Clinical & Payment Policies

Arkansas Total Care Policies

To easily search for a policy, use the Ctrl+F (Command+F on Mac) function on your keyboard to search by keyword, policy number, or effective date.

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 an “Arkansas Total Care” or a “Centene” heading. Arkansas Total Care uses InterQual® criteria for services for which an Arkansas Total Care clinical policy does not exist. InterQual is a nationally recognized, evidence-based decision support tool. You may access the InterQual SmartSheets™ for adult and pediatric procedures, durable medical equipment (DME), and imaging procedures by logging in to our Secure Provider Portal or calling Arkansas Total Care at 1-866-282-6280 (TTY: 711).

Arkansas Total Care may use a vendor for the utilization management of certain services. In such cases, the vendor’s guidelines may also be used to support medical necessity and other coverage decisions. Other non-clinical policies, such as payment policies, or contract terms may also be used to determine if a service that is not addressed in the Clinical Policy Manual or InterQual criteria is payable by Arkansas Total Care.

Drug policies and criteria listed under this section are only applicable to products paid under the medical benefit. Please see “Arkansas Total Care Pharmacy Policies” for prior authorization criteria on drugs paid under the pharmacy benefit.

Policy Title Policy Number Effective Date
25-hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 November 1, 2023
Abatacept (Orencia) (PDF) CP.PHAR.241 January 1, 2024
Abatacept (Orencia) (PDF) CP.PHAR.241 Retire by January 1, 2024
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 June 1, 2023
Acupuncture (PDF) CP.MP.92 September 1, 2023
Ado-Trastuzumab (Kadcyla) (PDF) CP.PHAR.229 June 1, 2023
Aducanumab (Aduhelm) (PDF) CP.PHAR.468 August 1, 2022
Aflibercept (Eylea) (PDF) CP.PHAR.184 December 1, 2023
Agalsidase beta (Fabrazyme) (PDF) CP.PHAR.158 June 1, 2022
Air Ambulance (PDF) CP.MP.175 August 1, 2023
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 December 1, 2023
Alglucosidase (Lumizyme) (PDF) CP.PHAR.160 August 1, 2022
Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft)(PDF) CP.PHAR.562 March 1, 2023
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF) CP.MP.108 December 1, 2023
Allogenic processed thymus tissue-agdc (Rethymic) (PDF) CP.PHAR.563 March 1, 2023
Allergy Testing and Therapy (PDF) CP.MP.100 November 1, 2023
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) CP.PHAR.94 March 1, 2023
Amisulpride (Barhemsys) (PDF) CP.PMN.236 August 1, 2023
Amivantamab-vmjw (Rybrevant) (PDF) CP.PHAR.544 August 1, 2023
Anifrolumab-fnia (Saphnelo) (PDF) CP.PHAR.551 January 1, 2024
Anifrolumab-fnia (Saphnelo) (PDF) CP.PHAR.551 Retire by January 1, 2024
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 November 1, 2023
Antithrombin III (ATryn, Thrombate III) (PDF) CP.PHAR.564 March 1, 2023
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) CP.PHAR.506 January 1, 2024
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) CP.PHAR.506 Retire by January 1, 2024
Apadamtase alfa (TAK-755) (PDF)  CP.PHAR.635  September 1, 2023
Applied Behavioral Analysis (PDF) CP.BH.104 May 1, 2023
Aprepitant (Aponvie, Cinvanti, Emend), (PDF) CP.PMN.19

Retire by February 1, 2024
Aprepitant (Aponvie, Cinvanti, Emend), (PDF) CP.PMN.19 February 1, 2024
Articular Cartilage Defect Repairs (PDF) CP.MP.26 July 1, 2023
Asfotase Alfa (Strensiq) (PDF) CP.PHAR.328  December 1, 2022
Assistive Reproductive Technology (PDF) CP.MP.55  June 1, 2023
Atezolizumab (Tecentriq) (PDF) CP.PHAR.235 March 1, 2023
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) CP.BH.124 August 1, 2023
Avacincaptad pegol (Izervay) (PDF) CP.PHAR.641 December 1, 2023
Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) CP.PHAR.521 June 1, 2022
Avelumab (Bavencio) (PDF) CP.PHAR.333 May 1, 2023
Axicabtagene Ciloleucel (Yescarta®) (PDF) CP.PHAR.362 March 1, 2023
Azacitidine (Vidaza) (PDF) CP.PHAR.387 December 1, 2023
Baclofen (Gablofen, Lioresal, Lyvispah, Ozobax) (PDF) CP.PHAR.149 December 1, 2023
Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (PDF) CP.PHAR.532 July 1, 2023
Bariatric Surgery (PDF) CP.MP.37 May 1, 2023
Belantamab mafodotin (Blenrep) (PDF) CP.PHAR.469 June 1, 2023
Belatacept (Nulojix) (PDF) CP.PHAR.201 December 1, 2023
Belimumab (Benlysta) (PDF) CP.PHAR.88  October 1, 2022
Belinostat (Beleodaq) (PDF) CP.PHAR.311 December 1, 2023
Bendamustine (Bendeka, Treanda) (PDF) CP.PHAR.307 January 1, 2024
