Molina Clinical Policy
The Molina Clinical Policies accessible on this page are specific to Molina Healthcare of Ohio Medicaid only and can be used as a tool to guide you in your medical decisions.
Molina has established Molina Clinical Policies that function as one of the sets of guidelines for coverage decisions or determinations.
Please know that these Molina Clinical Policies do not constitute plan authorization, nor is it an explanation of benefits.
Note: For Medicare, MyCare Ohio, and Marketplace Clinical Policies, please visit the Molina Clinical Policy page.
Archived Medicaid Molina Clinical Policies can be found here.
- Buy and Bill Medications
Actemra (tocilizumab) C10265-A - Effective 3/1/23
Actemra (tocilizumab) C10265-A - Effective 10/21/23
Acthar Gel (repository corticotropin injection) C8373-A
Adakveo (crizanlizumab-tmca) C17920-A
Adcetris (brentuximab vedotin) C15428-A - Effective 9/11/23
Aduhelm (aducanumab-avwa) Medical Necessity Review C21304-A - Effective 9/11/23
Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A
Amondys 45 (casimersen) Medical Necessity Review C21154-A - Effective 9/11/23
Amvuttra (vutrisiran) C24213-A
Antiemetics C20780-A – Effective 3/1/23
Antiemetics C20780-A – Effective 10/6/23
Azactam (aztreonam) C10143-A - Effective 9/11/23
Brineura (cerliponase alfa) C11526-A - Effective 3/1/23
Brineura (cerliponase alfa) C11526-A - Effective 10/21/23
Briumvi ublituximab-xiiy C25204-A - Effective 8/17/23
Briumvi ublituximab-xiiy C25204-A - Effective 10/21/23
Cablivi (caplacizumab-yhdp) C19481-A
Calcitonin Gene-Related Peptide (CGRP) antagonist C15443-C - Effective 9/16/23
Cancidas (caspofungin) C17928-A - Effective 9/11/23
Cimzia (certolizumab pegol) C10269-A - Effective 3/1/23
Cimzia (certolizumab pegol) C10269-A - Effective 10/21/23
Copaxone_Glatopa (glatiramer acetate) C10270-A - Effective 9/11/23
Cosela (trilaciclib) C21205-A - Effective 9/16/23
Cosentyx (secukinumab) C10410-A - Effective 3/1/23
Cosentyx (secukinumab) C10410-A - Effective 10/21/23
Crysvita (burosumab-twza) C14517-A - Effective 3/1/23
Crysvita (burosumab-twza) C14517-A - Effective 10/21/23
Cubicin (daptomycin) C10467-A - Effective 9/11/23
Cytogam (cytomegalovirus immune globulin) C9970-A
Dalvance (dalbavancin) C9351-A
Elaprase (idursulfase) C2720-A
Enjaymo (sutimlimab) C22996-A - Effective 9/11/23
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A
Enzyme Replacement Therapy for Lysosomal Storage Disorders C9997-A
Erythropoiesis-stimulating agents (ESAs) C15389-A - Effective 3/1/23
Erythropoiesis-stimulating agents (ESAs) C15389-A - Effective 10/21/23
Evenity (romosozumab-aqqg) C17324-A
Evkeeza (evinacumab_dgnb) C21101-A
Exondys 51 (eteplirsen) Medical Necessity Review C18464-A - Effective 9/11/23
Eylea (aflibercept) C5674-A - Effective 8/17/23
Fabrazyme (agalsidase beta) C4865-A
Fasenra (benralizumab) C13643-A - Effective 3/1/23
Fasenra (benralizumab) C13643-A - Effective 10/21/23
Furoscix (furosemide on-body infusor) C24669– A - Effective 10/6/23
Fuzeon (enfuvirtide) C9573– A - Effective 10/6/23
Gamifant (emapalumab-lzsg) C15970-A
Global J Code Criteria C11251-A
Hemophilia and Blood Factor Products C15607-A
Hepatitis B Immune Globulin C9971-A
Hereditary Angioedema Agents C21463-A
