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 12/16/23
Acthar Gel (repository corticotropin injection) C8373-A – Effective 1/10/24
Adakveo (crizanlizumab-tmca) C17920-A – Effective 11/19/23
Adcetris (brentuximab vedotin) C15428-A – Effective 5/1/24
Aduhelm (aducanumab-avwa) MNR C21304-A – Effective 1/10/24
ADZYNMA (ADAMTS13, recombinant-krhn) C27325-A – Effective 4/12/24
Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A - Effective 11/20/23
Amondys 45 C21154-A - Effective 11/20/23
Amvuttra (vutrisiran) C24213-A – Effective 11/19/23
Antiemetics C20780-A – Effective 5/1/24
Aphexda (motixafortide) C27171-A – Effective 4/12/24
Azactam (aztreonam) C10143-A - Effective 9/11/23
Benlysta (belimumab) C2722-A – Effective 1/10/24
Beovu (brolucizumab) C17923-A – Effective 1/10/24
Botulinum Toxin C8755-A - Effective 4/12/24
Brineura (cerliponase alfa) C11526-A - Effective 10/21/23
Briumvi ublituximab-xiiy C25204-A - Effective 10/21/23
Cablivi (caplacizumab-yhdp) C19481-A – Effective 11/19/23
Calcitonin Gene-Related Peptide (CGRP) Antagonist C15443-C - Effective 11/20/23
Cancidas (caspofungin) C17928-A - Effective 9/11/23
Cimzia (certolizumab pegol) C10269-A - Effective 12/16/23
Cinqair (reslizumab) C9761-A – Effective 1/15/24
Copaxone_Glatopa (glatiramer acetate) C10270-A - Effective 9/11/23
Cosela (trilaciclib) C21205-A - Effective 5/1/24
Cosentyx (secukinumab) C10410-A - Effective 5/1/24
Crysvita (burosumab-twza) C14517-A - Effective 10/21/23
Cubicin (daptomycin) C10467-A - Effective 5/1/24
Cytogam (cytomegalovirus immune globulin) C9970-A – Effective 4/12/24
Dalvance (dalbavancin) C9351-A – Effective 4/12/24
Durysta (bimatoprost implant) C19830-A – Effective 1/15/24
Elaprase (idursulfase) C2720-A – Effective 11/19/23
Enjaymo (sutimlimab) C22996-A - Effective 5/1/24
Entyvio (vedolizumab) C6773-A – Effective 1/10/24
Enzyme Replacement Therapy for Lysosomal Storage Disorders C9997-A – Effective 11/19/23
Erythropoiesis-stimulating agents (ESAs) C15389-A - Effective 10/21/23
Evenity (romosozumab-aqqg) C17324-A – Effective 11/19/23
Evkeeza (evinacumab_dgnb) C21101-A – Effective 5/1/24
Exondys 51 (eteplirsen) C18464-A - Effective 11/20/23
Eylea (aflibercept) C5674-A – Effective 1/10/24
Fabrazyme (agalsidase beta) C4865-A – Effective 11/19/23
Fasenra (benralizumab) C13643-A - Effective 1/10/24
Filgrastim C2437-A – Effective 11/19/23
Furoscix (furosemide injection) C24669-A - Effective 4/22/24
Gamifant (emapalumab-lzsg) C15970-A – Effective 11/19/23
Givlaari (givosiran) C17924-A – Effective 11/19/23
Hemophilia and Blood Factor Products C15607-A – Effective 11/19/23
Hepatitis B Immune Globulin C9971-A – Effective 4/12/24
Hereditary Angioedema Agents C21463-A – Effective 11/19/23
Hyaluronic Acid Injections C14676-A - Effective 1/10/24
Igalmi (dexmedetomidine) C23724-A – Effective 5/1/24
Ilaris (canakinumab) C2435-A - Effective 1/10/24
Ilumya (tildrakizumab) C15971-A - Effective 1/14/24
Immunoglobulin (SCIg, IVIg) MHI C21554-A – Effective 11/27/23
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A – Effective 5/1/24
Intravenous Bisphosphonates C16790-A - Effective 11/20/23
Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) C15214-A - Effective 11/13/23
Iron Deficiency Anemia Agents C14569-A - Effective 11/13/23
Izervay (avacincaptad intravitreal) C26436-A – Effective 1/10/24
Kanuma (sebelipase alfa) C9974-A - Effective 11/20/23
Kesimpta (ofatumumab) C21104-A – Effective 11/27/23
Korsuva (difelikefalin) C23743-A – Effective 11/27/23
Krystexxa (pegloticase) C2729-A – Effective 4/12/24
Lemtrada (alemtuzumab) C6919-A - Effective 8/17/23
Leqembi (lecanemab-irmb) C25201-A – Effective 1/10/24
Leqvio (inclisiran) C23141-A - Effective 5/1/24
Leukine (sargramostim) C2439-A - Effective 4/12/24
Lumizyme (alglucosidase alfa) C8716_A - Effective 10/21/23
Mepsevii (vestronidase alfa-vjbk) C17942-A - Effective 11/13/23
Mozobil (plerixafor injection) C9017-A - Effective 4/12/24
Multiple Sclerosis Agents - Interferons C10267-A - Effective 9/11/23
Mycamine (micafungin) C9347-A – Effective 11/27/23
NexoBrid anacaulase-bcdb C25200-A - Effective 8/17/23
Nexviazyme (alglucosidase alfa-ngpt) C21948-A – Effective 11/27/23
Nplate (romiplostim) C6662-A – Effective 11/27/23
Nucala (mepolizumab) C9704-A – Effective 1/10/24
