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Clinical & Payment Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Arkansas Total Care Clinical Policy Manual apply to Arkansas Total Care members. Policies in the Arkansas Total Care Clinical Policy Manual may have either a Arkansas Total Care or a “Centene” heading.  Arkansas Total Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Arkansas Total Care clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Arkansas Total Care. In addition, Arkansas Total Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual® criteria is payable by Arkansas Total Care. 

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Arkansas Total Care Payment Policy Manual apply with respect to Arkansas Total Care members. Policies in the Arkansas Total Care Payment Policy Manual may have either a Arkansas Total Care or a “Centene” heading.  In addition, Arkansas Total Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Arkansas Total Care. 

Arkansas Total Care Policies

Policy Title Policy Number Effective Date
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 6/1/2020
Adopted Clinical Practice and Preventive Health Guidelines (PDF) N/A 6/1/2020
Adult Rehabilitative Day Service (Psychosocial Rehabilitation Services)(PDF) CP.BH.AR.1800 3/1/2019
Afamelanotide (Scenesse) (PDF) CP.PHAR.444 6/1/2020
Aflibercept (Eylea) (PDF) CP.PHAR.184 6/1/2020
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 6/1/2020
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) CP.MP.108 1/1/2021
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 6/1/2020
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 4/16/2018
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 12/1/2020
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) CP.PHAR.506 12/1/2020
Applied Behavioral Analysis for Autism (PDF) CP.BH.104 6/1/2019
Articular Cartilage Defect Repairs (PDF) CP.MP.26 10/19/2018
Assistive Reproductive Technology (PDF) CP.MP.55 6/1/2019
Atezolizumab (Tecentriq) (PDF) CP.PHAR.235 6/1/2020
Avelumab (Bavencio) (PDF) CP.PHAR.333 6/1/2020
axicabtagene ciloleucel (Yescarta®) (PDF) CP.PHAR.362 6/1/2020
Azacitidine (Vidaza) (PDF) CP.PHAR.387 12/1/2020
Balloon Sinus Ostial Dilation (PDF) CP.MP.119 11/1/2020
Behavioral Assistance (Therapeutic Behavioral Services) (PDF) CP.BH.AR.1900 3/1/2019
Belantamab mafodotin (Blenrep) (PDF) CP.PHAR.469 12/1/2020
Belatacept (Nulojix) (PDF) CP.PHAR.201 12/1/2020
Belinostat (Beleodaq) (PDF) CP.PHAR.311 12/1/2020
Bendamustine (Bendeka, Treanda) (PDF) CP.PHAR.307 12/1/2020
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 6/1/2020
Bimatoprost Implant (Durysta)(PDF) CP.PHAR.486 6/1/2020
Biofeedback (PDF) CP.MP.168 7/1/2020
Bone-Anchored Hearing Aid (PDF) CP.MP.93 10/1/2020
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 9/1/2020
Brexanolone (Zulresso) (PDF) CP.PHAR.417 6/1/2020
Brexucabtagene Autoleucel (Tecartus) (PDF) CP.PHAR.472 9/1/2020
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445  6/1/2020
C1 Esterase Inhibitors (PDF) CP.PHAR.202 6/1/2020
cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 6/1/2020
Canakinumab (Ilaris) (PDF) CP.PHAR.246 12/1/2020
Carfilzomib (Kyprolis) (PDF) CP.PHAR.309 12/1/2020
Carrier Screening in Pregnancy (PDF) CP.MP.83 7/1/2020
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 12/10/2018
Cell-Free Fetal DNA Testing (PDF) CP.MP.84 3/16/2017
Cetuximab (Erbitux) (PDF) CP.PHAR.317 12/1/2020
Child and Youth Support Services (PDF) CP.BH.AR.1700 3/1/2019
