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Clinical Policies are applicable to all lines of business Apple Health (Medicaid), Marketplace, and Medicare unless superseded by National Coverage Determination (Medicare) or Apple Health (Medicaid) Health Care Authority guidelines.

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