Nulibry (fosdenopterin) C21306-A – Effective 11/27/23
Nulojix (belatacept) C9968-A – Effective 1/15/24
Nuzyra (omadacycline tosylate) C15914-A - Effective 5/1/24
Ocrevus (ocrelizumab) C11250-A - Effective 9/11/23
Octreotide C8839-A – Effective 11/27/23
Off-Label Use of Drugs and Biologic Agents C4141-A – Effective 1/10/24
Omvoh (mirikizumab) C27293-A - Effective 4/12/24
Onpattro (patisiran)_Tegsedi_(inotersen) C17894-A - Effective 11/13/23
Orencia (abatacept) C10420-A - Effective 4/12/24
Oxlumo (lumasiran) C21126-A – Effective 11/27/23
Ozurdex (dexamethasone intravitreal implant) C9975-A – Effective 2/3/24
Parsabiv (etelcalcetide) C17883-A - Effective 11/13/23
Physician Administered Drugs C11251-A - Effective 1/7/24
Pombiliti (cipaglucosidase alfa) C27242-A – Effective 4/12/24
Prevymis (letermovir) C15922-A - Effective 5/1/24
Prolia (denosumab) C8848-A – Effective 11/27/23
Pulmonary Arterial Hypertension (PAH) C9837-A - Effective 4/12/24
Qutenza (capsaicin) C2809-A - Effective 8/17/23
Radicava (edaravone) C11528-A - Effective 8/17/23
Ranibizumab and Biosimilars (Lucentis, Byooviz, Cimerli) C10417-A – Effective 12/16/23
Reblozyl (luspatercept-aamt) C18002-A – Effective 5/1/24
Rebyota (fecal microbiota, live-jslm) C25213-A - Effective 4/12/24
Revcovi (elapegademase) C16329-A - Effective 11/13/23
Rezzayo (rezafungin) C26183-A - Effective 4/12/24
Rituxan (rituximab) and Biosimilars C10423-A - Effective 1/10/24
Rolvedon, Neulasta, and Related Biosimilars C10419-A – Effective 3/6/24
Ryplazim (plasminogen, human) C22238-A – Effective 11/27/23
Rystiggo (rozanolixizumab) C26210-A – Effective 1/10/24
Saphnelo (anifrolumab) C21970-A – Effective 1/10/24
Sexual Dysfunction Criteria - Non-Coverage C16658-A - Effective 5/1/24
Signifor (pasireotide diaspartate) C15367-A - Effective 11/13/23
Simponi_Simponi Aria (golimumab) C10422-A - Effective 12/16/23
Sivextro (tedizolid) C9353-A – Effective 4/12/24
Skyrizi (risankizumab-rzaa) C17336-A - Effective 1/10/24
Soliris_Ultomiris (eculizumab_ravulizumab) C4867-A – Effective 11/27/23
Standard Oncology Criteria C16154-A - Effective 5/1/24
Stelara (usketinumab) C10424-A - Effective 1/10/24
Sunlenca (lenacapavir) C25206-A – Effective 4/12/24
Supprelin LA (histrelin acetate) Implant C20611-A – Effective 11/27/23Syfovre (pegcetacoplan intravitreal) C25311-A - Effective 1/14/24
Synagis (palivizumab) C6074-A – Effective 12/1/23
Tepezza (teprotumumab-trbw) C18462-A – Effective 1/10/24
Testosterone C2270-A – Effective 11/27/23
Tezspire(tezepelumab) C23042-A – Effective 1/10/24
Triptodur (triptorelin pamoate) C14649-A - Effective 11/13/23
Trogarzo (ibalizumab-uiyk) C14522-A - Effective 5/1/24
Tysabri (natalizumab) C10276-A - Effective 9/11/23
Tzield teplizumab C24729-A - Effective 8/17/23
Uplizna (inebilizumab-cdon) C20171-A – Effective 11/27/23
Vabysmo (faricimab) C22795-A – Effective 5/1/24
Veopoz (pozelimab-bbfg) C26434-A – Effective 1/10/24
Veklury (remdesivir) C20763-A – Effective 11/27/23
Vibativ (telavancin) C14575-A - Effective 5/1/24
Vimizim (elosulfase alfa) C7068-A – Effective 11/27/23
Vyondys 53 (golodirsen) C18466-A - Effective 11/20/23
Vyvgart (efgartigimod alfa) C23127-A – Effective 1/10/24
Xacduro (sulbactam and durlobactam) C26432-A – Effective 4/22/24
Xgeva (denosumab) C8849-A – Effective 4/12/24
Xipere (triamcinolone ocular inj) C22222-A – Effective 1/15/24
Xolair (omalizumab) C5678-A – Effective 1/10/24
Zinplava (bexlotoxumab) C14821-A - Effective 9/11/23
Zoladex (goserelin acetate) C8757-A - Effective 11/20/23
- Molina Clinical Policies
MCP 000 Evaluation of New Technology - Effective 9/16/23
MCP 006 Vagal Nerve Stimulation for Epilepsy - Effective 5/1/24
MCP 011 Lumbar Artificial Intervertebral Disc Replacement - Effective 4/22/24
MCP 030 Facet Joint Diagnostic Injections for Chronic Back Pain - Effective 7/26/23
MCP 030 Facet Joint Diagnostic Injections for Chronic Back Pain - Effective 7/13/24
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 033 Sacroiliac Injections and RFA for SIJ Pain - Effective 7/13/24
MCP 050 Hyperbaric Oxygen Therapy and Topical Oxygen Therapy - Effective 9/16/23
MCP 050 Hyperbaric Oxygen Therapy and Topical Oxygen Therapy - Effective 7/13/24
MCP 051 Genetic Testing - Effective 5/1/24
MCP 085 Radiofrequency Ablation for Chronic Back Pain - Effective 7/26/23