Clinical Policy: Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 6/1/2020
Clinical Trials (PDF) CP.MP.94 12/1/2017
Cochlear Implant Replacements (PDF) CP.MP.14 5/1/2019
Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) CP.PHAR.505 12/1/2020
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 9/1/2020
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 9/1/2020
Crisis Intervention (PDF) CP.BH.AR.1500 3/1/2019

Crizanlizumab-tmca (Adakveo) (PDF)

CP.PHAR.449 6/1/2020
Daratumumab (Darzalex) (PDF) CP.PHAR.310 6/1/2020
Darbepoetin alfa (Aranesp) (PDF) CP.PHAR.236 6/1/2020
Daunorubicin-cytarabine (Vyxeos) (PDF) CP.PHAR.352 12/1/2020
Deferoxamine (Desferal) (PDF) CP.PHAR.146 9/1/2020
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 6/1/2020
Dental Anesthesia (PDF) CP.MP.61 3/15/2017
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 12/1/2020
Disc Decompression Procedures (PDF) CP.MP.114 7/1/2020
Discography (PDF) CP.MP.115 10/19/2018
Donor lymphocyte infusion (PDF) CP.MP.101 12/1/2020
Dupilumab (Dupixent) (PDF) CP.PHAR.336 6/1/2020
Durable Medical Equipment (DME) (PDF) CP.MP.107 11/1/2020
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 6/1/2020
Eculizumab (Soliris) (PDF) CP.PHAR.97 6/1/2020
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 6/1/2020
Electric Tumor Treatment Fields (PDF) CP.MP.145 9/8/2017
Elotuzumab (Empliciti) (PDF) CP.PHAR.308 12/1/2020
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 6/1/2020
Eptinezumab-jjmr (Vyepti) (PDF) CP.PHAR.489 9/1/2020
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 6/1/2020
Eribulin mesylate (Halaven) (PDF) CP.PHAR.318 3/1/2021 - NEW
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 6/1/2020
Essure Removal (PDF) CP.MP.131 12/1/2020
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 12/1/2020
Eteplirsen  (Exondys 51) (PDF) CP.PHAR.288 6/1/2020
Experimental Technologies (PDF) CP.MP.36 3/15/2017
Facet Joint Interventions (PDF) CP.MP.171 12/10/2018
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215  10/1/2020
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) CP.PHAR.216 6/1/2020
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 12/1/2020
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 12/1/2020
Factor XIII A-Subunit, Recombinant (Tretten®) CP.PHAR.222 12/1/2020
Family Support Partners (PDF) CP.BH.AR.1600 3/1/2019
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 6/1/2020
Fecal incontinence treatments (PDF) CP.MP.137 3/5/2019
Ferric Derisomaltose (Monoferric)(PDF) CP.PHAR.480 6/1/2020
Ferriscan R2-MRI (PDF) CP.MP.53 12/1/2020
Fertility Preservation (PDF) CP.MP.130 11/1/2020
Fetal surgery in utero for prenatally diagnosed malformations (PDF) CP.MP.129 5/1/2019
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) CP.PHAR.297 6/1/2020
Fixed Wing Air Transportation (PDF) CP.MP.175 2/1/2021
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 9/1/2020
Functional MRI (PDF) CP.MP.43 3/15/2017
Gastric Electrical Stimulation (PDF) CP.MP.40 3/15/2017
Gemtuzumab (Mylotarg) (PDF) CP.PHAR.358 12/1/2020
Gender reassignment surgery (PDF) CP.MP.95 2/1/2021
Genetic Testing (PDF) CP.MP.89 3/16/2017
Givosiran (Givlaari) (PDF) CP.PHAR.457 6/1/2020
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 6/1/2020
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 6/1/2020
Group Psychotherapy (PDF) CP.BH.AR.600 3/1/2019
Heart-Lung Transplant (PDF) CP.MP.132 10/19/2018
Home Birth (PDF) CP.MP.136 2/1/2021
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 3/1/2021
Hospice Clinical Coverage (PDF) CP.MP.54 3/15/2017