Bendamustine (Bendeka, Treanda) (PDF) CP.PHAR.307 Retire by January 1, 2024
Benralizumab (Fasenra) (PDF) CP.PHAR.373 May 1, 2023
Beremagene Geperpavec (Vyjuvek) (PDF)  CP.PHAR.592  September 1, 2023
Betibeglogene autotemcel (PDF) CP.PHAR.545  August 1, 2023
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 January 1, 2024
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 Retire by January 1, 2024
Bimatoprost Implant (Durysta)(PDF) CP.PHAR.486 June 1, 2023
Behavioral Health Treatment Documentation Requirements (PDF) CP.BH.500 November 1, 2022
Biofeedback (PDF) CP.MP.168 January 1, 2023
Biofeedback for Behavioral Health Disorders (PDF) CP.BH.300 May 1, 2023
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 August 1, 2023
Bone-Anchored Hearing Aids (PDF) AR.CP.MP.93 August 1, 2023
Bortezomib (Velcade) (PDF) CP.PHAR.410 March 1, 2023
Bremelanotide (Vyleesi) (PDF) CP.PHAR.434  February 1, 2023
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 October 2, 2023
Brexanolone (Zulresso) (PDF) CP.PHAR.417 September 1, 2022
Brexucabtagene Autoleucel (Tecartus) (PDF) CP.PHAR.472 March 1, 2023
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445  March 1, 2023
Burn Surgery (PDF) CP.MP.186 January 1, 2023
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 August 1, 2023
C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (PDF) CP.PHAR.202 October 2, 2023
Cabotegravir, Cabotegravir-Rilpivirine (Apretude Cabenuva) (PDF) CP.PHAR.573 March 1, 2023
Cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 June 1, 2023
Canakinumab (Ilaris) (PDF) CP.PHAR.246 December 1, 2023
Caplacizumab-yhdp (Cablivi) CP.PHAR.416  June 1, 2023
Carbetocin (PDF) CP.PHAR.546 Pending FDA Approval
Cardiac Biomarker Testing (PDF) CP.MP.156 November 1, 2023
Carfilzomib (Kyprolis) (PDF) CP.PHAR.309 January 1, 2024
Carfilzomib (Kyprolis) (PDF) CP.PHAR.309 Retire by January 1, 2024
Casimersen (Amondys 45) (PDF) CP.PHAR.470 March 1, 2023
Casirivimab and Imdevimab (REGEN-COV) (PDF) CP.PHAR.520 July 1, 2023
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 September 1, 2023
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 January 1, 2024
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 Retire by January 1, 2024
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 October 2, 2023
Cetuximab (Erbitux) (PDF) CP.PHAR.317 January 1, 2024
Cetuximab (Erbitux) (PDF) CP.PHAR.317 Retire by January 1, 2024
Chloramphenicol (PDF) CP.PHAR.388 August 1, 2023
Ciltacabtagene Autoleucel (Carvykti) CP.PHAR.533  September 1, 2023
Clinical Trials (PDF) CP.MP.94 August 1, 2023
Cochlear Implanted Replacements (PDF) AR.CP.MP.14 December 1, 2023
Collagenase (Xiaflex) (PDF) CP.PHAR.82 August 1, 2023
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Cardiac Disorders (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Dermatologic Conditions (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Eye Disorders (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: General Approach to Genetic Testing (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Hearing Loss (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF) V2.2023 November 1, 2023
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Kidney Disorders (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Lung Disorders (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Pharmacogenetics (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Preimplantation Genetic Testing (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF) V2.2023 August 1, 2023
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF) V2.2023 August 1, 2023
Concert Genetics Oncology: Algorithmic Testing (PDF) V2.2023 November 1, 2023
Concert Genetics Oncology: Cancer Screening (PDF) V2.2023 November 1, 2023
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) V2.2023 November 1, 2023
Concert Genetics Oncology: Cytogenetic Testing (PDF) V2.2023 November 1, 2023
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) V2.2023 November 1, 2023
Continuous Glucose Monitors (PDF) CP.PMN.214 December 1, 2023
Copanlisib (Aliqopa) (PDF) CP.PHAR.357 December 1, 2023
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 August 1, 2023
Corticotropin (H.P. Acthar, Purified Cortrophin Gel) (PDF) CP.PHAR.168 May 1, 2023
Cosmetic and Reconstructive Procedures (PDF) CP.MP.31 December 1, 2023
Cosyntropin (Cortrosyn) (PDF) CP.PHAR.203 May 1, 2023

Crizanlizumab-tmca (Adakveo) (PDF)

CP.PHAR.449 March 1, 2023
Cytomegalovirus Immune Globulin (Cytogam) (PDF) CP.PHAR.277 August 1, 2023