Hyaluronic Acid Injections_Viscosupplementation for Knee OA C14676-A - Effective 3/1/23
Hyaluronic Acid Injections_Viscosupplementation for Knee OA C14676-A - Effective 10/21/23
Igalmi (dexmedetomidine) C23724-A
Ilumya (tildrakizumab) C15971-A
Immunoglobulin (SCIg, IVIg) MHI C21554-A
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A
INPEN (Insulin Smart Pen) Non-Coverage C21865-A
Intravenous Bisphosphonates C16790-A
Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) C15214-A
Iron Deficiency Anemia Agents C14569-A
Kanuma (sebelipase alfa) C9974-A
Kesimpta (ofatumumab) C21104-A
Korsuva (difelikefalin) C23743-A
Krystexxa (pegloticase) C2729-A
Lemtrada (alemtuzumab) C6919-A - Effective 8/17/23
Leqembi (lecanemab-irmb) MNR C25201-A - Effective 8/17/23
Leukine (sargramostim) C2439-A - Effective 8/17/23
Leuprolide long acting (Lupron Depot, Eligard, Lupron Depot Ped, Fensolvi, Camcevi) C8756-A
Lumizyme (alglucosidase alfa) C8716_A - Effective 3/1/23
Lumizyme (alglucosidase alfa) C8716_A - Effective 10/21/23
Mepsevii (vestronidase alfa-vjbk) C17942-A
Mozobil (plerixafor injection) C9017-A - Effective 8/17/23
Multiple Sclerosis Agents - Interferons C10267-A - Effective 9/11/23
NexoBrid anacaulase-bcdb C25200-A - Effective 8/17/23
Nexviazyme (alglucosidase alfa-ngpt) C21948-A
Nulibry (fosdenopterin) C21306-A
Nuzyra (omadacycline tosylate) C15914-A - Effective 9/11/23
Ocrevus (ocrelizumab) C11250-A - Effective 9/11/23
Onpattro (patisiran)_Tegsedi_(inotersen) C17894-A
Parsabiv (etelcalcetide) C17883-A
Physician Administered Drugs C11251-A - Effective 9/11/23
Prevymis (letermovir) C15922-A - Effective 9/11/23
Pulmonary Arterial Hypertension (PAH) C9837-A - Effective 3/1/23
Pulmonary Arterial Hypertension (PAH) C9837-A - Effective 10/21/23
Qutenza (capsaicin) C2809-A - Effective 8/17/23
Radicava (edaravone) C11528-A - Effective 8/17/23
Ranibizumab (Lucentis, Byooviz, Cimerli) MHI C10417-A
Reblozyl (luspatercept-aamt) C18002-A - Effective 9/11/23
Rebyota fecal microbiota live C25213-A - Effective 8/17/23
Revcovi (elapegademase) C16329-A
Rituxan (rituximab) and Biosimilars C10423-A
Rolvedon, Neulasta and Related Biosimilars C10419-A - Effective 9/11/23
Ryplazim (plasminogen, human) C22238-A
Saphnelo (anifrolumab) C21970-A
Sexual Dysfunction Criteria - Non-Coverage C16658-A - Effective 9/11/23
Signifor (pasireotide diaspartate) C15367-A
Simponi_Simponi Aria (golimumab) C10422-A
Skyrizi (risankizumab-rzaa) C17336-A
Soliris_Ultomiris (eculizumab_ravulizumab) C4867-A
Standard Oncology Criteria C16154-A - Effective 9/11/23
Stelara (usketinumab) C10424-A
Sunlenca lenacapavir C25206-A - Effective 8/17/23
Supprelin LA (histrelin acetate) Implant C20611-A
Tepezza (teprotumumab-trbw) C18462-A
Tezspire(tezepelumab) C23042-A
Triptodur (triptorelin pamoate) C14649-A
Trogarzo (ibalizumab-uiyk) C14522-A - Effective 9/11/23
Tygacil (tigecycline) C14555-A
Tysabri (natalizumab) C10276-A - Effective 9/11/23
Tzield teplizumab C24729-A - Effective 8/17/23
Uplizna (inebilizumab-cdon) C20171-A
Vibativ (telavancin) C14575-A - Effective 9/11/23
Viltepso (vitolarsen) Medical Necessity Review C20406-A
Vimizim (elosulfase alfa) C7068-A
Vyondys 53 (golodirsen) Medical Necessity Review C18466-A
Vyvgart (efgartigimod alfa) C23127-A
Xipere (triamcinolone ocular inj) C22222-A
Xolair (omalizumab) C5678-A - Effective 8/17/23