Hyaluronate derivatives (PDF) CP.PHAR.05 12/1/2020
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 6/1/2019
Hyperhidrosis Treatments (PDF) CP.MP.62 6/1/2019
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 6/1/2020
Ibandronate sodium (PDF) CP.PHAR.189 6/1/2020
Immune Globulins (PDF) CP.PHAR.103 6/1/2020
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 1/1/2021
Implantable Intrathecal Pain Pump (PDF) CP.MP.173 6/1/2019
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 1/1/2020
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 6/1/2020
Individual/Group Pharmacologic Counseling by RN  (Medication Training and Support) (PDF) CP.BH.AR.1200 3/1/2019
Inebilizumab (PDF) CP.PHAR.458 6/1/2020
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 6/1/2020
Infusion SOC optimization (PDF) CP.MP.159 10/31/2019
Inhaled Nitric Oxide (PDF) CP.MP.87 1/1/2021
Inotuzumab Ozogamicin (Besponsa) (PDF) CP.PHAR.359 10/1/2020
Intensity Modulated Radiation Therapy (PDF) CP.MP.69 6/1/2019
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 6/1/2020
Interpretation of Diagnosis (PDF) CP.BH.AR.800 3/1/2019
Intestinal & Multivisceral Transplant (PDF) CP.MP.58 7/1/2020
Intradiscal Steroid Injections (PDF) CP.MP.167 10/1/2020
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 6/1/2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 6/1/2020
Irinotecan Liposome (Onivyde) (PDF) CP.PHAR.304 3/1/2020 - NEW
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 6/1/2020
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 12/1/2020
Lefamulin (Xenleta)(PDF) CP.PMN.219 6/1/2020
Letermovir (Prevymis) (PDF) CP.PHAR.367 6/1/2020
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 9/1/2020
Levoleucovorin (Fusilev, Khapzory) (PDF) CP.PHAR.151 12/1/2020
Lung Transplantation (PDF) CP.MP.57 7/1/2020
Lurbinectedin (Zepzelca) (PDF) CP.PHAR.500 12/1/2020
Lutetium Lu 177 Dotatate (Lutathera) (PDF) CP.PHAR.384 9/1/2020
Lysis of Epidural Lesions (PDF) CP.MP.116 11/1/2020
Marital Family BH Counseling with Beneficiary Present (PDF) CP.BH.AR.400 3/1/2019
Marital Family BH Counseling without Beneficiary Present (PDF) CP.BH.AR.300 3/1/2019
Mecasermin (Increlex) (PDF) CP.PHAR.150 12/1/2020
Mechanical Stretch Devices (PDF) CP.MP.144 10/1/2020
Medical Necessity Criteria (PDF) CP.MP.68 3/16/2017
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 6/1/2020
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 6/1/2020
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 6/1/2020
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 6/1/2020
Multi-Family Behavioral Health Counseling (PDF) CP.BH.AR.500 3/1/2019
Multiple Sleep Latency Testing (PDF) CP.MP.24 10/19/2018
Nadofaragene Firadenovec (Instiladrin)(PDF) CP.PHAR.461 6/1/2020
Naltrexone (Vivitrol) (PD) CP.PHAR.96 10/1/2020
Natalizumab (Tysabri) (PDF) CP.PHAR.259 12/1/2020
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 3/16/2017
Neonatal Sepsis Management Guidelines (PDF) CP.MP.85 3/16/2017
Netupitant and Palonosetron (Akynzeo) (PDF) CP.PMN.158 9/1/2020
Nerve Blocks for Pain Management (PDF) CP.MP.170 10/1/2020
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 7/1/2020
NICU Discharge Guidelines (PDF) CP.MP.81 6/30/2020
Nivolumab (Opdivo) (PDF) CP.PHAR.121   6/1/2020
No Coverage Criteria (PDF) CP.PMN.255 12/1/2020
Non-Invasive Home Ventilator (PDF) CP.MP.184 12/1/2020
Nonmyeloablative allogeneic stem cell transplant (PDF) CP.MP.141 6/1/2019
nusinersen (Spinraza®) (PDF) CP.PHAR.327 6/1/2020
