Molina Clinical Policy (MCP)

Molina has established Molina Clinical Policy that function as one of the sets of guidelines for coverage decisions or determinations. In this site, the Molina Clinical Policy is made accessible to you to guide you in your medical decisions. Please know that these Clinical Policies do not constitute plan authorization, nor is it an explanation of benefits. The Molina Clinical Policies are applicable to all lines of business Medicaid, Marketplace, and Medicare unless superseded by National Coverage Determination (Medicare) or WA Medicaid Health Care Authority guidelines.

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