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