OB Home Health Programs (PDF) CP.MP.91 3/17/2017
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 6/1/2020
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) CP.PHAR.40 9/1/2020
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 6/1/2020
Onasemnogene abeparvovec (Zolgensma) (PDF) CP.PHAR.421 12/1/2020
Optic Nerve Decompression Surgery (PDF) CP.MP.128 10/11/2020
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 7/1/2020
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 3/15/2021 - NEW
Oxygen Use and Concentrators (PDF) CP.MP.190 1/1/2021
Ozanimod(PDF) CP.PHAR.462 6/1/2020
Paclitaxel, protein-bound (Abraxane) (PDF) CP.PHAR.176  6/1/2020
Pain Management Procedures (PDF) CP.MP.63 3/16/2017
Palivizumab (Synagis) (PDF) CP.PHAR.16 6/1/2020
Pancreas Transplantation (PDF) CP.MP.102 7/1/2020
Panitumumab (Vectibix) (PDF) CP.PHAR.321 12/1/2020
Panniculectomy (PDF) CP.MP.109 4/17/2017
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 9/1/2020
Pasireotide (Signifor, Signifor LAR) (PDF) CP.PHAR.332 12/1/2020
Patisiran (Onpattro) (PDF) CP.PHAR.395 12/1/2020
Peanut Allergen Powder-dnfp (Palforzia)(PDF) CP.PMN.220 6/1/2020
Pediatric Heart Transplant (PDF) CP.MP.138 7/1/2020
Pediatric Liver Transplant (PDF) CP.MP.120 11/1/2020
Peer Support (PDF) CP.BH.AR.1300 3/1/2019
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 6/1/2020
Pegaptanib (Macugen) (PDF) CP.PHAR.185 12/1/2020
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) CP.PHAR.296 6/1/2020
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 3/1/2021 - NEW
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 6/1/2020
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 6/1/2020
Percutaneous LAAD Stroke Prevention (PDF) CP.MP.147 7/1/2020
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 6/1/2020
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) CP.PHAR.501 12/1/2020
Pharmacologic Management (PDF) CP.BH.AR.1000 3/1/2019
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 9/1/2020
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 3/15/21 - NEW
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 10/1/2020
Pralatrexate (Folotyn) (PDF) CP.PHAR.313 12/1/2020
Psychiatric Diagnosis Evaluation (PDF) CP.BH.AR.100 3/1/2019
Psychoeducation Services (PDF) CP.BH.AR.2100 3/1/2019
Psychological Evaluation of Psych Testing (PDF) CP.BH.AR.900 3/1/2019
Psychotherapy (PDF) CP.BH.AR.200 3/1/2019
Radial Head Implant (PDF) CP.MP.148 7/1/2020
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 8/1/2020
Ramucirumab (Cyramza) (PDF) CP.PHAR.119  12/1/2020
Ranibizumab (Lucentis) (PDF) CP.PHAR.186 12/1/2020
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 12/10/2018
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 6/1/2020
Risdiplam (Evrysdi) (PDF) CP.PHAR.477 9/1/2020
Romidepsin (Istodax) (PDF) CP.PHAR.314 12/1/2020
Romiplostim (Nplate®) (PDF) CP.PHAR.179 12/1/2020
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 9/1/2020
Sacroiliac Joint Fusion (PDF) CP.MP.126 4/18/2017
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 10/1/2020
Sargramostim (Leukine) (PDF) CP.PHAR.295 9/1/2020
Satralizumab(PDF) CP.PHAR.463 6/1/2020
Sclerotherapy (PDF) CP.MP.146 10/1/2020
Selective Dorsal Rhizotomy (PDF) CP.MP.174 1/1/2020
Selective Nerve Root Blocks and Transforaminal Epidural (PDF) CP.MP.165 10/1/2020
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 6/1/2020
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 6/1/2020
Spinal Cord Stimulation (PDF) CP.MP.117 4/18/2017
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 5/1/2019
