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

Date Last Updated

Date Originally Approved

MCR-006 Vagal Nerve Stimulation

 

11/12/2019

 

04/25/2007

MCR-030 Facet Joint Diagnostic Injections for Chronic Back Pain

 

11/12/2019

 

07/05/2007

MCR 032 Epidural Steroid Injections for Chronic Back Pain

 

07/09/2019

 

07/05/2007

MCR 033 Sacroiliac Injections and RFA for SIJ Pain

 

07/09/2019

 

07/05/2007

MCR 050 Hyperbaric Oxygen Therapy

 

07/09/2019

 

04/08/2008

MCR 067 Back Braces

 

06/19/19

 

05/21/09

MCR-070 Oral and Tube Fed Enteral Nutrition

 

09/10/2019

 

10/11/2007

MCR-085 Radiofrequency Ablation for Chronic Back Pain

 

09/10/2019

 

07/05/2007

MCR-161 Robotically Assisted Surgery

 

10/08/2019

 

04/02/2014

MCR-204 Blepharoplasty

 

10/08/2019

 

09/30/2014

MCR-269 Speech Therapy

 

09/10/2019

 

03/24/2016

MCR-292 Phototherapy and Laser Therapy for Dermatological Conditions

 

11/12/2019

 

11/20/2008

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