|
Molina Clinical Policy
|
Date Last Updated
|
Date Originally Approved
|
|
MCP-000 Evaluation of New and Existing Technologies including Experimental and Investigational Designations
|
09/18/2019
|
04/24/2007
|
|
MCP-011 Artificial Disc Replacement
|
11/06/2018
|
06/14/2006
|
|
MCP-017 Pancreas Transplant Procedures
|
09/18/2019
|
06/01/2006
|
|
MCP-041 Cranial Orthotic Devices
|
10/08/2019
|
10/11/2007
|
|
MCP-045 Kidney Transplantation
|
09/18/2019
|
02/28/2008
|
|
MCP-054 Continuous Glucose Monitoring of the Interstitial fluid
|
09/18/2019
|
11/20/2008
|
|
MCP-051 Genetic Testing
|
06/11/2019
|
05/22/2008
|
|
MCP-091 Pediatric Bariatric Surgery
|
09/10/2019
|
10/11/2007
|
|
MCP-070 Oral and Tube Fed Enteral Nutrition
|
09/10/2009
|
09/10/2009
|
|
MCP-114 Liver Transplantation Adult and Pediatric
|
11/12/2019
|
08/23/2012
|
|
MCP-115 Lung Transplantation
|
09/18/2019
|
08/30/2012
|
|
MCP-116 Heart Transplantation
|
11/12/2019
|
09/24/2012
|
|
MCP-117 Small Bowel Transplantation, Small Bowel and Liver Transplantation, and Multivisceral Transplantation
|
09/18/2019
|
08/30/2012
|
|
MCP-118 Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)
|
11/06/2018
|
10/31/2012
|
|
MCP-119 Hematopoietic Stem Cell Transplantation for Acute Myelogenous Leukemia (AML)
|
01/14/2020
|
10/31/2012
|
|
MCP-120 Transarterial Chemo-embolization (TACE) for Primary Liver Hepatocellular Carcinoma (HCC)
|
07/09/2019
|
10/31/2012
|
|
MCP-121 Nitrous Oxide for Neonatal Hypoxic Respiratory Failure
|
09/18/2019
|
10/4/2012
|
|
MCP-122 Hematopoietic Stem Cell Transplantation for Multiple Myeloma
|
07/09/2019
|
12/12/2012
|
|
MCP-125 Hematopoietic Stem Cell Transplantation for Hodgkin's and Non-Hodgkin's Lymphoma
|
01/14/2020
|
04/24/2013
|
|
MCP-127 Thermography for the Detection of Breast Lesions
|
09/11/2018
|
12/11/2013
|
|
MCP-132 Percutaneous Ventricular Assist Devices
|
01/14/2020
|
02/27/2013
|
|
MCP-133 Ambulatory Electroencephalographic (EEG) and Video EEG Monitoring for Adults and Children
|
09/18/2019
|
4/24/2013
|
|
MCP-134 Plasmaphresis for Renal and Non-Renal Indications
|
06/11/2019
|
04/24/2013
|
|
MCP-143 Hematopoietic Stem Cell Transplantation for Aplastic Anemia
|
01/14/2020
|
06/26/2013
|
|
MCP-145 EPAP for Obstructive Sleep Apnea
|
01/14/2020
|
06/26/2013
|
|
MCP-148 Transcatheter Pulmonary Valve Replacment Melody
|
01/14/2020
|
10/30/2013
|
|
MCP-153 Proton Beam Therapy for Prostate Cancer
|
07/09/2019
|
10/30/2013
|
|
MCP-157 Noninvasive Prenatal Testing
|
07/09/2019
|
06/22/2017
|
|
MCP-160 Implanted Intrathecal Pain Pumps Chronic Pain
|
09/10/2019
|
04/02/2014
|
|
MCP-175 Transcatheter Aortic Valve Replacement for Aortic Stenosis
|
06/19/2019
|
07/10/2014
|
|
MCP-171 Bronchial Thermoplasty
|
09/10/2019
|
06/12/2014
|
|
MCP-180 NEBA System for ADHD
|
11/12/2019
|
08/13/2014
|
|
MCP-181 Radioactive Yttrium-90 Microspheres for Treatment of Liver Cancer
|
11/12/2019
|
07/10/2014
|
|
MCP-182 Implantable Neurostimulator for Sacral Neuromodulation in Treatment of Fecal Incontinence
|
09/11/2018
|
08/04/2014
|
|
MCP-183 Clinical Trials and Rare Disease Policy
|
10/08/2019
|
06/25/2014
|
|
MCP-184 Experimental and Investigational Services
|
10/08/2019
|
06/25/2014
|
|
MCP-187 Hematopoietic Stem Cell Transplantation for Chronic Myelogenous Leukemia (CML)
|
09/11/2018
|
07/25/2014
|
|
MCP-188 Hematopoietic Stem Cell Transplantation for Chronic Lymphoblastic Leukemia (CLL) and small lymphocytic lymphoma (SLL)
|
09/11/2018
|
07/29/2014
|
| MCP-193 Hematopoietic Stem Cell Transplantation for Neuroblastoma |
07/09/2019
|
07/17/2014
|
|
MCP-194 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
|
09/18/2019
|
09/17/2014
|
|
MCP-205 Functional Electrical Stimulation for Spinal Cord Injury
|
06/19/2019
|
08/27/2014
|
|
MCP-206 Virtual Bronchoscopy and Electromagnetic Navigationa; Bronchoscopy for Evaluation of Peripheral Pulmonary Lesions
|
09/11/2018
|
08/25/2014
|
|
MCP-207 Platelet-rich Plasma (PRP)
|
06/19/2019