Zinplava (bexlotoxumab) C14821-A - Effective 9/11/23
Zoladex (goserelin acetate) C8757-A
- Molina Clinical Policies
MCP 000 Evaluation of New Technology - Effective 9/16/23
MCP 006 Vagal Nerve Stimulation for Epilepsy - Effective 7/26/23
MCP 011 Artificial Disc Replacement - Effective 7/26/23
MCP 030 Facet Joint Diagnostic Injections for Chronic Back Pain - Effective 7/26/23
MCP 032 Epidural Steroid Injections for Back and Neck Pain - Effective 3/1/23
MCP 032 Epidural Steroid Injections for Back and Neck Pain - Effective 10/21/23
MCP 033 Sacroiliac Injections and RFA for SIJ Pain - Effective 7/26/23
MCP 050 Hyperbaric Oxygen Therapy and Topical Oxygen Therapy - Effective 9/16/23
MCP 051 Genetic Testing - Effective 9/11/23
MCP 085 Radiofrequency Ablation for Chronic Back Pain - Effective 7/26/23
MCP 105 Provenge (sipuleucel-T) - Effective 9/16/23
MCP 120 Transarterial Chemoembolization for Liver Tumors - Effective 7/26/23
MCP 121 Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure
MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 9/16/23
MCP 132 Percutaneous Ventricular Assist Devices
MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting - Effective 7/26/23
MCP 145 EPAP for Obstructive Sleep Apnea
MCP 148 Transcatheter Pulmonary Valve Replacement
MCP 161 Robotically Assisted Surgery - Effective 7/26/23
MCP 180 QEEG for ADHD with NEBA System - Effective 3/1/23
MCP 180 QEEG for ADHD with NEBA System - Effective 10/21/23
MCP 181 Radioembolization for Primary and Metastatic Tumors of the Liver - Effective 3/1/23
MCP 181 Radioembolization for Primary and Metastatic Tumors of the Liver - Effective 10/21/23
MCP 183 Clinical Trials and Rare Disease Policy - Effective 7/26/23
MCP 184 Experimental and Investigational Services - Effective 7/26/23
MCP 204 Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair - Effective 9/16/23
MCP 205 Functional Electrical Stimulation for Spinal Cord Injury - Effective 7/26/23
MCP 206 Virtual Bronchoscopy for Pulmonary Lesions - Effective 9/16/23
MCP 207 Platelet Rich Plasma_PRP - Effective 7/26/23
MCP 208 Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury - Effective 7/26/23
MCP 216a Gender Affirmation Treatment and Procedures_Medicaid - Effective 9/11/23
MCP 218 Recombinant Human Bone Morphogenetic Protein - Effective 7/26/23
MCP 222 Interspinous Decompression Devices for Spinal Stenosis - Effective 7/26/23
MCP 234 Bioimpedence Analysis for Lymphedema Assessment
MCP 235 Measurement of Carotid Artery Intima Thickness
MCP 243 Gastrointestinal Electrical Stimulation GES for Obesity
MCP 244 Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
MCP 250 Prostatic Urethral Lift or UroLift for BPH - Effective 3/1/23
MCP 250 Prostatic Urethral Lift or UroLift for BPH - Effective 10/21/23
MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 7/26/23
MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 10/21/23
MCP 282 Ozurdex (dexamethasone intravitreal implant) - Effective 7/26/23
MCP 292 Phototherapy and Laser Therapy for Dermatological Conditions - Effective 7/26/23
MCP 293 Spinraza_nusinersen - Effective 3/1/23
MCP 293 Spinraza_nusinersen - Effective 10/21/23
MCP 301 Iluvien (fluocinolone acetonide) Intravitreal Implant
MCP 302 Retisert_Yutiq_fluocinolone acetonide_Intravitreal Implants - Effective 7/26/23
