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 The MCPs are applicable to all lines of business Apple Health (Medicaid), Marketplace, and Medicare unless superseded by National Coverage Determination (Medicare) or Apple Health (Medicaid) Health Care Authority guidelines.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 MolinaClinicalPolicy.com.

Category MCP Last Approved Date Original Effective Date
Surgery MCP-011 Artificial Intervertebral Disc Replacement (ADR) Surgery (Lumbar and Cervical) 3/12/2024 6/14/2006
Medical MCP-050 Hyperbaric Oxygen Therapy (HBOT) and Topical Oxygen Therapy (TOT) 6/11/2024 4/30/2008
Genetic Testing MCP-051 Genetic Testing 3/11/2025 5/22/2008
Medical MCP-160 Implanted Intrathecal Pain Pump 10/8/2024 4/2/2014
Surgery MCP-161 Robotically Assisted Surgery 6/10/2025 4/2/2014
Medical MCP-171 Bronchial Thermoplasty 10/8/2024 6/12/2014
Medical MCP-207 Platelet-Rich Plasma (PRP) 6/10/2025 4/13/2022
Medical MCP-216a Gender Affirmation Treatment and Procedures (Medicaid) 5/13/2025 10/8/2014
Medical MCP-216c Gender Affirmation Treatment and Procedures (Marketplace) 5/13/2025 4/13/2022
Medical MCP-218 Bone Graft Substitutes for Bone Fusion 6/10/2025 12/8/2014
Medical MCP-266 Minimally Invasive Sacroiliac Joint Fusion 3/12/2024 12/8/2014
Medical MCP-269 Speech Therapy 3/11/2025 3/24/2016
Medical MCP-353 Electric Tumor Treatment Fields for Glioblastoma 1/14/2025 4/23/2020
Medical MCP-406 Enteral Nutrition 12/10/2024 10/13/2021
Medical MCP-407 Negative Pressure Wound Therapy 5/13/2025 12/8/2021
Medical MCP-444 Implantable Peripheral Nerve and Nerve Field Stimulators for Chronic Pain 3/11/2025 12/13/2023
Surgery MCP-468 Injections and Nerve Blocks for Neck and Back Pain 5/13/2025 4/9/2025
Surgery MCP-469 Radiofrequency Nerve Ablation for Neck and Back Pain 5/13/2025 4/9/2025
Surgery MCP-700 Foot Surgery: Bunionectomy 5/13/2025 4/13/2023
Surgery MCP-701 Foot Surgery: Hallux Rigidus 3/11/2025 4/13/2023
Surgery MCP-702 Foot Surgery: Lesser Toe Deformities (Hammer, Mallet, and Claw Toe) 3/11/2025 4/13/2023