Substance Abuse Assessment (PDF) CP.BH.AR.1100 3/1/2019
Supportive Employment (PDF) CP.BH.AR.2000 3/1/2019
Supportive Housing (PDF) CP.BH.AR.1400 3/1/2019
Tafasitamab-cxix (Monjuvi) (PDF) CP.PHAR.508 12/1/2020
Tandem Transplant (PDF) CP.MP.162 5/1/2019
Teprotumumab (Tepezza)(PDF) CP.PHAR.465 12/1/2020
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 12/1/2020
Therapy Services (PT/OT/ST) (PDF) CP.MP.49 4/1/2021 - NEW
Thymus Transplantation (PDF) CP.MP.189 10/1/2020
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 6/1/2020
Total Artificial Heart (PDF) CP.MP.127 1/1/2021
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 1/1/2020
Transcatheter closure of patent foramen ovale (PDF) CP.MP.151 1/1/2021
Transcranial Magnetic Stimulation(PDF) CP.MP.172 5/1/2019
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 6/1/2020
Treatment Plan (PDF) CP.BH.AR.700 3/1/2019
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) CP.PHAR.199  6/1/2020
Trigger Point Injections for Pain Management (PDF) CP.MP.169 2/1/2021
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 9/8/2017
Vagus Nerve Stimulation for Epilepsy (PDF) CP.MP.12 2/1/2021
Valoctocogene Roxaparvovec(PDF) CP.PHAR.466 6/1/2020
Valrubicin (Valstar) (PDF) CP.PHAR.439 12/1/2020
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 6/1/2020
Ventricular Assist Devices (PDF) CP.MP.46 6/1/2019
Ventriculectomy and Cardiomyoplasty (PDF) CP.MP.56 4/17/2017
Verteporfin (Visudyne) (PDF) CP.PHAR.187 12/1/2020
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 6/1/2020
Viltolarsen (Viltepso) (PDF) CP.PHAR.484 9/1/2020
Wheelchair seating (PDF) CP.MP.99 10/1/2018
Ziv-aflibercept (Zaltrap) (PDF) CP.PHAR.325 12/1/2020
Zika Virus Testing (PDF) CP.MP.111 7/1/2020
Zoledronic acid (PDF) CP.PHAR.59 6/1/2020
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 7/1/2014
Acupuncture (PDF) CP.MP.92 2/1/2021
Add on Code Billed Without Primary Code (PDF) CC.PP.030 10/18/2016
ADHD Assessment and Treatment (PDF) CP.MP.124 5/1/2021
Allergy Testing (PDF) CP.MP.100 5/1/2021
Ambulatory EEG (PDF) CP.MP.96 8/12/2016
Antithrombin III (Thrombate III, Atryn) (PDF) CP.MP.179 12/1/2020
Assistant Surgeon (PDF) CC.PP.029 2/7/2017
Bariatric Surgery (PDF) CP.MP.37 3/1/2021
Bevacizumab (PDF) CP.PHAR.93 2/10/2017
Bilateral Procedures (PDF) CC.PP.037 2/7/2017
Bronchial Thermoplasty (PDF) CP.MP.110 4/1/2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 5/21/2018
Cerumen Removal (PDF) CC.PP.008 8/12/2016
Clean Claims (PDF) CC.PP.021 10/18/2016
Coding Overview (PDF) CC.PP.011 10/18/2016
Cosmetic Procedures (PDF) CC.PP.024 10/18/2016
Diagnosis of Vaginitis (PDF) CP.MP.97 5/1/2021
Digital Analysis of EEGs (PDF) CP.MP.105 2/10/2017
Distinct Procedural Modifiers (PDF) CC.PP.020 10/18/2016
DNA Analysis of Stool (PDF) CP.MP.125 1/1/2021
Duplicate Primary Code Billing (PDF) CC.PP.044 2/7/2017
E&M Medical Decision-Making (PDF) CC.PP.051 7/25/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 12/1/2020
EM Bundling Edits (PDF) CC.PP.010 8/12/2016
Endometrial Ablation (PDF) CP.MP.106 12/10/2018
EpiFix Wound Treatment (PDF) CP.MP.140 11/1/2017
Evoked Potentials (PDF) CP.MP.134 5/1/2021
Fecal Calprotectin Assay (PDF) CP.MP.135 6/17/2017
FeNo Testing (PDF) CP.MP.103 1/1/2021
Global Maternity Billing (PDF) CC.PP.016 10/18/2016
H Pylori Testing (PDF) CP.MP.153 12/1/2020
Holter Monitors (PDF) CP.MP.113 4/1/2017
Homocysteine Testing (PDF) CP.MP.121 5/1/2021
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 10/18/2016