Dalteparin (Fragmin) (PDF) CP.PHAR.225 March 1, 2022
Daprodustat (Jesduvroq) (PDF) CP.PHAR.628 August 1, 2023
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 August 1, 2023
Daratumumab (Darzalex) (PDF) CP.PHAR.310 October 2, 2023
Darbepoetin Alfa (Aranesp) (PDF) CP.PHAR.236 October 9, 2023
Daunorubicin and Cytarabine (Vyxeos) (PDF) CP.PHAR.352 December 1, 2023
DaxibotulinumtoxinA-lanm (Daxxify) (PDF) CP.PHAR.651 December 1, 2023
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF) CP.BH.201 August 1, 2023
Deferoxamine (Desferal) (PDF) CP.PHAR.146 October 2, 2023
Degarelix (Firmagon) (PDF) CP.PHAR.170 December 1, 2023
Delafloxacin (Baxdela) (PDF) CP.PMN.115 August 1, 2023
Delandistrogene moxeparvovec-rokl  (Elevidys) (PDF)  CP.PHAR.593  December 1, 2023
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 October 9, 2023
Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) CP.PHAR.214 November 1, 2023
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 July 1, 2023
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 October 1, 2023
Digital EEG Spike Analysis (PDF) CP.MP.105 November 1, 2023
Disc Decompression Procedures (PDF) CP.MP.114 July 1, 2023
Discography (PDF) CP.MP.115 August 1, 2023
Donanemab (LY300281) (PDF) CP.PHAR.594 January 1, 2024
Donanemab (LY300281) (PDF) CP.PHAR.594 Retire by January 1, 2024
Donor Lymphocyte Infusion (PDF) CP.MP.101 December 1, 2023
Dostarlimab-gxly (Jemperli) (PDF) CP.PHAR.540 November 1, 2023
Drugs of Abuse: Definitive Testing (PDF) CP.MP.50 August 1, 2023
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF) CP.MP.107 May 1, 2023
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 June 1, 2023
Ecallantide (Kalbitor) (PDF) CP.PHAR.177 August 1, 2023
Eculizumab (Soliris) (PDF) CP.PHAR.97 August 1, 2023
Edaravone (Radicava) (PDF) CP.PHAR.343 June 1, 2023
EEG in the Evaluation of Headache (PDF) CP.MP.155 November 1, 2023
Efgartigimod alfa-fcab (Vyvgart) (PDF)
CP.PHAR.555
September 1, 2023
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 June 1, 2023
Electric Tumor Treatment Fields (Optune) (PDF) CP.MP.145 April 1, 2023
Elivaldogene autotemcel  (Skysona) (PDF) CP.PHAR.556 December 1, 2023
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 June 1, 2022
Elotuzumab (Empliciti) (PDF) CP.PHAR.308 December 1, 2023
Elranatamab-bcmm (Elrexfio) (PDF) CP.PHAR.652 December 1, 2023
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 May 1, 2023
Endometrial Ablation (PDF) CP.MP.106 August 1, 2023
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 August 1, 2023
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 August 1, 2023
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 May 1, 2023
Epcoritamab-bysp (Epkinly) (PDF) CP.PHAR.634 August 1, 2023
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 October 9, 2023
Epoprostenol (Flolan, Veletri) (PDF) CP.PHAR.192 March 1, 2023
Eptinezumab-jjmr (Vyepti) (PDF) CP.PHAR.489 December 1, 2023
Eribulin Mesylate (Halaven) (PDF) CP.PHAR.318 January 1, 2024
Eribulin Mesylate (Halaven) (PDF) CP.PHAR.318 Retire by January 1, 2024
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 May 1, 2023
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 August 1, 2023
Eteplirsen  (Exondys 51) (PDF) CP.PHAR.288 March 1, 2023
Etranacogene Dezaparvovec (Hemgenix) (PDF) CP.PHAR.580 August 1, 2023
Evinacumab-dgnb (Evkeeza) (PDF) CP.PHAR.511 May 1, 2023
Evoked Potential Testing (PDF) CP.MP.134 November 1, 2023
Experimental Technologies (PDF) CP.MP.36 July 1, 2023
Facet Joint Interventions (PDF) CP.MP.171 September 1, 2023
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) CP.MP.248 October 1, 2023
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF) CP.PHAR.220 March 1, 2023
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215  November 1, 2023
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) CP.PHAR.216 November 1, 2023
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 November 1, 2023
Factor IX Complex, Human (Profilnine) (PDF) CP.PHAR.219 March 1, 2023
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 March 1, 2023
Factor XIII A-Subunit, Recombinant (Tretten®) CP.PHAR.222 March 1, 2023
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 March 1, 2023
Faricimab (Vabysmo) (PDF) CP.PHAR.581 June 1, 2023
Fecal Incontinence Treatments (PDF) CP.MP.137 December 1, 2023
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 December 1, 2023
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 Retire by December 1, 2023