MCP 085 Radiofrequency Ablation for Chronic Back Pain - Effective 7/13/24
MCP 105 Provenge (sipuleucel-T) – Effective 5/1/24
MCP 120 Transarterial Chemoembolization for Liver Tumors - Effective 7/26/23
MCP 121 Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure – Effective 12/15/23
MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 12/16/23
MCP 132 Percutaneous Ventricular Assist Devices - Effective 3/15/24
MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting - Effective 5/1/24
MCP 145 EPAP for Obstructive Sleep Apnea - Effective 3/6/24
MCP 161 Robotically Assisted Surgery - Effective 7/26/23
MCP 161 Robotically Assisted Surgery - Effective 7/13/24
MCP 180 QEEG for ADHD with NEBA System - Effective 10/21/23
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 204 Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair - Effective 7/13/24
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 207 Platelet-Riched Plasma (PRP) - Effective 7/13/24
MCP 216a Gender Affirmation Treatment and Procedures_Medicaid - Effective 5/29/24
MCP 218 Recombinant Human Bone Morphogenetic Protein - Effective 7/26/23
MCP 218 Bone Graft Substitutes for Bone Fusion - Effective 7/13/24
MCP 222 Interspinous Decompression Devices for Spinal Stenosis - Effective 7/26/23
MCP 222 Interspinous Decompression Devices for Spinal Stenosis - Effective 7/13/24
MCP 235 Measurement of Carotid Artery Intima Thickness – Effective 12/15/23
MCP 250 Prostatic Urethral Lift or UroLift for BPH - Effective 10/21/23
MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 5/1/24
MCP 292 Phototherapy and Laser Therapy for Dermatological Conditions - Effective 7/26/23
MCP 293 Spinraza_nusinersen - Effective 10/21/23
MCP 301 Iluvien (fluocinolone acetonide) Intravitreal Implant – Effective 12/16/23
MCP 302 Retisert_Yutiq_fluocinolone acetonide_Intravitreal Implants - Effective 7/26/23
MCP 302 Retisert_Yutiq_fluocinolone acetonide_Intravitreal Implants - Effective 7/13/24
MCP 308 Visudyne_verteporfin_for Ocular Photodynamic Therapy - Effective 10/21/23
MCP 315 Breast Implant Removal - Effective 9/16/23
MCP 315 Breast Implant Removal - Effective 7/13/24
MCP 318 Luxturna (voretigene neparvovec rzyl) - Effective 10/21/23
MCP 321 Category III CPT Codes - Effective 3/6/24
MCP 322 Lutathera (lutetium Lu 177 dotatate) - Effective 11/13/23
MCP 328 Corneal Collagen Cross Linking - Effective 10/21/23
MCP 329 Enclosed Bed Systems - Effective 1/7/24
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 7/13/24
MCP 335 Deep Brain Stimulation DBS for Epilepsy - Effective 5/1/24
MCP 337 Gastroesophageal Reflux Disease GERD Treatment – Effective 12/15/23
MCP 338 Plantar Fasciitis Treatment - Effective 5/1/24
MCP 339 Interspinous Process Fixation Devices for Spinal Fusion - Effective 5/1/24
MCP 340 Implantable Neurostimulator for Central Sleep Apnea - Effective 5/1/24
MCP 342 Dexycu (dexamethasone intraocular suspension) - Effective 7/26/23
MCP 342 Dexycu (dexamethasone intraocular suspension) - Effective 7/13/24
MCP 343 Intervertebral Stabilization Devices – Effective 12/15/23
MCP 344 Ketogenic Diet for Treatment of Intractable Seizures - Effective 5/1/24
MCP 347 Autologous Chondrocyte Implantation for Knee – Effective 12/16/23
MCP 350 MyoPro Orthosis - Effective 5/1/24
MCP 351 Minimally Invasive Lumbar Decompression MILD for Spinal Stenosis - Effective 3/6/24
MCP 352 Dynamic Exoskeletal Orthoses for Lower Extremity Injuries - Effective 3/6/24
MCP 353 Electric Tumor Treatment Fields for Glioblastoma - Effective 5/1/24
MCP 357 Skin Substitutes - Effective 3/6/24
MCP 357 Skin Substitutes - Effective 7/13/24
MCP 361 Renal Autotransplantation - Effective 7/26/23
MCP 361 Renal Autotransplantation - Effective 7/13/24
MCP 363 Hypoglossal Nerve Stimulation for the Treatment of OSA - Effective 9/16/23
MCP 366 Cluneal Nerve Block for LBP - Effective 11/13/23
MCP 367 Scenesse (afamelanotide) Implant - Effective 7/26/23
MCP 367 Scenesse (afamelanotide) Implant - Effective 7/13/24
MCP 372 Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain – Effective 1/10/24
MCP 377 Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers - Effective 10/21/23
MCP 378 Tecartus (brexucabtagene autoleucel) - Effective 11/13/23
MCP 381 Focused Microwave Thermotherapy for Breast Cancer - Effective 10/21/23
