| Molina Clinical Policy |
Last Approved Date |
Original Effective Date |
| MCP-000 Evaluation of New and Existing Technologies |
2021-07 |
2007-04 |
| MCP-011 Artificial Disc Replacement |
2021-04 |
2006-06 |
| MCP-017 Pancreas Transplant Procedures |
2021-07 |
2006-06 |
| MCP-041 Cranial Orthotic Devices |
2021-02 |
2007-10 |
| MCP-045 Kidney Transplantation |
2021-07 |
2008-02 |
| MCP-051 Genetic Testing |
2021-03 |
2008-05 |
| MCP-091 Pediatric Bariatric Surgery |
2020-08 |
2011-04 |
| MCP-114 Liver Transplantation Adult and Pediatric |
2020-11 |
2012-08 |
| MCP-115 Lung Transplantation |
2020-11 |
2012-08 |
| MCP-116 Heart Transplantation |
2021-04 |
2012-09 |
| MCP-117 Small Bowel Transplantation, Small Bowel and Liver Transplantation, and Multivisceral Transplantation |
2020-11 |
2012-08 |
| MCP-118 Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia (ALL) |
2021-09 |
2012-10 |
| MCP-119 Hematopoietic Stem Cell Transplantation for Acute Myelogenous Leukemia (AML) |
2021-02 |
2012-10 |
| MCP-120 Transarterial Chemo-embolization (TACE) for Primary Liver Hepatocellular Carcinoma (HCC) |
2021-06 |
2012-10 |
| MCP-121 Nitrous Oxide for Neonatal Hypoxic Respiratory Failure |
2020-11 |
2012-10 |
| MCP-122 Hematopoietic Stem Cell Transplantation for Multiple Myeloma |
2021-09 |
2012-12 |
| MCP-125 Hematopoietic Stem Cell Transplantation for Hodgkin's and Non-Hodgkin's Lymphoma |
2021-02 |
2013-04 |
| MCP-127 Thermography for the Detection of Breast Lesions |
2021-09 |
2013-12 |
| MCP-132 Percutaneous Ventricular Assist Devices |
2021-02 |
2013-02 |
| MCP-133 Ambulatory Electroencephalographic (EEG) and Video EEG Monitoring for Adults and Children |
2021-03 |
2013-04 |
| MCP-134 Plasmaphresis for Renal and Non-Renal Indications |
2020-11 |
2013-04 |
| MCP-143 Hematopoietic Stem Cell Transplantation for Aplastic Anemia |
2021-02 |
2013-06 |
| MCP-145 Expiratory Positive Airway Pressure (EPAP) for Obstructive Sleep Apnea |
2021-02 |
2013-10 |
| MCP-148 Transcatheter Pulmonary Valve Replacement |
2021-02 |
2013-10 |
| MCP-153 Proton Beam Therapy for Prostate Cancer |
2020-11 |
2013-10 |
| MCP-157 Noninvasive Prenatal Testing (NIPT) |
2021-01 |
2013-12 |
| MCP-160 Implanted Intrathecal Pain Pumps Chronic Pain |
2020-08 |
2014-04 |
| MCP-171 Bronchial Thermoplasty |
2020-08 |
2014-06 |
| MCP-175 Transcatheter Aortic Valve Replacement for Aortic Stenosis |
2020-08 |
2014-07 |
| MCP-180 NEBA System for ADHD |
2021-09 |
2014-08 |
| MCP-181 Radioactive Yttrium-90 Microspheres for Treatment of Liver Cancer |
2021-09 |
2014-07 |
| MCP-182 Implantable Neurostimulator for Sacral Neuromodulation in Treatment of Fecal Incontinence |
2020-11 |
2014-08 |
| MCP-183 Clinical Trials and Rare Disease Policy |
2021-08 |
2014-06 |
| MCP-184 Experimental and Investigational Services |
2021-08 |
2014-06 |
| MCP-187 Hematopoietic Stem Cell Transplantation for Chronic Myelogenous Leukemia (CML) |
2021-09 |
2014-07 |
| MCP-188 Hematopoietic Stem Cell Transplantation for Chronic Lymphoblastic Leukemia (CLL) and small lymphocytic lymphoma (SLL) |
2021-09 |
2014-07 |
| MCP-193 Hematopoietic Stem Cell Transplantation for Neuroblastoma |
2021-09 |
2014-07 |
| MCP-194 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors |
2020-11 |
2014-09 |
| MCP-205 Functional Electrical Stimulation for Spinal Cord Injury |
2021-08 |
2014-08 |
| MCP-206 Virtual Bronchoscopy and Electromagnetic Navigational Bronchoscopy for Evaluation of Peripheral Pulmonary Lesions |
2021-08 |
2014-08 |
| MCP-207 Platelet-rich Plasma (PRP) |
2021-06 |
2014-10 |
| MCP-208 Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury |
2021-06 |
2014-10 |