Ferric Derisomaltose (Monoferric)(PDF) CP.PHAR.480 December 1, 2023
Ferric Derisomaltose (Monoferric)(PDF) CP.PHAR.480 Retire by December 1, 2023
Ferric Gluconate (Ferrlecit) (PDF) CP.PHAR.166 July 1, 2023
Ferric Pyrophosphate Citrate (Triferic) (PDF) CP.PHAR.624 December 1, 2023
Ferric Pyrophosphate Citrate (Triferic) (PDF) CP.PHAR.624 Retire by December 1, 2023
Ferriscan R2-MRI (PDF) CP.MP.53 December 1, 2023
Ferumoxytol (Feraheme) (PDF) CP.PHAR.165 December 1, 2023
Ferumoxytol (Feraheme) (PDF) CP.PHAR.165 Retire by December 1, 2023
Fertility Preservation (PDF) CP.MP.130 October 1, 2023
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 December 1, 2023
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) CP.PHAR.526 June 1, 2023
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) CP.PHAR.297 October 2, 2023
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 March 1, 2022
Fosdenopterin (Nulibry) (PDF) CP.PHAR.471  June 1, 2023
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 August 1, 2023
Functional MRI (PDF) CP.MP.43 April 1, 2023
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 June 1, 2022
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) CP.MP.209 August 1, 2023
Gastric Electrical Stimulation (PDF) CP.MP.40 July 1, 2023
Gemtuzumab (Mylotarg) (PDF) CP.PHAR.358 December 1, 2023
Gender-Affirming Procedures (PDF) CP.MP.95 October 1, 2023
Givosiran (Givlaari) (PDF) CP.PHAR.457 March 1, 2023
Glofitamab-gxbm (Columvi) (PDF)  CP.PHAR.636  September 1, 2023
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 March 1, 2023
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 January 1, 2024
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 Retire by January 1, 2024
Goserelin Acetate (Zoladex) (PDF) CP.PHAR.171 December 1, 2023
Granisetron (Kytril, Sancuso, Sustol) (PDF) CP.PMN.74 August 1, 2023
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 November 1, 2023
Hemin (Panhematin) (PDF) CP.PHAR.181 May 1, 2023
Histrelin (Vantas, Supprelin LA) (PDF) CP.PHAR.172 June 1, 2023
Holter Monitors (PDF) CP.MP.113 November 1, 2023
Home and Community Based Services (HCBS) (PDF) AR.CP.BH.503 November 1, 2023
Home Births (PDF) CP.MP.136 March 1, 2023
Home Ventilators (PDF) CP.MP.184 August 1, 2023
Hospice Services (PDF) CP.MP.54 September 1, 2023
Hyaluronate Derivatives (PDF) CP.PHAR.05 December 1, 2023
Hydroxyprogesterone caproate (Makena) (PDF) CP.PHAR.14 June 1, 2023
Hyperhidrosis Treatments (PDF) CP.MP.62 June 1, 2023
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 June 1, 2022
Ibandronate Injection (Boniva) (PDF) CP.PHAR.189 March 1, 2023
Idecabtagene vicleucel (Abecma) (PDF) CP.PHAR.481  August 1, 2022
Idursulfase (Elaprase) (PDF) CP.PHAR.156 June 1, 2022
Iloprost (Ventavis) (PDF) CP.PHAR.193 March 1, 2023
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 November 1, 2022
Immune Globulins (PDF) CP.PHAR.103 November 1, 2023
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 April 1, 2023
Implantable Intrathecal or Epidural Pain Pump (PDF) CP.MP.173 March 1, 2023
Implantable Loop Recorder (PDF) CP.MP.243 June 1, 2023
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 June 1, 2023
Inclisiran (Leqvio) (PDF) CP.PHAR.568 December 1, 2023
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 July 1, 2023
Inotersen (Tegsedi) (PDF) CP.PHAR.405  February 1, 2023
Inebilizumab (PDF) CP.PHAR.458 August 1, 2023
Infertility and Fertility Preservation (PDF) CP.PHAR.131 January 1, 2024
Infertility and Fertility Preservation (PDF) CP.PHAR.131 Retire by January 1, 2024
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 June 1, 2023
Inotuzumab Ozogamicin (Besponsa) (PDF) CP.PHAR.359 December 1, 2023
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) CP.PHAR.534 August 1, 2023
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 October 1, 2023
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 March 1, 2023
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 July 1, 2023 
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 October 1, 2023
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 March 1, 2023
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 July 1, 2023
Irinotecan Liposome (Onivyde) (PDF) CP.PHAR.304 December 1, 2023
Iron Sucrose (Venofer) (PDF) CP.PHAR.167 July 1, 2023
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 June 1, 2023
Isavuconazonium (Cresemba)
CP.PMN.154

December 1, 2023
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF) CP.MP.61 December 1, 2023
Ixekizumab (Taltz) (PDF) CP.PHAR.257 June 1, 2023
