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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 The Molina Clinical Policies are applicable to all lines of business Medicaid, Marketplace, and Medicare unless superseded by National Coverage Determination (Medicare) or WA Medicaid Health Care Authority guidelines.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

02/06/2018

04/24/2007

MCP-11 Artificial Disc Replacement

02/06/2018

06/14/2006

MCP-017 Pancreas Transplantation Procedures

02/06/2018

06/01/2006

MCP-041 Cranial Orthotic Devices for the Treatment of Positional Cranial Deformity

03/08/2018

10/11/2007

MCP-045 Kidney Transplantation

01/16/2018

02/28/2008

MCP-051 Genetic Testing

05/02/2017

05/22/2008

MCP-063 Magnetic Resonance Spectroscopy (MRS) for diagnosing brain tumors

04/04/2017

12/17/2008

MCP-066 Applied Behavioral Analysis for Autism

11/08/2016

4/23/2009

MCP-091 Pediatric Bariatric Surgery

04/03/2018

10/11/2007

MCP-114 Liver Transplantation Adult and Pediatric

12/19/17

08/23/2012

MPG-115 Lung Transplantation

05/02/2017

08/30/2012

MCP-116 Heart Transplantation

05/02/2017

09/24/2012

MCP-117 Small Bowel Transplantation, Small Bowel and Liver Transplantation, and Multivisceral Transplantation

05/02/2017

08/30/2012

MCP-118 Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)

11/07/2017

10/31/2012

MCP-119 Hematopoietic Stem Cell Transplantation for Acute Myelogenous Leukemia (AML)

11/07/2017

10/31/2012

MCP-120 Transarterial Chemo-embolization (TACE) for Primary Liver Hepatocellular Carcinoma (HCC)

11/07/2017

10/31/2012

MCP-121 Nitrous Oxide for Neonatal Hypoxic Respiratory Failure

02/06/2018

10/4/2012

MCP-122 Hematopoietic Stem Cell Transplantation for Multiple Myeloma

11/07/2017

12/12/2012

MCP-125 Hematopoietic Stem Cell Transplantation for Hodgkin's and Non-Hodgkin';s Lymphoma

02/06/2018

04/24/2013

MCP-127 Thermography for the Detection of Breast Lesions

02/06/2018

12/11/2013

MCP-132 Percutaneous Ventricular Assist Devices

02/06/2018

02/27/2013

MCP-133 Ambulatory Electroencephalographic (EEG) and Video EEG Monitoring for Adults and Children

02/06/2018

4/24/2013

MCP-134 Plasmaphresis for Renal and Non-Renal Indications

02/06/2018

04/24/2013

MCP-136 Functional Brain MRI

09/12/2017

06/26/2013

MCP-137 Low-Dose Helical (Spiral) Computed Tomography for Lung Cancer-Screening

09/12/2017

06/26/2013

MCP-143 Hematopoietic Stem Cell Transplantation for Aplastic Anemia

10/10/2017

06/26/2013

MCP-145-EPAP for Obstructive Sleep Apnea

02/06/2018

06/26/2013

MCP-148 Transcatheter Pulmonary Valve Replacment Melody

12/19/17

10/30/2013

MCP-153 Proton Beam Therapy for Prostate Cancer

07/11/2017

10/30/2013

MCP-157 Noninvasive Prenatal Testing

08/23/2017

06/22/2017

MCP 160 Implanted Intrathecal Pain Pumps Chronic Pain

04/04/2017

04/02/2014

MCP-175 Transcatheter Aortic Valve Replacement for Aortic Stenosis

12/19/17

07/10/2014

MCP-180 NEBA System for ADHD

12/19/17​

08/13/2014

MCP-181 Radioactive Yttrium-90 Microspheres for Treatment of Liver Cancer

02/06/2018

07/10/2014

MCP-182 Implantable Neurostimulator for Sacral Neuromodulation in Treatment of Fecal Incontinence