MCP 383 IB-Stim Device for Abdominal Pain in Adolescents - Effective 3/6/24
MCP 384 Water Vapor Thermal Therapy for BPH - Effective 3/6/24
MCP 385 Peroral Endoscopic Myotomy for Esophageal Achalasia - Effective 7/26/23
MCP 385 Peroral Endoscopic Myotomy for Esophageal Achalasia - Effective 7/13/24
MCP 386 Coolief Cooled Radiofrequency - Effective 3/6/24
MCP 389 XEN Gel Stent for Glaucoma - Effective 3/6/24
MCP 392 Monarch External Trigeminal Nerve Stimulation eTNS System
MCP 395 Kymriah (tisagenlecleucel) - Effective 9/16/23
MCP 396 Yescarta (axicabtagene ciloleucel) - Effective 11/13/23
MCP 397 Moleculight Wound Care Device - Effective 7/26/23
MCP 397 Moleculight Wound Care Device - Effective 7/13/24
MCP 399 Electrostimulation and Electromagnetic Therapy for Wound Care - Effective 11/13/23
MCP 400 Breyanzi (lisocabtagene maraleucel) - Effective 11/13/23
MCP 402 Plantar Fasciitis Surgery - Effective 9/16/23
MCP 402 Plantar Fasciitis Surgery - Effective 7/13/24
MCP 403 Abecma (idecabtagene vicleucel) - Effective 11/13/23
MCP 404 Shoulder Arthroscopy Guidelines - Effective 7/26/23
MCP 405 Dextenza (dexamethasone intracanalicular insert) - Effective 7/26/23
MCP 405 Dextenza (dexamethasone intracanalicular insert) - Effective 7/13/24
MCP 407 Wound Vac (NPWT) - Effective 5/1/24
MCP 408 Balloon Sinus Ostial Dilation Balloon Sinuplasty - Effective 3/6/24
MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis - Effective 5/1/24
MCP 411 Susvimo_ranibizumab intravitreal_injection implant - Effective 5/1/24
MCP 412 Prescription Digital Therapeutics - Effective 9/16/23
MCP 412 Prescription Digital Therapeutics - Effective 7/13/24
MCP 413 Carvykti (ciltacabtagene autoleucel) - Effective 11/13/23
MCP 414 Gastric Electrical Stimulation - Effective 12/15/23
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 5/1/24
MCP 417 Neutron and Proton Beam Radiation Therapy Policy – Effective 5/1/24
MCP 423 Topical and Intralesional Therapies - Effective 9/16/23
MCP 425 Hydrogel Spacer for Prostate Radiotherapy (SpaceOAR) - Effective 5/1/24
MCP 426 Stem Cell Therapy for Orthopedic Applications - Effective 3/6/24
MCP 427 Microwave Ablation of Lung and Liver Tumors - Effective 3/6/24
MCP 430 Responsive Neurostimulation (RNS) for Epilepsy - Effective 7/13/24
MCP 432 Developmental Testing - 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 (Autologous) – Effective 11/27/23
MCP 441 Pancreatic Islet Cell Allotransplantation Lantidra (donislecel-jujn) - Effective 10/21/23
MCP 442 MISHA Knee Implant System - Effective 10/21/23
MCP 443 Fractional Laser Treatment of Traumatic and Burn Scars – Effective 12/16/23
MCP 444 Implantable Peripheral Nerve and Nerve Field Stimulators for Chronic Pain – Effective 5/1/24
MCP 446 Wheelchair Mounted Robotic Arm Devices – Effective 7/5/24
MCP 452 Intraosseous Basivertebral Nerve Ablation - Effective 7/13/24
MCP 662 Whole Body MRI and/or CT - Effective 11/13/23
MCP 667 Xenoview_Xenon MRI - Effective 12/16/23
MCP 700 Foot Surgery Bunionectomy - Effective 9/11/23
MCP 700 Foot Surgery-Bunionectomy - Effective 7/13/24
MCP 701 Foot Surgery Hallux Rigidus - Effective 9/11/23
MCP 701 Foot Surgery-Hallux Rigidus - Effective 7/13/24
MCP 702 Foot Surgery Lesser Toe Deformities Hammer Mallet and Claw Toe - Effective 9/11/23
MCP 702 Foot Surgery-Lesser Toe Deformities-Hammer Mallet and Claw Toe - Effective 7/13/24
- Evolent (formerly known as New Century Health) Policies
UM CARDIO_1076 Arterial Duplex – Effective 3/22/24
UM CARDIO_1077 Arterial PVR and Stress Arterial PVR – Effective 3/22/24
UM CARDIO_1078 Ankle Brachial Index – Effective 3/22/24
UM CARDIO_1079 Duplex Scan of Hemodialysis Access – Effective 3/22/24
UM CARDIO_1080 Automatic Implantable Cardioverter Defibrillator – Effective 3/22/24
UM CARDIO_1081 Carotid Duplex – Effective 3/22/24
UM CARDIO_1082 Ambulatory EKG Monitoring – Effective 3/22/24
UM CARDIO_1083 Vessel Mapping for Hemodialysis Access or CABG Surgery – Effective 3/22/24
UM CARDIO_1084 Myocardial Perfusion Imaging-Exercise Nuclear Stress Testing – Effective 3/22/24
UM CARDIO_1085 Patient Activated Event Recorder – Effective 3/22/24
UM CARDIO_1093 Venous Duplex – Effective 3/22/24
UM CARDIO_1094 Percutaneous Coronary Intervention – Effective 3/22/24
UM CARDIO_1095 Aortic Valve Replacement – Effective 12/16/23