Lanadelumab-fylo (Takhzyro) (PDF) CP.PHAR.396 August 1, 2023
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 December 1, 2023
Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy (PDF) CP.MP.250 October 1, 2023
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 November 1, 2022
Lecanemab-irmb (Leqembi) (PDF) CP.PHAR.596 December 1, 2023
Lefamulin (Xenleta) (PDF) CP.PMN.219 August 1, 2023
Letermovir (Prevymis) (PDF) CP.PHAR.367 September 1, 2023
Leucovorin Injection (PDF) CP.PHAR.393 December 1, 2023
Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) CP.PHAR.173 January 1, 2024
Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) CP.PHAR.173 Retire by January 1, 2024
Levoleucovorin (Fusilev, Khapzory) (PDF) CP.PHAR.151 December 1, 2023
Linezolid (Zyvox) (PDF) CP.PMN.27 August 1, 2023
Liposuction for Lipedema (PDF) CP.MP.244 July 1, 2023
Lisocabtagene maraleucel (Breyanzi) (PDF) CP.PHAR.483 June 1, 2022
Loncastuximab tesirine-lpyl (Zynlonta) (PDF) CP.PHAR.539 October 2, 2023
Lovotibeglogene Autotemcel (Lovo-Cel) (PDF) CP.PHAR.627 Pending FDA Approval
Lumasiran (Oxlumo) (PDF) CP.PHAR.473 May 1, 2023
Lurbinectedin (Zepzelca) (PDF) CP.PHAR.500 October 2, 2023
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 December 1, 2023
Lutetium Lu 177 Dotatate (Lutathera) (PDF) CP.PHAR.384 August 1, 2023
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF) CP.PHAR.582 July 1, 2023
Lysis of Epidural Lesions (PDF) CP.MP.116 July 1, 2023
Margetuximab-cmkb (Margenza) (PDF) CP.PHAR.522 March 1, 2023
Measurement of Serum 1,25-dihydroxyvitamin D (PDF) CP.MP.152 November 1, 2023
Mecasermin (Increlex) (PDF) CP.PHAR.150 August 1, 2023
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) CP.MP.144 January 1, 2023
Melphalan (Hepzato) (PDF) CP.PHAR.653 December 1, 2023
Melphalan flufenamide (Pepaxto) (PDF) CP.PHAR.535 June 1, 2023
Mepolizumab (Nucala) (PDF) CP.PHAR.200 April 1, 2022
Mesenchymal stem cell-NTF (NurOwn) (PDF)  CP.PHAR.637 September 1, 2023
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134  December 1, 2022
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238  June 1, 2023
Metreleptin (Myalept) (PDF) CP.PHAR.425 August 1, 2023
Mirvetuximab soravtansine-gynx (Elahere) (PDF) CP.PHAR.617 August 1, 2023
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) CP.PHAR.495 October 2, 2023
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 December 1, 2023
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 December 1, 2023
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 August 1, 2023
Mosunetuzumab-axgb (Lunsumio) (PDF) CP.PHAR.618 August 1, 2023
Motixafortide (Aphexda) (PDF) CP.PHAR.655 December 1, 2023
Moxetumomab Pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 December 1, 2023
Multiple Sleep Latency Testing (PDF) CP.MP.24 June 1, 2023
Nadofaragene Firadenovec (Instiladrin)(PDF) CP.PHAR.461 August 1, 2023
Naltrexone (Vivitrol) (PDF) CP.PHAR.96 March 1, 2023
Natalizumab (Tysabri) (PDF) CP.PHAR.259 January 1, 2024
Natalizumab (Tysabri) (PDF) CP.PHAR.259 Retire by January 1, 2024
Naxitamab-gqgk (Danyelza) (PDF) CP.PHAR.523 March 1, 2023
Necitumumab (Portrazza) (PDF) CP.PHAR.320 December 1, 2023
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF) CP.MP.48 December 1, 2023
Netupitant and Palonosetron (Akynzeo) (PDF) CP.PMN.158 October 2, 2023
Nerve Blocks and Neurolysis for Pain Management (PDF) CP.MP.170 October 1, 2023
Nirsevimab (Beyfortus) 08.07.23 (PDF) CP.PHAR.614 December 1, 2023
Nivolumab (Opdivo) (PDF) CP.PHAR.121   May 1, 2023
Nivolumab and Relatlimab (Opdualag) (PDF) CP.PHAR.588 August 1, 2023
No Coverage Criteria (PDF) CP.PMN.255 November 1, 2023
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF) CP.MP.141 April 1, 2023
Nusinersen (Spinraza®) (PDF) CP.PHAR.327 March 1, 2023
Obstetrical Home Care Programs (PDF) CP.MP.91 June 1, 2023
Obinutuzumab (Gazyva) (PDF) CP.PHAR.305 December 1, 2023
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 December 1, 2023
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) CP.PHAR.40 February 1, 2023
Ofatumumab (Arzerra, Kesimpta) (PDF) CP.PHAR.306 December 1, 2023
Off-Label Use (PDF) CP.PMN.53 December 1, 2023
Olaparib (Lynparza) (PDF) CP.PHAR.360 May 1, 2023
Olaratumab (Lartruvo) (PDF) CP.PHAR.326 December 1, 2023
Olipudase alfa-rpcp (Xenpozyme) (PDF) CP.PHAR.586 August 1, 2023
Omadacycline (Nuzyra) (PDF) CP.PMN.188 August 1, 2023
Omalizumab (Xolair) (PDF) CP.PHAR.01 May 1, 2023
Omecetaxine (Synribo) (PDF) CP.PHAR.108 June 1, 2023
Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy (PDF) CP.MP.249 August 1, 2023
