unless superseded by National Coverage Determination (Medicare) or Apple Health (Medicaid) Health Care Authority guidelines.
In this site, the MCPs with information specific to Washington State are made accessible to you to guide you in your medical decisions. All other MCPs are available at link
|
Category |
MCP |
Last Approved Date |
Original Effective Date |
|
Surgery |
MCP-011 Artificial Intervertebral Disc Replacement (ADR) Surgery (Lumbar and Cervical) |
3/12/2024 |
6/14/2006 |
|
Genetic Testing |
3/10/2026 |
5/22/2008 |
|
|
Medical |
10/14/2025 |
4/2/2014 |
|
|
Surgery |
6/10/2025 |
4/2/2014 |
|
|
Medical |
8/5/2025 |
6/25/2014 |
|
|
Medical |
6/10/2025 |
4/13/2022 |
|
|
Medical |
MCP-216a Gender Affirmation Treatment and Procedures (Medicaid) |
3/10/2026 |
10/8/2014 |
|
Medical |
MCP-216c Gender Affirmation Treatment and Procedures (Marketplace) |
3/10/2026 |
4/13/2022 |
|
Medical |
6/10/2025 |
12/8/2014 |
|
|
Medical |
2/10/2026 |
12/8/2014 |
|
|
Medical |
2/10/2026 |
3/24/2016 |
|
|
Medical |
2/10/2026 |
4/23/2020 |
|
|
Medical |
12/9/2025 |
10/13/2021 |
|
|
Medical |
5/13/2025 |
12/8/2021 |
|
|
Medical |
MCP-444 Implantable Peripheral Nerve and Nerve Field Stimulators for Chronic Pain |
2/10/2026 |
12/13/2023 |
|
Durable Medical Equipment |
2/10/2026 |
12/13/2023 |
|
|
Surgery |
1/13/2026 |
4/9/2025 |
|
|
Surgery |
MCP-469 Radiofrequency Nerve Ablation for Neck and Back Pain |
1/13/2026 |
4/9/2025 |
|
Surgery |
3/10/2026 |
4/13/2023 |
|
|
Surgery |
3/10/2026 |
4/13/2023 |
|
|
Surgery |
MCP-702 Foot Surgery: Lesser Toe Deformities (Hammer, Mallet, and Claw Toe) |
3/10/2026 |
4/13/2023 |