MCP 308 Visudyne_verteporfin_for Ocular Photodynamic Therapy - Effective 3/1/23
MCP 308 Visudyne_verteporfin_for Ocular Photodynamic Therapy - Effective 10/21/23
MCP 312 Magnetic Resonance Guided Focused Ultrasound_MRgFUS_for Essential Tremor - Effective 9/16/23
MCP 314 Genicular Radiofrequency Ablation RFA and Genicular Nerve Blocks for Chronic Knee Pain - Effective 7/26/23
MCP 315 Breast Implant Removal - Effective 9/16/23
MCP 318 Luxturna (voretigene neparvovec rzyl) - Effective 3/1/23
MCP 318 Luxturna (voretigene neparvovec rzyl) - Effective 10/21/23
MCP 321 Category III CPT Codes
MCP 322 Lutathera (lutetium Lu 177 dotatate)
MCP 328 Corneal Collagen Cross Linking - Effective 3/1/23
MCP 328 Corneal Collagen Cross Linking - Effective 10/21/23
MCP 332 Medically Necessary Services: Policy No. 332 - Effective 7/26/23
MCP 333 Steroid-Eluting Sinus Stents and Implants (PROPEL, SINUVA) - Effective 10/6/23
MCP 333 Steroid-Eluting Sinus Stents and Implants (PROPEL, SINUVA) - Effective 7/26/23
MCP 335 Deep Brain Stimulation DBS for Epilepsy - Effective 9/16/23
MCP 337 Gastroesophageal Reflux Disease GERD Treatment
MCP 338 Plantar Fasciitis Treatment - Effective 7/26/23
MCP 339 Interspinous Process Fixation Devices for Spinal Fusion - Effective 7/26/23
MCP 340 Implantable Neurostimulator for Central Sleep Apnea
MCP 342 Dexycu (dexamethasone intraocular suspension) - Effective 7/26/23
MCP 343 Intervertebral Stabilization Devices
MCP 344 Ketogenic Diet for Treatment of Intractable Seizures - Effective 7/26/23
MCP 347 Autologous Chondrocyte Implantation for Knee
MCP 350 MyoPro Orthosis - Effective 7/26/23
MCP 351 MILD for Spinal Stenosis
MCP 352 IDEO Intrepid Dynamic Exoskeletal Orthosis
MCP 353 Electric Tumor Treatment Fields for Glioblastoma - Effective 7/26/23
MCP 357 Skin Substitutes - Effective 9/16/23
MCP 361 Renal Autotransplantation - Effective 7/26/23
MCP 362 Haploididentical Transplantation - Effective 7/26/23
MCP 363 Hypoglossal Nerve Stimulation for the Treatment of OSA - Effective 9/16/23
MCP 366 Cluneal Nerve Block for LBP
MCP 367 Scenesse (afamelanotide) Implant - Effective 7/26/23
MCP 368 Transcatheter Tricuspid Valve Replacement - Effective 3/1/23
MCP 370 Durysta (bimatoprost) Implant - Effective 7/26/23
MCP 372 Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain
MCP 377 Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers - Effective 3/1/23
MCP 377 Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers - Effective 10/21/23
MCP 378 Tecartus (brexucabtagene autoleucel)
MCP 381 Focused Microwave Thermotherapy for Breast Cancer - Effective 3/1/23
MCP 381 Focused Microwave Thermotherapy for Breast Cancer - Effective 10/21/23
MCP 383 IB-Stim Device for Abdominal Pain in Adolescents
MCP 384 Water Vapor Thermal Therapy for BPH
MCP 385 Peroral Endoscopic Myotomy for Esophageal Achalasia - Effective 7/26/23
MCP 386 Coolief Cooled Radiofrequency
MCP 389 XEN Gel Stent for Glaucoma
MCP 391 Radiofrequency Ablation of Primary or Metastatic Liver Tumors
MCP 392 Monarch External Trigeminal Nerve Stimulation eTNS System
MCP 395 Kymriah (tisagenlecleucel) - Effective 9/16/23
MCP 396 Yescarta (axicabtagene ciloleucel)
MCP 397 Moleculight Wound Care Device - Effective 7/26/23