| MCP-209 Hematopoietic Stem Cell Transplantation for Sickle Cell Anemia |
2020-11 |
2014-11 |
| MCP-210 Donor Lymphocyte Infusion |
2021-04 |
2014-11 |
| MCP-218 Recombinant Human Bone Morphogenetic Protein (rhBMP) for Bone Fusion |
2021-06 |
2014-12 |
| MCP-222 Interspinous Decompression Devices for Spinal Stenosis |
2021-06 |
2015-03 |
| MCP-224 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy |
2021-02 |
2014-12 |
| MCP-225 Intensity Modulated Radiation Therapy (IMRT) |
2020-11 |
2015-03 |
| MCP-226 Proton Beam Radiation Therapy |
2021-07 |
2015-03 |
| MCP-234 Bioimpedance for Lymphedema Assessment |
2020-11 |
2015-02 |
| MCP-235 Measurement of Carotid Artery Intima-Media Thickness |
2020-11 |
2015-02 |
| MCP-243 Gastrointestinal Electrical Stimulation (GES) and Vagus Nerve Blocking Therapy (VBLOC) for Obesity |
2020-11 |
2015-07 |
| MCP-244 Lower-Limb Robotic Exoskeleton [ReWalk-P (Personal)] for Paraplegia in Spinal Cord Injury |
2020-11 |
2015-08 |
| MCP-245 Heart Transplantation with a Total Artificial Heart (TAH) |
2020-11 |
2015-04 |
| MCP-250 Prostatic Urethral Lift or UroLift for BPH |
2021-09 |
2015-06 |
| MCP-256 Hematopoietic Stem Cell Transplantation for MPS |
2021-09 |
2016-02 |
| MCP-257 Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain (RACZ Procedure) |
2021-08 |
2015-10 |
| MCP-261 Computer Aided Evaluation (CAE) of Malignancy with Breast MRI and Lung Radiography |
2021-08 |
2016-01 |
| MCP-265 Hematopoietic Stem Cell Transplantation for Immunodeficiency Disorders |
2020-12 |
2016-02 |
| MCP-266 iFuse Implant System (SI-BONE Inc.) for Sacroiliac Joint Fusion for Treatment of Low Back Pain |
2021-08 |
2016-01 |
| MCP-272 Hematopoietic Stem Cell Transplantation for Ewing's Sarcoma |
2020-12 |
2016-05 |
| MCP-275 Noninvasive Positive Pressure Ventilation in the Home Setting |
2021-04 |
2016-05 |
| MCP-283 Hematopoietic Stem Cell Transplantation Wilms Tumor |
2021-09 |
2017-01 |
| MCP-295 High Intensity Focused Ultrasound for Prostate CA |
2021-06 |
2017-05 |
| MCP-309 Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndromes (MDS) |
2020-09 |
2018-03 |
| MCP-311 Salpingectomy for Female Sterilization |
2021-04 |
2018-07 |
| MCP-312 Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor |
2021-04 |
2018-07 |
| MCP-314 Genicular Radiofrequency Ablation and Genicular Nerve Blocks for Chronic Knee Pain |
2021-04 |
2018-09 |
| MCP-315 Breast Implant Removal |
2021-04 |
2018-06 |
| MCP-321 Category III CPT Codes |
2021-06 |
2018-07 |
| MCP-323 Pre-Transplant Evaluation |
2021-06 |
2018-09 |
| MCP-324 Hematopoietic Stem Cell Transplantation for Primary Myelofibrosis (Myeloproliferative Neoplasms MPS) |
2020-12 |
2018-12 |
| MCP-328 Corneal Collagen Cross-Linking (CXL) |
2020-11 |
2018-12 |
| MCP-329 Enclosed Protective Bed Systems (Safety Enclosure Frame/Canopy) for Hospital Beds |
2020-12 |
2018-12 |
| MCP-332 Medically Necessary Service |
2021-08 |
2018-12 |
| MCP-335 Deep Brain Stimulation for Epilepsy with the Activa PC Neurostimulator |
2021-04 |
2019-03 |
| MCP-337 Gastroesophageal Reflux Disease (GERD) Treatment |
2020-12 |
2019-03 |
| MCP-338 Plantar Fasciitis Treatments |
2021-04 |
03/11/2019 |
| MCP-339 Interspinous Process Fixation Devices for Spinal Fusion |
2021-04 |
2019-03 |
| MCP-340 Implantable Neurostimulator (remedē System) for Central Sleep Apnea (CSA) |
2021-04 |
2019-03 |
| MCP-341 Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation |
2021-04 |
2019-06 |
| MCP-343 Intervertebral Stabilization Devices for Spinal Fusion |
2020-12 |
2019-09 |
| MCP-344 Ketogenic Diet Induction for Treatment of Intractable Seizures in the Hospital Setting |
2021-04 |
2019-06 |