UM CARDIO_1096 Aorta Coronary Bypass Surgery – Effective 10/6/23
UM CARDIO_1097 Ascending Aortic Graft Surgery – Effective 12/16/23
UM CARDIO_1098 Descending Thoracic Aortic Graft Surgery – Effective 12/16/23
UM CARDIO_1099 Mitral Valve Surgery – Effective 10/6/23
UM CARDIO_1100 Tricuspid Valve Surgery – Effective 12/16/23
UM CARDIO_1101 Cardiac Electrophysiology Study without Arrhythmia Induction – Effective 10/6/23
UM CARDIO_1112 Cardiac Telemetry - Effective 3/22/24
UM CARDIO 1113 Cardiac Magnetic Resonance Imaging – Effective 3/22/24
UM CARDIO_1114 Cardiovascular Stress Test – Effective 3/22/24
UM CARDIO_1115 Coronary Computed Tomographic Angiography – Effective 3/22/24
UM CARDIO_1117 Enhanced External Counterpulsation (EECP) – Effective 3/22/24
UM CARDIO_1119 Pharmacological Nuclear Stress Test-Myocardial Perfusion Imaging – Effective 3/22/24
UM CARDIO_1120 Radionuclide Angiogram (MUGA) – Effective 3/22/24
UM CARDIO_1121 Transthoracic Echocardiography – Effective 3/22/24
UM CARDIO_1122 Transesophageal Echocardiography – Effective 3/22/24
UM CARDIO_1123 Stress Echocardiography – Effective 3/22/24
UM CARDIO_1124 Positron Emission Tomography PET Myocardial Imaging – Effective 3/22/24
UM CARDIO_1125 Renal_Retroperitoneal Vascular Duplex Ultrasound - Effective 3/22/24
UM CARDIO_1126 Abdominal Aortic Ultrasound – Effective 3/22/24
UM CARDIO_1127 Left Heart Catheterization – Effective 3/22/24
UM CARDIO_1139 Electrophysiology Study with Arrhythmia Induction – Effective 12/16/23
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 – Effective 10/6/23
UM CARDIO 1143 Non Invasive Programmed Stimulation of AICD – Effective 1/10/24
UM CARDIO_1144 Defibrillator Battery Replacement – Effective 10/6/23
UM CARDIO_1145 Pacemaker Battery and Lead(s) Replacement – Effective 10/6/23
UM CARDIO 1146 Implantation of Loop Recorder Systems – Effective 3/22/24
UM CARDIO_1147 Pacemaker Implantation – Effective 3/22/24
UM CARDIO_1148 Synchronized Electrical Cardioversion – Effective 10/6/23
UM CARDIO_1149 Cardiac Resynchronization Therapy Implantation – Effective 3/22/24
UM CARDIO_1152 Device Physiologic CV Data Element Interrogation – Effective 12/16/23
UM CARDIO_1158 Microvolt T-Wave Alternans - Effective 3/22/24
UM CARDIO_1159 Tilt Table Testing - Effective 11/13/23
UM CARDIO_1162 Endo Vascular Abdominal Aortic and Iliac Artery Aneurysm Repair – effective 12/16/23
UM CARDIO_1163 Carotid Endarterectomy – Effective 12/16/23
UM CARDIO_1164 Femoral Popliteal Bypass Surgery – Effective 10/6/23
UM CARDIO_1165 Hemodialysis Access Creation – Effective 10/6/23
UM CARDIO_1166 Central Venous Access Procedures – Effective 10/6/23
UM CARDIO_1168 Inferior Vena Cava Filter Device – Effective 12/16/23
UM CARDIO_1169 Catheter Based Carotid Artery Digital Angio – Effective 3/22/24
UM CARDIO_1170 Abd Aortography Plus Bilateral Iliofemoral Extremity Runoff – Effective 3/22/24
UM CARDIO_1171 Carotid Artery Stenting – Effective 3/22/24
UM CARDIO_1172 Endovascular Iliac Interventions – Effective 3/22/24
UM CARDIO_1173 Endovascular Femoropopliteal Interventions Effective 3/22/24
UM CARDIO_1174 Endovascular Tibioperoneal Interventions – Effective 3/22/24
UM CARDIO_1175 Perioperative Cardiovascular Evaluation Before Surgery – Effective 12/16/23
UM CARDIO_1252 Endovascular Venous Laser-Radiofrequency Ablation – Effective 3/22/24
UM CARDIO_1253 Lower Extremity Venous Stripping Ligation – Effective 3/22/24
UM CARDIO_1254 Lower Extremity Venous Sclerotherapy – Effective 3/22/24
UM CARDIO_1255 Lower Extremity Venous Stab Phlebectomy – Effective 3/22/24
UM CARDIO_1256 Device Interrogation - Effective 3/22/24
UM CARDIO_1257 Device (PPM AICD CRT-D CRT-P Subcut-ICD ILR) Programming - Effective 11/13/23
UM CARDIO 1268 Aorto-Renal Endarterectomy or Bypass Surgery – Effective 1/10/24
UM CARDIO_1269 Coronary Fractional Flow Reserve - Effective 3/22/24
UM CARDIO_1291 Coronary Atherectomy - Effective 11/13/23
UM CARDIO_1292 Coronary Intra Vascular Arterial Ultrasound - Effective 3/22/24
UM CARDIO 1293 Renal Angiography – Effective 3/22/24
UM CARDIO_1294 Renal Artery Intervention - Effective 3/22/24
UM CARDIO_1295 Trans Catheter Aortic Valve Replacement – Effective 3/22/24
UM CARDIO_1296 Trans Catheter Mitral Valve Repair - Effective 3/22/24