02/06/2018

08/04/2014

MCP-183 Clinical Trials and Rare Disease Policy

10/10/2017

06/25/2014

MCP-184 Experimental and Investigational Services

10/10/2017

06/25/2014

MCP-187 Hematopoietic Stem Cell Transplantation for Chronic Myelogenous Leukemia (CML)

02/06/2018

07/25/2014

MCP-188 Hematopoietic Stem Cell Transplantation for Chronic Lymphoblastic Leukemia (CLL) and small lymphocytic lymphoma (SLL)

02/06/2018

07/29/2014

MCP-193 Hematopoietic Stem Cell Transplantation for Neuroblastoma

 

07/11/2017

07/17/2014

MCP-194 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors

01/16/2018

09/17/2014

MCP-205 Functional Electrical Stimulation for Spinal Cord Injury

02/06/2018

08/27/2014

MCP-206 Virtual Bronchoscopy and Electromagnetic Navigationa; Bronchoscopy for Evaluation of Peripheral Pulmonary Lesions

02/06/2018

08/25/2014

MCP-207 Platelet-rich Plasma (PRP)

07/11/2017

10/08/2014

MCP-208 Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury

12/19/17

10/14/2014

MCP-209 Hematopoietic Stem Cell Transplantation for Sickle Cell Anemia

01/16/2018

11/11/2014

MCP-210 Donor Lymphocyte Infusion

07/11/2017

11/11/2014

MCP-222 Interspinous Decompression Devices for Spinal Stenosis

04/03/2018

03/16/2015

MCP-225 Intensity Modulated Radiation Therapy

04/03/2018

03/25/2015

MCP-226 Proton Beam Radiation Therapy Ocular and Skull Base Tumors

02/06/2018

03/25/2015

MCP-234 Bioimpedance for Lymphedema Assessment

02/06/2018

02/02/2015

MCP-235 Measurement of Carotid Intima-Media Thickness for Prediction of Clinical Vascular Events

02/06/2018

02/02/2015

MCP-238 Magnetic Resonance Neurography

02/06/2018

02/05/2015

MCP 243 Gastrointestinal Electrical Stimulation (GES) for Obesity

11/07/2017

07/08/2015

MCP-244 Lower-limb Robotic Exoskeleton [ReWalk-P (Personal)] for Paraplegia in Spinal Cord Injury

02/06/2018

07/08/2015

MCP-245 Heart Transplantation with a Total Artificial Heart (TAH)

05/02/2017

04/06/2015

MCP-250 Prostatic Urethral Lift or UroLift for BPH

07/11/2017

06/02/2015

MCP-254 Surgical Repair of Pectus Carinatum Pectus Excavatum

11/07/2017

10/12/2015

MCP-256 Hematopoietic Stem Cell Transplantation for MPS

03/07/2017

02/02/2016

MCP-257 Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain Racz Procedure

11/07/2017

10/12/2015

MCP-261 Computer Aided Evaluation CAE Malignancy Breast MRI Lung Radiography

02/06/2018

02/06/2018

MCP-265 Hematopoietic Stem Cell Transplantation for Immunodeficiency Disorders

06/06/2017

02/10/2016

MCP-266 iFuse Implant for Sacroiliac Joint Fusion

03/08/2018

01/13/2016

MCP-270 Digital Breast Tomosynthesis for Breast Cancer Screening

04/03/2018

03/25/2015

MCP-272 Hematopoietic Stem Cell Transplantation Ewing's Sarcoma

02/06/2018

05/03/2016

MCP-275 Noninvasive Positive Pressure Ventilation

02/06/2018

05/23/2016

MCP-283 Hematopoietic Stem Cell Transplantation Wilms Tumor.pdf

01/01/2017

01/01/2017

MCP-309 Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndromes (MDS)

02/06/2018

02/06/2018

MCP-317 CAR T-cell Therapy(MDS)

02/06/2018

02/06/2018

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