Molina Clinical Policy (MCP)

Molina has established Molina Clinical Policy (MCP) that function 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 The MCPs are applicable to all lines of business Apple Health (Medicaid), Marketplace, and Medicare unless superseded by National Coverage Determination (Medicare) or Apple Health (Medicaid) Health Care Authority guidelines.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

Category MCP Last Approved Date Original Effective Date
Medical MCP-011 Artificial Intervertebral Disc Replacement (ADR) Surgery (Lumbar and Cervical) 4/11/2023 6/14/2006
Medical MCP-030 Facet Joint/MBB Diagnostic Injections for Chronic Spinal Pain 7/11/2023 7/5/2007
Medical MCP-032 Epidural Steroid Injections (ESI) for Back and Neck Pain 10/10/2023 7/5/2007
Medical MCP-033 Sacroiliac Injections and Radiofrequency Ablation for Sacroiliac Joint Pain 7/11/2023 7/5/2007
Medical MCP-050 Hyperbaric Oxygen Therapy (HBOT) and Topical Oxygen Therapy (TOT) 5/9/2023 4/30/2008
Genetic Testing MCP-051 Genetic Testing 5/9/2023 5/22/2008
Medical MCP-085 Radiofrequency Ablation (RFA) for Chronic Back Pain Associated with the Facet Joint 7/11/2023 7/5/2007
Medical MCP-160 Implanted Intrathecal Pain Pump 9/12/2023 4/2/2014
Medical MCP-161 Robotically Assisted Surgery 7/11/2023 4/2/2014
Medical MCP-171 Bronchial Thermoplasty 10/10/2023 6/12/2014
Medical MCP-216a Gender Affirmation Treatment and Procedures (Medicaid) 3/14/2023 4/13/2022
Medical MCP-216b Gender Affirmation Treatment and Procedures (Medicare) 4/19/2023 4/13/2022
Medical MCP-216c Gender Affirmation Treatment and Procedures (Marketplace) 4/19/2023 4/13/2022
Medical MCP-218 Recombinant Human Bone Morphogenetic Protein (rhBMP) 7/11/2023 12/8/2014
Medical MCP-266 Minimally Invasive Sacroiliac Joint Fusion 8/8/2023 12/8/2014
Medical MCP-269 Speech Therapy 2/14/2023 3/24/2016
Medical MCP-406 Enteral Nutrition 11/14/2023 10/13/2021
Medical MCP-444 Implantable Peripheral Nerve and Nerve Field Stimulators for Chronic Pain 1/9/2024 12/13/2023