UM CARDIO_1318 Peripheral Arterial and Venous Ultrasound - Effective 11/13/23
UM CARDIO_1319 Venogram Invasive Vein Mapping - Effective 10/21/23
UM CARDIO_1320 Percutaneous Left Atrial Appendage Closure – Effective 3/22/24
UM CARDIO_1321 Temporal Artery Biopsy - Effective 11/13/23
UM CARDIO 1336 Automated Ambulatory Blood Pressure Monitoring – Effective 3/22/24
UM CARDIO_1337 Abdominal Aortic Aneurysm Open Repair – Effective 12/16/23
UM CARDIO_1339 Hemodialysis Access Maintenance - Effective 3/22/24
UM CARDIO_1358 Intra Cardiac Echocardiography - Effective 11/13/23
UM CARDIO_1368 Percutaneous IlioCaval Intervention – Effective 3/22/24
UM CARDIO_1369 Pericardial Disease Interventions – Effective 10/6/23
UM CARDIO_1370 Thoracentesis and Pleurodesis – Effective 12/16/23
UM CARDIO_1388 Endomyocardial Biopsy – Effective 10/6/23
UM CARDIO_1389 Subcutaneous ICD Device Implantation - Effective 3/22/24
UM CARDIO_1390 Ventricular Assist Device (VAD) Percutaneous and Permanent – Effective 3/22/24
UM CARDIO_1402 Wireless Pulmonary Artery Pressure Device Policy - Effective 10/21/23
UM CARDIO_1417 Percutaneous Closure of PFO – Effective 12/16/23
UM CARDIO_1418 Intervention on Adults with Congenital Heart Defects - Effective 11/13/23
UM CARDIO 1453 Ultrasound Guided Vascular Access – Effective 1/10/24
UM CARDIO_1456 Vascular Embolization and Occlusion – Effective 10/6/23
- Evolent – Radiation/Oncology Policies
UM ONC 1179 Abraxane (nab paclitaxel) - Effective 8/1/24
UM ONC 1485 Akeega (niraparib and abiraterone acetate) - Effective 8/1/24
UM ONC 1277 Alecensa (alectinib) - Effective 8/1/24
UM ONC 1130 Alimta or Pemfexy (pemetrexed) - Effective 8/1/24
UM ONC 1327 Aliqopa (copanlisib) - Effective 8/1/24
UM ONC 1313 Alunbrig (brigatinib) - Effective 8/1/24
UM ONC 1220 Arzerra (ofatumumab) - Effective 8/1/24
UM ONC 1352 Asparlas (calaspargase pegol-mknl) - Effective 8/1/24
UM ONC 1490 Augtyro (repotrectinib) - Effective 8/1/24
UM ONC 1378 Ayvakit (avapritinib) - Effective 8/1/24
UM ONC 1342 Azedra (iobenguane I-131) - Effective 8/1/24
UM ONC 1374 Balversa (erdafitinib) - Effective 8/1/24
UM ONC 1306 Bavencio (avelumab) - Effective 8/1/24
UM ONC 1260 Beleodaq (belinosat) - Effective 8/1/24
UM ONC 1330 Besponsa (inotuzumab ozogamicin) - Effective 8/1/24
UM ONC 1454 Besremi (ropeginterferon alfa-2b-nijft) - Effective 8/1/24
UM ONC 1028 Bevacizumab Products - Effective 8/1/24
UM ONC 1411 Blenrep (belantamab mafodotin-blmf) - Effective 8/1/24
UM ONC 1270 Blincyto (blinatumomab) - Effective 8/1/24
UM ONC 1221 Bosulif (bosutinib) - Effective 8/1/24
UM ONC 1335 Braftovi (encorafenib) - Effective 8/1/24
UM ONC 1377 Brukinsa (zanubrutinib) - Effective 8/1/24
UM ONC 1331 Calquence (acalabrutinib) - Effective 8/1/24
UM ONC 1204 Caprelsa (vandetanib) - Effective 8/1/24
UM ONC 1395 Clolar (clofarabine) - Effective 8/1/24
UM ONC 1480 Columvi (glofitamab-gxbm) - Effective 8/1/24
UM ONC 1237 Cometriq or Cabometyx (cabozantinib) - Effective 8/1/24
UM ONC 1346 Copiktra (duvelisib) - Effective 8/1/24
UM ONC 1279 Cotellic (cobimetinib) - Effective 8/1/24
UM ONC 1209 Criteria for Evidence Based Cancer Therapies - Effective 8/1/24
UM ONC 1261 Cyramza (ramucirumab) - Effective 8/1/24
UM ONC 1419 Danyelza (naxitamab-gqgk) - Effective 8/1/24
UM ONC 1280 Darzalex and Darzalex Faspro - Effective 8/1/24
UM ONC 1354 Daurismo (glasdegib) - Effective 8/1/24
UM ONC 1334 Doptelet (avatrombopag) - Effective 8/1/24
UM ONC 1471 Elahere (mirvetuximab soravtansine-gynx) - Effective 8/1/24
UM ONC 1403 Elitek (rasburicase) - Effective 8/1/24
UM ONC 1482 Elrexfio (elranatamab-bcmm) - Effective 8/1/24
UM ONC 1356 Elzonris (tagraxofusp) - Effective 8/1/24
UM ONC 1281 Empliciti (elotuzumab) - Effective 8/1/24
UM ONC 1373 Endari (l-glutamine) - Effective 8/1/24
UM ONC 1379 Enhertu (fam-trastuzumab deruxtecan-nxki) - Effective 8/1/24
UM ONC 1479 Epkinly (epcoritamab-bysp) - Effective 8/1/24
UM ONC 1133 Erbitux (cetuximab) - Effective 8/1/24
UM ONC 1222 Erivedge (vismodegib) - Effective 8/1/24
UM ONC 1333 Erleada (apalutamide) - Effective 8/1/24
UM ONC 1447 Exkivity (mobocertinib) - Effective 8/1/24
UM ONC 1448 Ferriprox (deferiprone) - Effective 8/1/24
UM ONC 1425 Fotivda (tivozanib) - Effective 8/1/24
UM ONC 1491 Fruzaqla (fruquintinib) - Effective 8/1/24