MCP 399 Electrostimulation and Electromagnetic Therapy for Wound Care
MCP 400 Breyanzi (lisocabtagene maraleucel)
MCP 402 Plantar Fasciitis Surgery - Effective 9/16/23
MCP 403 Abecma (idecabtagene vicleucel)
MCP 404 Shoulder Arthroscopy Guidelines - Effective 7/26/23
MCP 405 Dextenza (dexamethasone intracanalicular insert) - Effective 7/26/23
MCP 407 Wound Vac (NPWT) - Effective 9/11/23
MCP 408 Balloon Sinus Ostial Dilation_Balloon Sinuplasty
MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis - Effective 7/26/23
MCP 411 Susvimo_ranibizumab intravitreal_injection implant - Effective 7/26/23
MCP 412 Prescription Digital Therapeutics - Effective 9/16/23
MCP 413 Carvykti (ciltacabtagene autoleucel)
MCP 414 Gastric Electrical Stimulation - Effective 9/11/23
MCP 415 Pluvicto (lutetium Lu 177 vipivotide tetraxetan) - Effective 9/16/23
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 9/16/23
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 10/21/23
MCP 417 Neutron and Proton Beam Radiation Therapy Policy
MCP 421 Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Parenteral Nutrition (IPN)
MCP 422 Neuromuscular Electrical Training for the Treatment of OSA or Snoring (eXciteOSA)
MCP 423 Topical and Intralesional Therapies - Effective 9/16/23
MCP 425 Hydrogel Spacer for Prostate Radiotherapy (SpaceOAR) - Effective 8/17/23
MCP 426 Stem Cell Therapy for Orthopedic Applications
MCP 427 Microwave Tumor Ablation
MCP 428 Mobile Cardiac Outpatient Telemetry
MCP 429 Hemgenix (etranacogene dezaparvovec-drlb) - Effective 9/16/23
MCP 432 Developmental Testing - Effective 10/21/23
MCP 433 Roctavian (valoctocogene roxaparvovec) - Effective 10/21/23
MCP 435 OMISIRGE (omidubicel onlv) - Effective 9/16/23
MCP 438 Adstiladrin_nadofaragene firadenovec vncg - Effective 9/16/23
MCP 439 Vyjuvek (beremagene geperpavec) - Effective 9/16/23
MCP 440 Pancreatic Islet Cell Transplantation - Effective 9/16/23
MCP 441 Pancreatic Islet Cell Allotransplantation Lantidra (donislecel-jujn) - Effective 10/21/23
MCP 442 MISHA Knee Implant System - Effective 10/21/23
MCP 662 Whole Body MRI - Effective 7/26/23
MCP 667 Xenoview_Xenon MRI - Effective 9/16/23
MCP 700 Foot Surgery Bunionectomy - Effective 9/11/23
MCP 701 Foot Surgery Hallux Rigidus - Effective 9/11/23
MCP 702 Foot Surgery Lesser Toe Deformities Hammer Mallet and Claw Toe - Effective 9/11/23
- New Century Policies
UM CARDIO_1076 Arterial Duplex)-7292022
UM CARDIO_1076 Arterial Duplex Lower Extremities – Effective 10/6/23
UM CARDIO_1077 Arterial PVR and Stress Arterial PVR_07292022
UM CARDIO_1077 Arterial PVR and Stress Arterial PVR – Effective 10/6/23
UM CARDIO_1078 Ankle Brachial Index_02252022
UM CARDIO_1078 Ankle Brachial Index – Effective 10/6/23
UM CARDIO_1079 Duplex Scan of Hemodialysis Access_07292022
UM CARDIO_1079 Duplex Scan of Hemodialysis Access – Effective 10/6/23
UM CARDIO_1080 Automatic Implantable Cardioverter Defibrillator_10282022
UM CARDIO_1080 Automatic Implantable Cardioverter Defibrillator – Effective 10/6/23
UM CARDIO_1081 Carotid Duplex_02252022
UM CARDIO_1081 Carotid Duplex – Effective 10/6/23
UM CARDIO_1082 Ambulatory EKG Monitoring_07292022
UM CARDIO_1082 Ambulatory EKG Monitoring – Effective 10/6/23
UM CARDIO_1083 Vessel Mapping for Hemodialysis Access or CABG Surgery_11282022