|
10/08/2014
|
|
MCP-208 Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury
|
06/19/2019
|
10/14/2014
|
|
MCP-209 Hematopoietic Stem Cell Transplantation for Sickle Cell Anemia
|
09/18/2019
|
11/11/2014
|
|
MCP-210 Donor Lymphocyte Infusion
|
09/10/2019
|
11/11/2014
|
|
MCP-218 Recombinant Human Bone Morphogenetic Protein (rhBMP) for Bone Fusion
|
11/12/2019
|
07/10/2018
|
|
MCP-222 Interspinous Decompression Devices for Spinal Stenosis
|
10/08/2019
|
03/16/2015
|
|
MCP-224 Stereotactic Radiosurgery
|
09/18/2019
|
12/18/2014
|
|
MCP-225 Intensity Modulated Radiation Therapy (IMRT)
|
09/19/2019
|
03/25/2015
|
|
MCP-226 Proton Beam Radiation Therapy Ocular and Skull Base Tumors
|
09/11/2018
|
03/25/2015
|
|
MCP-234 Bioimpedance for Lymphedema Assessment
|
11/12/2019
|
02/02/2015
|
|
MCP-235 Measurement of Carotid Artery Intima-Media Thickness
|
10/08/2019
|
02/02/2015
|
|
MCP-238 Magnetic Resonance Neurography
|
02/06/2018
|
02/05/2015
|
|
MCP-243 Gastrointestinal Electrical Stimulation (GES) and Vagus Nerve Blocking Therapy (VBLOC) for Obesity
|
11/12/2019
|
07/08/2015
|
|
MCP-244 Lower-limb Robotic Exoskeleton [ReWalk-P (Personal)] for Paraplegia in Spinal Cord Injury
|
09/11/2018
|
07/08/2015
|
|
MCP-245 Heart Transplantation with a Total Artificial Heart (TAH)
|
05/07/2019
|
04/06/2015
|
|
MCP-250 Prostatic Urethral Lift or UroLift for BPH
|
07/09/2019
|
06/02/2015
|
|
MCP-254 Surgical Repair of Pectus Carinatum Pectus Excavatum
|
09/18/2019
|
10/12/2015
|
|
MCP-256 Hematopoietic Stem Cell Transplantation for MPS
|
05/07/2019
|
02/02/2016
|
|
MCP-257 Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain Racz Procedure
|
11/12/2019
|
10/12/2015
|
|
MCP-261 Computer Aided Evaluation (CAE) of Malignancy with Breast MRI and Lung Radiography
|
06/19/2019
|
01/01/2016
|
|
MCP-265 Hematopoietic Stem Cell Transplantation for Immunodeficiency Disorders
|
09/18/2019
|
02/10/2016
|
|
MCP-266 iFuse Implant System (SI-BONE Inc.) for Sacroiliac Joint Fusion for Treatment of Low Back Pain
|
06/06/2019
|
01/13/2016
|
|
MCP-272 Hematopoietic Stem Cell Transplantation Ewing's Sarcoma
|
09/18/2019
|
05/03/2016
|
|
MCP-275 Noninvasive Positive Pressure Ventilation
|
09/11/2018
|
05/23/2016
|
|
MCP-283 Hematopoietic Stem Cell Transplantation Wilms Tumor
|
06/19/2019
|
01/01/2017
|
|
MCP-295 High Intensity Focused Ultrasound for Prostate CA
|
06/19/2019
|
01/01/2017
|
|
MCP-309 Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndromes (MDS)
|
09/11/2018
|
03/08/2018
|
|
MCP-311 Salpingectomy for Female Sterilization
|
10/08/2019
|
10/02/2018
|
|
MCP-312 Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor
|
10/08/2019
|
07/10/2018
|
|
MCP-314 Genicular Radiofrequency Ablation and Genicular Nerve Blocks for Chronic Knee
|
11/12/2018
|
09/13/2018
|
|
MCP-315 Breast Implant Removal
|
10/08/2019
|
06/14/2018
|
|
MCP-317 CAR T-cell Therapy(MDS)
|
09/11/2018
|
04/12/2018
|
|
MCP-323 Pre-Transplant Evaluation NEW
|
11/12/2019
|
09/13/2018
|
|
MCP-324 Hematopoietic Stem Cell Transplantation for Primary Myelofibrosis (Myeloproliferative Neoplasms MPS)
|
09/18/2019
|
12/19/2018
|
|
MCP-328 Corneal Collagen Cross-Linking (CXL)
|
02/12/2019
|
12/19/2018
|
|
MCP-329 Enclosed Protective Bed Systems (Safety enclosure frame/canopy) for Hospital Beds
|
09/18/2019
|
12/19/2018
|
|
MCP-332 Medically Necessary Service
|
02/12/2019
|
12/19/2018
|
|
MCP-338 Plantar Fasciitis Treatments
|
05/07/2019
|
03/11/2019
|
|
MCP-339 Interspinous Process Fixation Devices for Spinal Fusion
|
05/07/2019
|
03/11/2019
|
|
MCP-340 Implantable Neurostimulator (remedē System) for Central Sleep Apnea (CSA)
|
05/07/2019
|
03/11/2019
|
|
MCP-343 Intervertebral Stabilization Devices
|
09/18/2019
|
09/18/2019
|
|
MCP-346 Bioness Foot Drop System
|
09/18/2019
|
09/18/2019
|
|
MCP-347 Autologous Chondrocyte Implantation Knee
|
09/18/2019
|
09/18/2019
|
|
MCP-350 MyoPro Orthosis
|
12/10/2019
|
12/10/2019
|
|
MCP-364 COVID-19
|
03/09/2020
|
03/09/2020
|