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 December 1, 2023
Onasemnogene Abeparvovec (Zolgensma) (PDF) CP.PHAR.421 June 1, 2022
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) CP.PHAR.536 June 1, 2023
Orthognathic Surgery (PDF) CP.MP.202  December 1, 2023
Osteogenic Stimulation (PDF) CP.MP.194  October 1, 2023
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 July 1, 2023
Outpatient Oxygen Use (PDF) CP.MP.190 June 1, 2023
Paclitaxel protein-bound (Abraxane) (PDF) CP.PHAR.176 August 1, 2023
Panitumumab (Vectibix) (PDF) CP.PHAR.321 January 1, 2024
Panitumumab (Vectibix) (PDF) CP.PHAR.321 Retire by January 1, 2024
Panniculectomy (PDF) CP.MP.109 December 1, 2023
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 August 1, 2023
Pasireotide (Signifor, Signifor LAR) (PDF) CP.PHAR.332 December 1, 2023
Patisiran (Onpattro) (PDF) CP.PHAR.395 December 1, 2023
Peanut Allergen Powder-dnfp (Palforzia)(PDF) CP.PMN.220 March 1, 2021
Pediatric Oral Function Therapy (PDF) CP.MP.188 July 1, 2023
Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF) CP.PHAR.353 December 1, 2023
Pegaptanib (Macugen) (PDF) CP.PHAR.185 May 1, 2023
Pegcetacoplan (Empaveli) (PDF) CP.PHAR.524 August 1, 2023
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) CP.PHAR.296 December 1, 2023
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) CP.PHAR.296 Retire by December 1, 2023
Pegloticase (Krystexxa) (PDF) CP.PHAR.115 March 1, 2023
Pegunigalsidase alfa-iwxj (Elfabrio) (PDF) CP.PHAR.512 August 1, 2023
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 December 1, 2023
Pegvisomant (Somavert) (PDF) CP.PHAR.389 December 1, 2023
Pegzilarginase (AEB1102) (PDF) CP.PHAR.587 Pending FDA Approval
Pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 August 1, 2023
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 August 1, 2023
Percutaneous Left Atrial Appendage Closure for Stroke Prevention (PDF) CP.MP.147 July 1, 2023
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 June 1, 2023
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) CP.PHAR.501 October 2, 2023
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 November 1, 2023
Plasminogen (Ryplazim) (PDF) CP.PHAR.513 December 1, 2023
Plerixafor (Mozobil) (PDF) CP.PHAR.323 August 1, 2023
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 October 2, 2023
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 November 1, 2023
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 October 1, 2023
Pozelimab (REGN3918) (PDF) CP.PHAR.626 December 1, 2023
Prademagene Zamikeracel (EB-101) (PDF) CP.PHAR.609 March 1, 2023
Pralatrexate (Folotyn) (PDF) CP.PHAR.313 December 1, 2023
Protein C Concentrate, Human (Ceprotin) PDF) CP.PHAR.330 March 1, 2023
Proton and Neutron Beam Therapy (PDF) CP.MP.70 January 1, 2023
Ramucirumab (Cyramza) (PDF) CP.PHAR.119  May 1, 2023
Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF) CP.PHAR.186 August 1, 2023
Ravulizumab-cwvz (Ultomiris) (PDF) CP.PHAR.415 August 1, 2023
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 September 1, 2023
Repair of Nasal Valve Compromise (PDF) CP.MP.210 July 1, 2023
Reslizumab (Cinqair) (PDF) CP.PHAR.223 May 1, 2023
Retifanlimab-dlwr (Zynyz) (PDF) CP.PHAR.629 August 1, 2023
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 June 1, 2023
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 June 1, 2023
Risankizumab-rzaa (Skyrizi) (PDF) CP.PHAR.426 January 1, 2024
Risankizumab-rzaa (Skyrizi) (PDF) CP.PHAR.426 Retire by January 1, 2024
Risdiplam (Evrysdi) (PDF) CP.PHAR.477 March 1, 2023
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 August 1, 2023
Rolapitant (Varubi) (PDF) CP.PMN.102 August 1, 2023
Romidepsin (Istodax) (PDF) CP.PHAR.314 December 1, 2023
Romiplostim (Nplate®) (PDF) CP.PHAR.179 May 1, 2023
Ropeginterferon alfa-2b-njft (Besremi) (PDF) CP.PHAR.570 May 1, 2023
Rozanolixizumab-noli (Rystiggo) (PDF) CP.PHAR.648 December 1, 2023
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 June 1, 2023
Sacroiliac Joint Fusion (PDF) CP.MP.126 November 1, 2023
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 October 1, 2023
Sargramostim (Leukine) (PDF) CP.PHAR.295 August 1, 2023
Satralizumab-mwge (Enspryng) (PDF) CP.PHAR.463 August 1, 2023
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF) CP.MP.146 November 1, 2023
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 June 1, 2022
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) CP.MP.174 January 1, 2023
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 October 1, 2023