UM ONC 1288 Fusilev or Khapzory (levoleucovorin) - Effective 8/1/24
UM ONC 1457 Fyarro (sirolimus) - Effective 8/1/24
UM ONC 1414 Gavreto (pralsetinib) - Effective 8/1/24
UM ONC 1259 Gazyva (obinutuzumab) - Effective 8/1/24
UM ONC 1304 Generic Drugs - Effective 8/1/24
UM ONC 1258 Gilotrif (afatanib) - Effective 8/1/24
UM ONC 1205 Halaven (eribulin) - Effective 8/1/24
UM ONC 1486 Hepzato (melphalan) - Effective 8/1/24
UM ONC 1272 Ibrance (palbociclib) - Effective 8/1/24
UM ONC 1241 Iclusig (ponatinib) - Effective 8/1/24
UM ONC 1323 Idhifa (enasidenib) - Effective 8/1/24
UM ONC 1262 Imbruvica (ibrutinib) - Effective 8/1/24
UM ONC 1314 Imfinzi (durvalumab) - Effective 8/1/24
UM ONC 1469 Imjudo (tremelimumab) - Effective 8/1/24
UM ONC 1282 Imlygic (Talimogene Laherparepvec) - Effective 8/1/24
UM ONC 1223 Inlyta (axitinib) - Effective 8/1/24
UM ONC 1410 Inqovi (decitabine and cedazuridine) - Effective 8/1/24
UM ONC 1366 Inrebic (fedratinib) - Effective 8/1/24
UM ONC 1309 Iressa (gefitinib) - Effective 8/1/24
UM ONC 1230 Istodax (romidepsin) - Effective 8/1/24
UM ONC 1495 Iwilfin (eflornithine) - Effective 8/1/24
UM ONC 1248 Ixempra (ixabepilone) - Effective 8/1/24
UM ONC 1242 Jakafi (ruxolitinib) - Effective 8/1/24
UM ONC 1476 Jaypirca (pirtobrutinib) - Effective 8/1/24
UM ONC 1415 Jelmyto (mitomycin for pyelocalyceal instillation) - Effective 8/1/24
UM ONC 1433 Jemperli (dostarlimab-gxly) - Effective 8/1/24
UM ONC 1219 Jevtana (cabazitaxel) - Effective 8/1/24
UM ONC 1238 Kadcyla (ado-trastuzumab emtansine) - Effective 8/1/24
UM ONC 1263 Keytruda (pembrolizumab) - Effective 8/1/24
UM ONC 1459 Kimmtrak (tebentafusp-tebn) - Effective 8/1/24
UM ONC 1310 Kisqali (ribociclib) - Effective 8/1/24
UM ONC 1396 Koselugo (selumetinib) - Effective 8/1/24
UM ONC 1473 Krazati (adagrasib) - Effective 8/1/24
UM ONC 1224 Kyprolis (carfilzomib) - Effective 8/1/24
UM ONC 1283 Lenvima (lenvatinib) - Effective 8/1/24
UM ONC 1089 Libtayo (cemiplimab-rwlc) - Effective 8/1/24
UM ONC 1311 Lonsurf (trifluridinetipiracil) - Effective 8/1/24
UM ONC 1492 Loqtorzi (toripalimab-tpzi) - Effective 8/1/24
UM ONC 1347 Lorbrena (lorlatinib) - Effective 8/1/24
UM ONC 1440 Lumakras (sotorasib) - Effective 8/1/24
UM ONC 1348 Lumoxiti (moxetumomab pasudotox) - Effective 8/1/24
UM ONC 1474 Lunsumio (mosunetuzumab-axgb) - Effective 8/1/24
UM ONC 1273 Lynparza (olaparib) - Effective 8/1/24
UM ONC 1466 Lytgobi (futibatinib) - Effective 8/1/24
UM ONC 1420 Margenza (margetuximab-cmkb) - Effective 8/1/24
EMOD 0001 Medical Oncology Drug- Effective 8/1/24
UM ONC 1249 Mekinist (trametinib) - Effective 8/1/24
UM ONC 1397 Mektovi (binimetinib) - Effective 8/1/24
UM ONC 1412 Monjuvi (tafasitamab-cxix) - Effective 8/1/24
UM ONC 1343 Mulpleta (lusutrombopag) - Effective 8/1/24
UM ONC 1072 Myeloid Growth Factors - Effective 8/1/24
UM ONC 1325 Mylotarg (gemtuzumab ozogamicin) - Effective 8/1/24
UM ONC 1316 Nerlynx (neratinib) - Effective 8/1/24
UM ONC 1194 Nexavar (sorafenib) - Effective 8/1/24
UM ONC 1284 Ninlaro (ixazomib) - Effective 8/1/24
UM ONC 1363 Nubeqa (darolutamide) - Effective 8/1/24
UM ONC 1312 Odomzo (sonidegib) - Effective 8/1/24
UM ONC 1493 Ogsiveo (nirogacestat) - Effective 8/1/24
UM ONC 1488 Ojjaara (momelotinib) - Effective 8/1/24
UM ONC 1063 Oncaspar (pegaspargase) - Effective 8/1/24
UM ONC 1276 Onivyde (irinotecan liposome) - Effective 8/1/24
UM ONC 1274 Opdivo (nivolumab) - Effective 8/1/24
UM ONC 1462 Opdualag (nivolumab and relatlimab-rmbw) - Effective 8/1/24
UM ONC 1477 Orserdu (elacestrant) - Effective 8/1/24
UM ONC 1376 Oxbryta (voxelotor) - Effective 8/1/24
UM ONC 1381 Padcev (enfortumab vedotin-ejfv) - Effective 8/1/24
UM ONC 1467 Pedmark (sodium thiosulfate) - Effective 8/1/24
UM ONC 1398 Pemazyre (pemigatinib) - Effective 8/1/24
UM ONC 1399 Photofrin (porfimer) - Effective 8/1/24
UM ONC 1360 Piqray (alpelisib) - Effective 8/1/24
UM ONC 1362 Polivy (polatuzumab vedotin) - Effective 8/1/24
UM ONC 1239 Pomalyst (pomalidomide) - Effective 8/1/24
UM ONC 1344 Poteligeo (mogamulizumab-kpkc) - Effective 8/1/24
UM ONC 1244 Promacta (eltrombopag) - Effective 8/1/24
UM ONC 1464 Pyrukynd (mitapivat) - Effective 8/1/24
UM ONC 1404 Qinlock (ripretinib) - Effective 8/1/24
UM ONC 1405 Retevmo (selpercatinib) - Effective 8/1/24
UM ONC 1193 Revlimid (lenalidomide) - Effective 8/1/24