Inpatient Consultation (PDF) CC.PP.038 2/7/2017
Inpatient Only Procedures (PDF) MP.PP.018 10/18/2016
IV Hydration (PDF) CC.PP.012 10/18/2016
Laser Skin Treatment (PDF) CP.MP.123 4/1/2017
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 3/15/21 - NEW
Leveling of Emergency Room (PDF) CC.PP.053  1/1/2019
Long Term Care Placement Criteria (PDF) CP.MP.71 3/16/2017
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 2/1/2021
Maximum Units (PDF) CC.PP.007 8/12/2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 12/1/2020
Mechanical Stretch Devices (PDF) CP.MP.144 11/1/2017
Moderate Conscious Sedation (PDF) CC.PP.015 10/18/2016
Modifier -25 clinical validation (PDF) CC.PP.013 10/18/2016
Modifier -59 clinical validation (PDF) CC.PP.014 10/18/2016
Modifier DOS Validation (PDF) CC.PP.034 10/18/2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 10/18/2016
Monitored Anesthesia Care (PDF) CP.MP.161 12/15/2018
Multiple CPT Code Replacement (PDF) CC.PP.033 10/18/2016
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF) CC.PP.065 3/15/21 - NEW
Multiple Procedure Reduction: Ophthalmology (PDF) CC.PP.069 3/15/21 - NEW
Multiple Procedure Payment Reduction for Therapeutic Services (PDF) CC.PP.068 3/15/21 - NEW
NCCI Unbundling (PDF) CC.PP.031 10/18/2016
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 2/1/2021
Never Paid Events (PDF) CC.PP.017 10/18/2016
New Patient (PDF) CC.PP.036 2/7/2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  3/15/21 - NEW
Outpatient Consultation (PDF) CC.PP.039 2/7/2017
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 3/15/21 - NEW
Paclitaxel (PDF) CP.PHAR.176 5/16/2016
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 6/30/2020
Physician’s Consultation Services (PDF) CC.PP.054 9/1/2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 10/18/2016
Place of Service Mismatch (PDF) CC.PP.063  12/15/2018
Post-Operative Visits (PDF) CC.PP.042 2/7/2017
Pre-Operative Visits (PDF) CC.PP.041 2/7/2017
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/1/2018
Professional Component (PDF) CC.PP.027 10/18/2016
PROM Testing (PDF) CP.MP.149 11/8/2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 4/1/2021 - NEW
Pulse Oximetry (PDF) CC.PP.025 10/18/2016
Renal Hemodialysis (PDF) CC.PP.067 3/15/21 - NEW
Rituximab (PDF) CP.PHAR.260 2/10/2017
Robotic Surgery (PDF) CC.PP.050 11/1/2017
Same Day Visits (PDF) CC.PP.040 2/7/2017
Status "B" Bundled Services (PDF) CC.PP.046 2/7/2017
Status P Bundled Services (PDF) CC.PP.049 6/17/2017
Sickle Cell Disease Observation (PDF) CP.MP.88 3/16/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 10/18/2016
Supportive Living (PDF) ARTC.PP.1000 7/20/2020
Thyroid Testing in Pediatrics (PDF) CP.MP.154 12/1/2020
Transcranial Magnetic Stimulation (PDF) CP.BH.200 2/1/2021
Transgender Related Services (PDF) CC.PP.047 2/22/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 2/10/2017
Unbundled Professional Services (PDF) CC.PP.043 4/6/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 4/6/2017
Unlisted Procedure Codes (PDF) CC.PP.009 8/12/2016
Urine Specimen Validity Testing (PDF) CC.PP.056 11/8/2017
Urodynamic Testing (PDF) CP.MP.98 5/1/2021
Vitamin D Testing in Children (PDF) CP.MP.157 5/21/2018
Wheelchair Accessories (PDF) CC.PP.502 8/12/2016
Wireless Motility Capsule (PDF) CP.MP.143 11/1/2017
Policy Title Policy Number Effective Date
Behavioral Health Covered Benefits and Services (PDF) CC.BH.UM.28 2/15/21 - NEW
Behavioral Health Covered Benefits and Services - Attachment F (PDF) CC.BH.UM.28 Attachment F 2/15/21 - NEW