Setmelanotide (Imcivree) (PDF) CP.PHAR.491  December 1, 2022
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 June 1, 2023
Siltuximab (Sylvant) (PDF)  CP.PHAR.329 March 1, 2023
Sirolimus Protein-Bound Particles (Fyarro), topical gel (Hyftor) CP.PHAR.574 March 1, 2023
Skilled Nursing Facility Leveling (PDF) CP.MP.206 October 1, 2022
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF) CP.MP.185 September 1, 2023
Sodium thiosulfate (Pedmark) (PDF) CP.PHAR.610 August 1, 2023
Sotatercept (ACE-011) (PDF) CP.PHAR.657 Pending FDA Approval
Sotrovimab (VIR-7831) (PDF) CP.PHAR.541 July 1, 2023
Spesolimab-sbzo (Spevigo) (PDF) CP.PHAR.606 August 1, 2023
Spinal Cord Stimulation (PDF) CP.MP.117 July 1, 2023
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 March 1, 2023
Substance Use Disorders Treatment and Services (PDF) CP.BH.100 November 1, 2022
Sutimlimab-jome (Enjaymo) (PDF) CP.PHAR.503 June 1, 2023
Tafasitamab-cxix (Monjuvi) (PDF) CP.PHAR.508 December 1, 2023
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 December 1, 2021
Talimogene laherparepvec (Imlygic) (PDF) CP.PHAR.542 August 1, 2023
Talquetamab-tgvs (Talvey) (PDF) CP.PHAR.649 December 1, 2023
Tebentafusp-(Kimmtrak) (PDF) CP.PHAR.575  June 1, 2023
Teclistamab-cqyv (Tecvayli) (PDF) CP.PHAR.611 August 1, 2023
Tedizolid (Sivextro) (PDF) CP.PMN.62 August 1, 2023
Teduglutide (Gattex) (PDF) CP.PHAR.114 March 1, 2023
Temozolomide (Temodar) (PDF) CP.PHAR.77 Retire by February 1, 2024
Temozolomide (Temodar) (PDF) CP.PHAR.77 February 1, 2024
Temsirolimus (Torisel) (PDF) CP.PHAR.324 December 1, 2023
Teplizumab-mzwv (Tzield) (PDF) CP.PHAR.492 Pending FDA Approval
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 August 1, 2023
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 November 1, 2023
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 December 1, 2023
Tezepelumab (Tezspire) (PDF) CP.PHAR.576  May 1, 2023
Therapeutic Utilization of Inhaled Nitric Oxide (PDF) CP.MP.87 June 1, 2023
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) CP.MP.154 November 1, 2023
Thyrotropin alfa (Thyrogen) (PDF) CP.PHAR.95 August 1, 2023
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 March 1, 2023
Tisotumab Vedotin-tftv (Tivdak) (PDF) CP.PHAR.561  December 1, 2023
Tixagevimab-Cilgavimab (Evusheld) (PDF) CP.PHAR.571 July 1, 2023
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF) CP.PHAR.211 March 1, 2022
Tocilizumab (Actemra) (PDF) CP.PHAR.263 June 1, 2023
Tofersen (Qalsody) (PDF) CP.PHAR.591 December 1, 2023
Topotecan (Hycamtin) (PDF) CP.PHAR.64 July 1, 2023
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 June 1, 2023
Trabectedin (Yondelis) (PDF) CP.PHAR.204 March 1, 2023
Tralokinumab-ldrm (Adbry) (PDF) CP.PHAR.577  June 1, 2022
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 April 1, 2023
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF) CP.BH.200 August 1, 2023
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 October 9, 2023
Tremelimumab-actl (Imjudo) (PDF) CP.PHAR.612 August 1, 2023
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199 August 1, 2022
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 March 1, 2023
Trigger Point Injections for Pain Management (PDF) CP.MP.169 October 1, 2023
Triptorelin pamoate (Trelstar, Triptodur) (PDF) CP.PHAR.175 December 1, 2023
Ublituximab-xiiy (Briumvi) (PDF) CP.PHAR.621 December 1, 2023
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 August 1, 2023
Ustekinumab (Stelara) (PDF) CP.PHAR.264 January 1, 2024
Ustekinumab (Stelara) (PDF) CP.PHAR.264 Retire by January 1, 2024
Vagus Nerve Stimulation (PDF) CP.MP.12 October 1, 2023
Valoctocogene Roxaparvovec (PDF) CP.PHAR.466 Pending FDA Approval
Valrubicin (Valstar) (PDF) CP.PHAR.439 December 1, 2023
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 January 1, 2024
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 Retire by January 1, 2024
Velaglucerase alfa (VPRIV) (PDF) CP.PHAR.163 December 1, 2021
Velmanase Alfa-tycv (Lamzede) (PDF) CP.PHAR.601 June 1, 2023
Ventricular Assist Devices (PDF) CP.MP.46 October 1, 2023
Verteporfin (Visudyne) (PDF) CP.PHAR.187 March 1, 2023
Vestronidase Alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 June 1, 2023
Viltolarsen (Viltepso) (PDF) CP.PHAR.484 March 1, 2023
Vincristine Liposome (Marqibo) (PDF) CP.PHAR.315 January 1, 2024
Vincristine Liposome (Marqibo) (PDF) CP.PHAR.315 Retire by January 1, 2024
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 March 1, 2023
Vosoritide (Voxzogo) (PDF) CP.PHAR.525 March 1, 2023
