Molina Clinical Review

Molina has established Molina Clinical Review that function as one of the sets of guidelines for coverage decisions or determinations. In this site, the Molina Clinical Review is made accessible to you to guide you in your medical decisions. Please know that these Clinical Reviews do not constitute plan authorization, nor is it an explanation of benefits.

Molina Clinical Review	Last Approved Date	Original Effective Date
MCR-006 Vagal Nerve Stimulation (VNS) for Epilepsy	2021-03	2007-04
MCR-030 Facet Joint/MBB Diagnostic Injections for Chronic Spinal Pain	2021-05	2007-07
MCR-032 Epidural Steroid Injections (ESI) for Back and Neck Pain	2021-05	2007-07
MCR-033 Sacroiliac Injections and Radiofrequency Ablation (RFA) for Sacroiliac Joint Pain	2021-05	2007-07
MCR-050 Hyperbaric Oxygen Therapy	2021-05	2008-04
MCR-067 Back Braces	2021-05	2009-05
MCR-070 Oral and Tube Fed Enteral Nutrition	2021-05	2009-09
MCR-085 Radiofrequency Ablation (RFA) for Chronic Back Pain Associated with the Facet Joint	2021-05	2007-07
MCR-161 Robotically Assisted Surgery	2021-05	2014-04
MCR-204 Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair	2021-05	2014-09
MCR-269 Speech Therapy	2021-05	2012-08
MCR-292 Phototherapy and Laser Therapy for Dermatological Conditions	2021-05	2012-10

Molina Clinical Review	Date Last Updated	Date Originally Approved
MCR-124 - 3D Interpretation and Reporting of Imaging Studies	02/12/2019	12/12/2012
MCR-600 TMJ(temporomandibular joint) MRI	02/12/2019	12/13/2017
MCR-601 Brain MRI	02/12/2019	11/7/2017
MCR-602 CT Orbits-Sella -Temporal Bone IAC Mastoid -Posterior Fossa CT	02/12/2019	12/13/2017
MCR-604 CT Face/Sinuses	02/12/2019	12/13/2017
MCR-605 CT Soft Tissue Neck	02/12/2019	12/13/2017
MCR-606 CT Angiography Brain	02/12/2019	12/13/2017
MCR 607- CT Angiography Neck	02/12/2019	12/13/2017
MCR-608 Orbit/Face/Neck/Sinus	02/12/2019	12/13/2017
MCR-609 MRA Angiography Brain	02/12/2019	12/13/2017
MCR-610 MRI Angiography Neck	02/12/2019	12/13/2017
MCR-611 Brain MRI (includes Internal Auditory Canal)	02/12/2019	7/26/2017
MCR-612 CT Chest/Thorax	02/12/2019	09/06/2017
MCR-613 CTA Chest	02/12/2019	12/13/2017
MCR-614 MRI Chest	02/12/2019	12/13/2017
MCR-615 MRA Chest	02/12/2019	12/13/2017
MCR-616 CT Cervical Spine	02/12/2019	07/25/2017
MCR-617 CT Thoracic Spine	02/12/2019	09/19//2017
MCR-618 Lumbar Spine CT	02/12/2019	09/19/2017
MCR-619 MRI Cervical Spine	02/12/2019	07/25/2017
MCR-620 MRI Thoracic Spine	02/12/2019	09/19/2017
MCR-621 MRI Lumbar Spine	02/12/2019	09/19/2017
MCR-622 MRI Angiography Spinal Canal	02/12/2019	12/13/2017
MCR-623 CT Angiography Pelvis	02/12/2019	12/13/2017
MCR - 624 CT Pelvis	02/12/2019	12/13/2017
MCR-625 MRI Pelvis	02/12/2019	12/13/2017
MCR -626 MR Angiography Pelvis	02/12/2019	9/19/2017
MCR-627 CT Upper Extremity (arm), (hand, wrist, elbow, long bone or shoulder)	02/12/2019	12/13/2017
MCR- 628 CT Angiography Upper Extremity (arm)	02/12/2019	12/13/2017
629 MCR MRI Upper Extremity (arm), (hand, wrist, elbow, long bone or shoulder)	02/12/2019	12/13/2017
630 MCR MR Angiography Upper Extremity (arm)	02/12/2019	12/13/2017
631 MCR CT Lower Extremity (leg) (foot, ankle, knee, long bone or hip)	02/12/2019	12/13/2017
632 MCR CT Angiography Lower Extremity (leg)	02/12/2019	12/13/2017
633 MCR MRI Lower Extremity (leg) (foot, ankle, knee, long bone or hip)	02/12/2019	12/13/2017
634 MCR MRA (Angiography) Lower Extremity (leg)	02/12/2019	12/13/2017
635 MCR CT Abdomen	02/12/2019	9/19/2017
636 MCR CT Angiography Abdomen/Pelvis	02/12/2019	12/13/17
637 MCR CT Angiography Abdomen	02/12/2019	12/13/17
638 MCR CT Abdomen/Pelvis	02/12/2019	9/19/2017
639 MCR MRI Abdomen	02/12/2019	9/19/2017
641 MCR MR Angiography Abdomen	02/12/2019	9/19/2017
642(a) MCR CT Diagnostic Colonography	02/12/2019	12/13/17
642(b) MCR CT Screening Colonography	02/12/2019	12/13/17
643 MCR Fetal MRI	02/12/2019	12/13/17
644 MCR MRI Heart	02/12/2019	12/13/17
645 MCR CT Heart Calcium Scoring	02/12/2019	12/13/17
646 MCR CT Heart	02/12/2019	12/13/17
647 MCR CT Angiography Coronary Arteries (CCTA)	02/12/2019	12/13/17
648 MCR CT Angiography Abdomen/Pelvis with run-off	02/12/2019	12/13/17
649 MCR MRI Breast	02/12/2019	12/13/17
650 MCR CT Bone Density Study	02/12/2019	12/13/17
651 MCR MRI Bone Marrow	02/12/2019	12/13/17
652 MCR Myocardial Perfusion Imaging (NUC Card)	02/12/2019	12/13/17
653 MCR PET Scan, Heart (Cardiac)	02/12/2019	12/13/17
654 MCR MUGA Scan	02/12/2019	12/13/17
655 MCR PET Scan, Brain	02/12/2019	12/13/2017
656 MCR PET Scan, (Skull to Thigh, Whole Body)	02/12/2019	12/13/17
657 MCR Functional Brain MRI	02/12/2019	6/26/13
658 MCR Low Dose CT Scan for Lung Cancer Screening	02/12/2019	6/26/2013
659 MCR Magnetic Resonance Neurography	02/12/2019	2/5/15
660 MCR Magnetic Resonance Spectroscopy	02/12/2019	12/17/08
MCR-661 - Brain SPECT 12.19.18	02/12/2019	10/25/2018

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