UM CARDIO_1083 Vessel Mapping for Hemodialysis Access or CABG Surgery – Effective 10/6/23
UM CARDIO_1084 Myocardial Perfusion Imaging-Exercise Nuclear Stress Testing_07292022
UM CARDIO_1084 Myocardial Perfusion Imaging-Exercise Nuclear Stress Testing – Effective 10/6/23
UM CARDIO_1085 Patient Activated Event Recorder_07292022
UM CARDIO_1085 Patient Activated Event Recorder – Effective 10/6/23
UM CARDIO_1093 Venous Duplex_07292022
UM CARDIO_1093 Venous Duplex – Effective 10/6/23
UM CARDIO_1094 Percutaneous Coronary Intervention_10282022
UM CARDIO_1094 Percutaneous Coronary Intervention – Effective 10/6/23
UM CARDIO_1095 Aortic Valve Replacement_09302022
UM CARDIO_1096 Aorta Coronary Bypass Surgery_10282022
UM CARDIO_1096 Aorta Coronary Bypass Surgery – Effective 10/6/23
UM CARDIO_1097 Ascending Aortic Graft Surgery_10282022
UM CARDIO_1098 Descending Thoracic Aortic Graft Surgery_09302022
UM CARDIO_1099 Mitral Valve Surgery_09302022
UM CARDIO_1099 Mitral Valve Surgery – Effective 10/6/23
UM CARDIO_1100 Tricuspid Valve Surgery_09302022
UM CARDIO_1101 Cardiac Electrophysiology Study without Arrhythmia Induction_07292022
UM CARDIO_1101 Cardiac Electrophysiology Study without Arrhythmia Induction – Effective 10/6/23
UM CARDIO_1112 Cardiac Telemetry_07292022
UM CARDIO_1113 Cardiac Magnetic Resonance Imaging_11282022
UM CARDIO_1114 Cardiovascular Stress Test_09302022
UM CARDIO_1114 Cardiovascular Stress Test – Effective 10/6/23
UM CARDIO_1115 Coronary Computed Tomographic Angiography_09302022
UM CARDIO_1115 Coronary Computed Tomographic Angiography – Effective 10/6/23
UM CARDIO_1117 Enhanced External Counterpulsation (EECP)_01282022
UM CARDIO_1117 Enhanced External Counterpulsation (EECP) – Effective 10/6/23
UM CARDIO_1119 Pharmacological Nuclear Stress Test-Myocardial Perfusion Imaging_07292022
UM CARDIO_1119 Pharmacological Nuclear Stress Test-Myocardial Perfusion Imaging – Effective 10/6/23
UM CARDIO_1120 Radionuclide Angiogram (MUGA)_07292022
UM CARDIO_1120 Radionuclide Angiogram (MUGA) – Effective 10/6/23
UM CARDIO_1121 Transthoracic Echocardiography_03252022
UM CARDIO_1121 Transthoracic Echocardiography – Effective 10/6/23
UM CARDIO_1122 Transesophageal Echocardiography_02252022
UM CARDIO_1122 Transesophageal Echocardiography – Effective 10/6/23
UM CARDIO_1123 Stress Echocardiography_07292022
UM CARDIO_1123 Stress Echocardiography – Effective 10/6/23
UM CARDIO_1124 Positron Emission Tomography PET Myocardial Imaging_07292022
UM CARDIO_1124 Positron Emission Tomography PET Myocardial Imaging – Effective 10/6/23
UM CARDIO_1125 Renal_Retroperitoneal Vascular Duplex Ultrasound_12312021
UM CARDIO_1125 Renal_Retroperitoneal Vascular Duplex Ultrasound - Effective 10/21/23
UM CARDIO_1126 Abdominal Aortic Ultrasound_08262022
UM CARDIO_1126 Abdominal Aortic Ultrasound – Effective 10/6/23
UM CARDIO_1127 Diagnostic Heart Catheterization_02252022
UM CARDIO_1127 Left Heart Catheterization – Effective 10/6/23
UM CARDIO_1139 Electrophysiology Study with Arrhythmia Induction_09302022
UM CARDIO_1141 EPS with AI_Pacing after DI and Atrial or SVT and AP Ablation_07292022
UM CARDIO_1141 EPS with AI_Pacing after DI and Atrial or SVT and AP Ablation – Effective 10/6/23
UM CARDIO_1142 EPS with AI and AFib AVN and AP Ablation_07292022