Vutrisiran (Amvuttra) (PDF) CP.PHAR.550  December 1, 2022
Waiver Environmental Modifications Criteria (PDF) ARTC.CC.25 September 1, 2022
Wireless Motility Capsule (PDF) CP.MP.143 November 1, 2023
Zavegepant (Zavzpret) (PDF) CP.PHAR.630 August 1, 2023
Ziv-aflibercept (Zaltrap) (PDF) CP.PHAR.325 December 1, 2023
Zoledronic Acid (PDF) CP.PHAR.59 March 1, 2023

Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 July 1, 2014
Add-On Code Billed Without Primary Code (PDF) CC.PP.030 October 18, 2016
Aducanumab (Aduhelm) (PDF) CP.PHAR.468 December 1, 2021
Assistant Surgeon (PDF) CC.PP.029 February 7, 2017
Bevacizumab (PDF) CP.PHAR.93 September 1, 2021
Bilateral Procedures (PDF) CC.PP.037 February 7, 2017
Bronchial Thermoplasty (PDF) CP.MP.110 May 1, 2023
Cerumen Removal (PDF) CC.PP.008 August 12, 2016
Clean Claims (PDF) CC.PP.021 October 18, 2016
Coding Overview (PDF) CC.PP.011 October 18, 2016
Cosmetic Procedures (PDF) CC.PP.024 October 18, 2016
Distinct Procedural Modifiers (PDF) CC.PP.020 October 18, 2016
Duplicate Primary Code Billing (PDF) CC.PP.044 February 7, 2017
E&M Medical Decision-Making (PDF) CC.PP.051 July 25, 2017
EM Bundling Edits (PDF) CC.PP.010 August 12, 2016
Global Maternity Billing (PDF) CC.PP.016 October 18, 2016
Homocysteine Testing (PDF) CP.MP.121 May 1, 2023
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 October 18, 2016
Inpatient Consultation (PDF) CC.PP.038 February 7, 2017
Inpatient Only Procedures (PDF) MP.PP.018 October 18, 2016
IV Hydration (PDF) CC.PP.012 October 18, 2016
Laser Therapy for Skin Conditions (PDF) CP.MP.123 May 1, 2023
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 March 15, 2021
Leveling of Emergency Room (PDF) CC.PP.053  January 1, 2019
Long Term Care Placement Criteria (PDF) CP.MP.71 June 1, 2022
Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) CP.MP.139 May 1, 2023
Maximum Units (PDF) CC.PP.007 August 12, 2016
Moderate Conscious Sedation (PDF) CC.PP.015 October 18, 2016
Modifier -25 Clinical Validation (PDF) CC.PP.013 October 18, 2016
Modifier -59 Clinical Validation (PDF) CC.PP.014 October 18, 2016
Modifier DOS Validation (PDF) CC.PP.034 October 18, 2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 October 18, 2016
Multiple CPT Code Replacement (PDF) CC.PP.033 October 18, 2016
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF) CC.PP.065 March 15, 2021
Multiple Procedure Reduction: Ophthalmology (PDF) CC.PP.069 March 15, 2021
Multiple Procedure Payment Reduction for Therapeutic Services (PDF) CC.PP.068 March 15, 2021
NCCI Unbundling (PDF) CC.PP.031 October 18, 2016
Never Paid Events (PDF) CC.PP.017 October 18, 2016
New Patient (PDF) CC.PP.036 February 7, 2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  March 15, 2021
Outpatient Consultation (PDF) CC.PP.039 February 7, 2017
Paclitaxel (PDF) CP.PHAR.176 July 1, 2023
Physician’s Consultation Services (PDF) CC.PP.054 September 1, 2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 October 18, 2016
Place of Service Mismatch (PDF) CC.PP.063  December 15, 2018
Post-Operative Visits (PDF) CC.PP.042 February 7, 2017
Pre-Operative Visits (PDF) CC.PP.041 February 7, 2017
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 November 1, 2018
Professional Component (PDF) CC.PP.027 October 18, 2016
Pulmonary Function Testing (PDF) CP.MP.242 May 1, 2023
Pulse Oximetry (PDF) CC.PP.025 October 18, 2016
Renal Hemodialysis (PDF) CC.PP.067 March 15, 2021
Robotic Surgery (PDF) CC.PP.050 November 1, 2017
Same Day Visits (PDF) CC.PP.040 February 7, 2017
Status "B" Bundled Services (PDF) CC.PP.046 February 7, 2017
Status "P" Bundled Services (PDF) CC.PP.049 June 17, 2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 October 18, 2016
Supportive Living (PDF) ARTC.PP.1000 July 20, 2020
Transgender Related Services (PDF) CC.PP.047 February 22, 2017
Ultrasound in Pregnancy (PDF) CP.MP.38 May 1, 2023
Unbundled Professional Services (PDF) CC.PP.043 April 6, 2017
Unbundled Surgical Procedures (PDF) CC.PP.045 April 6, 2017
Unlisted Procedure Codes (PDF) CC.PP.009 August 12, 2016
Urine Specimen Validity Testing (PDF) CC.PP.056 November 8, 2017
Urodynamic Testing (PDF) CP.MP.98 May 1, 2023
Velmanase Alfa-tycv (Lamzede) (PDF) CP.PHAR.601 June 1, 2023
Wheelchair Accessories (PDF) CC.PP.502 August 12, 2016
Wheelchair Seating (PDF) CP.MP.99 May 1, 2023

Policy Title Policy Number Effective Date
Behavioral Health Covered Benefits and Services Addendum F (PDF) CC.BH.UM.28 Addendum F July 19, 2022
Waiver Environmental Modifications Criteria (PDF) ARTC.CC.25 September 1, 2022