UM ONC 1475 Rezlidhia (olutasidenib) - Effective 8/1/24
UM ONC 1367 Rozlytrek (entrectinib) - Effective 8/1/24
UM ONC 1301 Rubraca (rucaparib) - Effective 8/1/24
UM ONC 1441 Rybrevant (amivantamab-vmjw) - Effective 8/1/24
UM ONC 1315 Rydapt (midostaurin) - Effective 8/1/24
UM ONC 1361 Rylaze (asparaginase Erwinia chrysanthemi recombinant-rywn) - Effective 8/1/24
UM ONC 1393 Sarclisa (isatuximab-irfc) - Effective 8/1/24
UM ONC 1455 Scemblix (asciminib) - Effective 8/1/24
UM ONC 1042 Somatostatin Analog - Effective 8/1/24
UM ONC 1196 Sprycel (dasatinib) - Effective 8/1/24
UM ONC 1232 Stivarga (regorafenib) - Effective 8/1/24
UM ONC 1383 Sylvant (siltuximab) - Effective 8/1/24
UM ONC 1240 Synribo (omacetaxine) - Effective 8/1/24
UM ONC 1406 Tabrecta (capmatinib) - Effective 8/1/24
UM ONC 1250 Tafinlar (dabrafenib) - Effective 8/1/24
UM ONC 1287 Tagrisso (osimertinib) - Effective 8/1/24
UM ONC 1483 Talvey (talquetamab-tgvs) - Effective 8/1/24
UM ONC 1349 Talzenna (talazoparib) - Effective 8/1/24
UM ONC 1043 Tarceva (erlotinib) - Effective 8/1/24
UM ONC 1384 Targretin (bexarotene) - Effective 8/1/24
UM ONC 1199 Tasigna (nilotinib) - Effective 8/1/24
UM ONC 1345 Tavalisse (fostamatinib) - Effective 8/1/24
UM ONC 1385 Tazverik (tazemetostat) - Effective 8/1/24
UM ONC 1299 Tecentriq (atezolizumab) - Effective 8/1/24
UM ONC 1470 Tecvayli (teclistamab-cqyv) - Effective 8/1/24
UM ONC 1422 Tepmetko (tepotinib) - Effective 8/1/24
UM ONC 1391 Thalomid (thalidomide) - Effective 8/1/24
UM ONC 1340 Tibsovo (ivosidenib) - Effective 8/1/24UM ONC 1449 Tivdak (tisotumab vedotin-tftv) - Effective 8/1/24
UM ONC 1200 Torisel (temsirolimus) - Effective 8/1/24
UM ONC 1134 Trastuzumab Products Pertuzumab and Phesgo - Effective 8/1/24
UM ONC 1215 TreandaBendekaBelrapz(bendamustine) - Effective 8/1/24
UM ONC 1407 Trodelvy (sacituzumab govitecan-hziy) - Effective 8/1/24
UM ONC 1494 Truqap (capivasertib) - Effective 8/1/24
UM ONC 1442 Truseltiq (infigratinib) - Effective 8/1/24
UM ONC 1401 Tukysa (tucatinib) - Effective 8/1/24
UM ONC 1364 Turalio (pexidartinib) - Effective 8/1/24
UM ONC 1387 Unituxin (dinutuximab) - Effective 8/1/24
UM ONC 1070 Valstar (valrubicin) - Effective 8/1/24
UM ONC 1484 Vanflyta (quizartinib) - Effective 8/1/24
UM ONC 1135 Vectibix (panitumumab) - Effective 8/1/24
UM ONC 1297 Venclexta (venetoclax) - Effective 8/1/24
UM ONC 1328 Verzenio (abemaciclib) - Effective 8/1/24
UM ONC 1350 Vitrakvi (larotrectinib) - Effective 8/1/24
UM ONC 1341 Vizimpro (dacomitinib) - Effective 8/1/24
UM ONC 1461 Vonjo (pacritinib) - Effective 8/1/24
UM ONC 1225 Voraxaze (glucarpidase) - Effective 8/1/24
UM ONC 1195 Votrient (pazopanib) - Effective 8/1/24
UM ONC 1326 Vyxeos (daunorubicin and cytarabine liposomal) - Effective 8/1/24
UM ONC 1446 Welireg (belzutifan) - Effective 8/1/24
UM ONC 1206 Xalkori (crizotinib) - Effective 8/1/24
UM ONC 1245 Xofigo (radium Ra 223 dichloride) - Effective 8/1/24
UM ONC 1351 Xospata (Gilteritinib) - Effective 8/1/24
UM ONC 1365 Xpovio (selinexor) - Effective 8/1/24
UM ONC 1228 Xtandi (enzalutamide) - Effective 8/1/24
UM ONC 1201 Yervoy (ipilimumab) - Effective 8/1/24
UM ONC 1290 Yondelis (trabectedin) - Effective 8/1/24
UM ONC 1226 Zaltrap (ziv-aflibercept) - Effective 8/1/24
UM ONC 1307 Zejula (niraparib) - Effective 8/1/24
UM ONC 1207 Zelboraf (vemurafenib) - Effective 8/1/24
UM ONC 1408 Zepzelca (lurbinectedin) - Effective 8/1/24
UM ONC 1234 Zevalin (ibritumomab tiuxetan) - Effective 8/1/24
UM ONC 1227 Zolinza (vorinostat) - Effective 8/1/24
UM ONC 1264 Zydelig (idelalisib) - Effective 8/1/24
UM ONC 1265 Zykadia (ceritinib) - Effective 8/1/24
UM ONC 1434 Zynlonta (loncastuzimab tesirine-lpyl) - Effective 8/1/24
UM ONC 1478 Zynyz (retifanlimab-dlwr) - Effective 8/1/24
UM ONC 1208 Zytiga or Yonsa (abiraterone acetate) - Effective 8/1/24
- SKYGEN Policies
UM-2-4000-D Utilization Review Criteria
UM-2-4000-1 Diagnostic Services - Effective 5/24/24
UM-2-4000-2 Preventive Services - Effective 5/24/24
UM-2-4000-3 Restorative Services - Effective 5/24/24
UM-2-4000-4 Periodontic Services - Effective 5/24/24
UM-2-4000-5 Prosthodontic Services - Effective 5/24/24
UM-2-4000-6 Oral Surgery Services - Effective 5/24/24
UM-2-4000-7 Orthodontic Services - Effective 5/24/24
UM-2-4000-8 Anesthesia Services - Effective 5/24/24