UM CARDIO_1142 EPS with AI and AFib AVN and AP Ablation – Effective 10/6/23
UM CARDIO_1143 Non Invasive Programmed Stimulation of AICD_11282022
UM CARDIO_1144 Defibrillator Battery Replacement_02252022
UM CARDIO_1144 Defibrillator Battery Replacement – Effective 10/6/23
UM CARDIO_1145 Pacemaker Battery and Lead(s) Replacement_07292022
UM CARDIO_1145 Pacemaker Battery and Lead(s) Replacement – Effective 10/6/23
UM CARDIO_1146 Implantation of Loop Recorder Systems_02252022
UM CARDIO_1146 Implantation of Loop Recorder Systems – Effective 10/6/23
UM CARDIO_1147 Pacemaker Implantation_01282022
UM CARDIO_1147 Pacemaker Implantation – Effective 10/6/23
UM CARDIO_1148 Synchronized Electrical Cardioversion_01282022
UM CARDIO_1148 Synchronized Electrical Cardioversion – Effective 10/6/23
UM CARDIO_1149 Cardiac Resynchronization Therapy Implantation_07292022
UM CARDIO_1149 Cardiac Resynchronization Therapy Implantation – Effective 10/6/23
UM CARDIO_1152 Device Physiologic CV Data Element Interrogation_10282022
UM CARDIO_1158 Microvolt T-Wave Alternans_07292022
UM CARDIO_1159 Tilt Table Testing_07292022
UM CARDIO_1162 Endo Vascular Abdominal Aortic and Iliac Artery Aneurysm Repair_09302022
UM CARDIO_1163 Carotid Endarterectomy_09302022
UM CARDIO_1164 Femoral Popliteal Bypass Surgery_03252022
UM CARDIO_1164 Femoral Popliteal Bypass Surgery – Effective 10/6/23
UM CARDIO_1165 Hemodialysis Access Creation_02252022
UM CARDIO_1165 Hemodialysis Access Creation – Effective 10/6/23
UM CARDIO_1166 Central Venous Access Procedures_11282022
UM CARDIO_1166 Central Venous Access Procedures – Effective 10/6/23
UM CARDIO_1168 Inferior Vena Cava Filter Device_09302022
UM CARDIO_1169 Catheter Based Carotid Artery Digital Angio_01282022
UM CARDIO_1169 Catheter Based Carotid Artery Digital Angio – Effective 10/6/23
UM CARDIO_1170 Abd Aortography Plus Bilateral Iliofemoral Extremity Runoff_10282022
UM CARDIO_1170 Abd Aortography Plus Bilateral Iliofemoral Extremity Runoff – Effective 10/6/23
UM CARDIO_1171 Carotid Artery Stenting_01282022
UM CARDIO_1171 Carotid Artery Stenting – Effective 10/6/23
UM CARDIO_1172 Endovascular Iliac Interventions_10282022
UM CARDIO_1172 Endovascular Iliac Interventions – Effective 10/6/23
UM CARDIO_1173 Endovascular Femoropopliteal Interventions_09302022
UM CARDIO_1173 Endovascular Femoropopliteal Interventions Effective 10/6/23
UM CARDIO_1174 Endovascular Tibioperoneal Interventions_10282022
UM CARDIO_1174 Endovascular Tibioperoneal Interventions – Effective 10/6/23
UM CARDIO_1175 Perioperative Cardiovascular Evaluation Before Surgery_10282022
UM CARDIO_1252 Endovascular Venous Laser-Radiofrequency Ablation_04292022
UM CARDIO_1252 Endovascular Venous Laser-Radiofrequency Ablation – Effective 10/6/23
UM CARDIO_1253 Lower Extremity Venous Stripping Ligation_07292022
UM CARDIO_1253 Lower Extremity Venous Stripping Ligation – Effective 10/6/23
UM CARDIO_1254 Lower Extremity Venous Sclerotherapy_04292022
UM CARDIO_1254 Lower Extremity Venous Sclerotherapy – Effective 10/6/23
UM CARDIO_1255 Lower Extremity Venous Stab Phlebectomy_04292022
UM CARDIO_1255 Lower Extremity Venous Stab Phlebectomy – Effective 10/6/23
UM CARDIO_1256 Device Interrogation_07292022
UM CARDIO_1257 Device (PPM AICD CRT-D CRT-P Subcut-ICD ILR) Programming_07292022