| MCP-346 Functional Electrical Stimulation for Stroke or TBI (Bioness L300 & L300 Go Foot Drop System) |
2020-12 |
2019-09 |
| MCP-347 Autologous Chondrocyte Implantation for Knee Cartilage Lesions |
2020-12 |
2019-09 |
| MCP-350 MyoPro Orthosis (Myomo, Inc.) for Upper Extremity Paralysis/Paresis |
2021-02 |
2019-12 |
| MCP-351 Minimally Invasive Lumbar Decompression (MILD) for Treatment of Lumbar Spinal Stenosis |
2021-02 |
2019-12 |
| MCP-352 Intrepid Dynamic Exoskeletal Orthosis (IDEO) for Lower Extremity Injuries |
2021-02 |
2019-12 |
| MCP-353 Electric Tumor Treatment Fields for Glioblastoma |
2021-04 |
2020-04 |
| MCP-355 Occipital Nerve Block Therapy for Treatment of Headaches and Occipital Neuralgia |
2021-03 |
2020-04 |
| MCP-357 Skin Substitutes for Chronic Wound Healing in the Out-Patient Setting |
2021-03 |
2020-04 |
| MCP-361 Renal Autotransplantation |
2021-06 |
2020-04 |
| MCP-362 Haploidentical Allogeneic Hematopoietic Cell Transplantation in Blood Cancers |
2021-06 |
2020-04 |
| MCP-363 Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea |
2021-07 |
2020-06 |
| MCP-364 COVID-19 Co-Pays and Cost Share |
2021-03 |
2020-03 |
| MCP-366 Cluneal Nerve Block For Treatment of Low Back Pain |
2020-08 |
2020-06 |
| MCP-368 Transcatheter Tricuspid Valve Replacement for Tricuspid Valve |
2020-08 |
2020-06 |
| MCP-369 Facet Joint Allograft Implants for Facet Disease |
2020-08 |
2020-06 |
| MCP-371 Myocardial Strain Imaging |
2020-11 |
2020-09 |
| MCP-372 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain |
2020-11 |
2020-09 |
| MCP-374 Actigraphy |
2020-11 |
2020-09 |
| MCP-377 Extracorporeal Shockwave Therapy in the Treatment of Chronic Diabetic Foot Ulcers |
2020-11 |
2020-09 |
| MCP-381 Focused Microwave Thermotherapy for Breast Cancer |
2020-11 |
2020-09 |
| MCP-382 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders |
2020-11
|
2020-09 |
| MCP-383 Percutaneous Electrical Nerve Field Stimulator (PENFS) [IB-Stim Device] for Functional Abdominal Pain in Adolescents |
2021-01 |
2020-12 |
| MCP-384 Rezum System for Benign Prostatic Hyperplasia |
2021-01 |
2020-12 |
| MCP-385 Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia |
2021-01 |
2020-12 |
| MCP-386 Coolief Cooled Radiofrequency Ablation (CRFA) for the Management of Chronic Pain |
2021-01 |
2020-12 |
| MCP-387 Prialt (ziconotide intrathecal infusion) |
2021-02 |
2020-12 |
| MCP-388 Optical Coherence Tomography of the Anterior Eye Segment |
2021-01 |
2020-12 |
| MCP-389 XEN Gel Stent for Glaucoma |
2021-01 |
2020-12 |
| MCP-390 Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension |
2021-01 |
2020-12 |
| MCP-391 Radiofrequency Ablation of Primary or Metastatic Liver Tumors |
2021-01 |
2020-12 |
| MCP-392 Monarch Trigeminal Nerve Stimulation (eTNS) System |
2021-01 |
2020-12 |
| MCP-393 Wireless Pulmonary Artery Pressure Monitoring (CardioMEMS) for Congestive Heart Failure |
2021-03 |
2021-02 |
| MCP-394 Vagus Nerve Stimulation for Depression |
2021-03 |
2021-02 |
| MCP-395 Chimeric Antigen Receptor (CAR) T-Cell Therapy: Kymriah (tisagenlecuecel) |
2021-03 |
2018-04 |
| MCP-396 Chimeric Antigen Receptor (CAR) T-Cell Therapy: Yescarta (axicabtagene ciloleucel) |
2021-08 |
2018-04 |
| MCP-397 MolecuLight i:X Wound Care Device |
2021-05 |
2021-04 |
| MCP-400 Chimeric Antigen Receptor (CAR) T-Cell Therapy: Breyanzi (lisocabtagene maraleucel; liso-cel) |
2021-08 |
2021-04 |
| MCP-401 Foot Surgery Guidelines for Deformities of the Toes |
2021-05 |
2021-05 |
| MCP-402 Plantar Fasciitis Release Surgery |
2021-05 |
2021-04 |
| MCP-403 Chimeric Antigen Receptor (CAR) T-Cell Therapy: Abecma (idecabtagene vicleucel) |
2021-08 |
2021-06 |
| MCP-404 Shoulder Arthroscopy Guidelines |
2021-07 |
2020-04 |