UM CARDIO_1268 Aorto-Renal Endarterectomy or Bypass Surgery_09302022
UM CARDIO_1269 Coronary Fractional Flow Reserve_07292022
UM CARDIO_1269 Coronary Fractional Flow Reserve - Effective 10/21/23
UM CARDIO_1291 Coronary Atherectomy_08262022
UM CARDIO_1292 Coronary Intra Vascular Arterial Ultrasound_07292022
UM CARDIO_1292 Coronary Intra Vascular Arterial Ultrasound - Effective 10/21/23
UM CARDIO_1293 Renal Angiography_12312021
UM CARDIO_1293 Renal Angiography – Effective 10/6/23
UM CARDIO_1294 Renal Artery Intervention_07292022
UM CARDIO_1294 Renal Artery Intervention - Effective 10/21/23
UM CARDIO_1295 Trans Catheter Aortic Valve Replacement_09302022
UM CARDIO_1296 Trans Catheter Mitral Valve Repair_09302022
UM CARDIO_1296 Trans Catheter Mitral Valve Repair - Effective 10/21/23
UM CARDIO_1318 Peripheral Arterial and Venous Ultrasound_07292022
UM CARDIO_1319 Venogram Invasive Vein Mapping_03252022
UM CARDIO_1319 Venogram Invasive Vein Mapping - Effective 10/21/23
UM CARDIO_1320 Percutaneous Left Atrial Appendage Closure_09302022
UM CARDIO_1321 Temporal Artery Biopsy_07292022
UM CARDIO_1336 Automated Ambulatory Blood Pressure Monitoring_11282022
UM CARDIO_1337 Abdominal Aortic Aneurysm Open Repair_09302022
UM CARDIO_1339 Hemodialysis Access Maintenance_01282022
UM CARDIO_1339 Hemodialysis Access Maintenance - Effective 10/21/23
UM CARDIO_1358 Intra Cardiac Echocardiography_07292022
UM CARDIO_1368 Percutaneous IlioCaval Intervention_01282022
UM CARDIO_1368 Percutaneous IlioCaval Intervention – Effective 10/6/23
UM CARDIO_1369 Pericardial Disease Interventions_01282022
UM CARDIO_1369 Pericardial Disease Interventions – Effective 10/6/23
UM CARDIO_1370 Thoracentesis and Pleurodesis_09302022
UM CARDIO_1388 Endomyocardial Biopsy_01282022
UM CARDIO_1388 Endomyocardial Biopsy – Effective 10/6/23
UM CARDIO_1389 Subcutaneous ICD Device Implantation_07292022
UM CARDIO_1389 Subcutaneous ICD Device Implantation - Effective 10/21/23
UM CARDIO_1390 Ventricular Assist Device (VAD) Percutaneous and Permanent_01282022
UM CARDIO_1390 Ventricular Assist Device (VAD) Percutaneous and Permanent – Effective 10/6/23
UM CARDIO_1402 Wireless Pulmonary Artery Pressure Device Policy_08262022
UM CARDIO_1402 Wireless Pulmonary Artery Pressure Device Policy - Effective 10/21/23
UM-CARDIO-1417-Percutaneous-Closure-of-PFO-10282022
UM CARDIO_1418 Intervention on Adults with Congenital Heart Defects_07292022
UM CARDIO_1427 Cardiac Surveillance Following COVID-19 Infection_03252022
UM CARDIO_1427 Cardiac Surveillance Following COVID-19 Infection - Effective 10/21/23
UM CARDIO_1453 Ultrasound Guided Vascular Access_12312021
UM CARDIO_1453 Ultrasound Guided Vascular Access - Effective 10/21/23
UM CARDIO_1456 Vascular Embolization and Occlusion_01282022UM CARDIO_1456 Vascular Embolization and Occlusion – Effective 10/6/23
- SKYGEN Policies
UM-2-4000-D Utilization Review Criteria
UM-2-4000-1 Diagnostic Services - Effective 9/1/23
UM-2-4000-2 Preventive Services - Effective 9/1/23
UM-2-4000-3 Restorative Services - Effective 9/1/23
UM-2-4000-4 Periodontic Services - Effective 9/1/23
UM-2-4000-5 Prosthodontic Services - Effective 9/1/23
UM-2-4000-6 Oral Surgery Services - Effective 9/1/23
UM-2-4000-7 Orthodontic Services - Effective 9/1/23
UM-2-4000-8 Anesthesia Services - Effective 9/1/23