Skip to Main Content

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.

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 including peer-reviewed medical literature, government agency/program approval status, evidence-based guidelines, 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 an 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 an 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
25-hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 January 1, 2022
Abaloparatide (Tymlos) (PDF) CP.PHAR.345

March 1, 2022
Abatacept (Orencia) (PDF) CP.PHAR.241  
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 June 1, 2022 - NEW
Acupuncture (PDF) CP.MP.92 October 1, 2021
ADHD Assessment and Treatment (PDF) CP.MP.124 May 1, 2022
Ado-Trastuzumab (Kadcyla) (PDF) CP.PHAR.229 June 1, 2022 
Aducanumab (Aduhelm) (PDF) CP.PHAR.468 August 1, 2022
Aducanumab (Aduhelm) (PDF) CP.PHAR.468

Retire by August 1, 2022
Adult Rehabilitative Day Service (Psychosocial Rehabilitation Services)(PDF) CP.BH.AR.1800 March 1, 2019
Afamelanotide (Scenesse) (PDF) CP.PHAR.444 March 1, 2022
Aflibercept (Eylea) (PDF) CP.PHAR.184 June 1, 2022 
Agalsidase beta (Fabrazyme) (PDF) CP.PHAR.158 June 1, 2022
Air Ambulance (PDF) CP.MP.175 October 1, 2021
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 June 1, 2022
Alglucosidase (Lumizyme) (PDF) CP.PHAR.160 August 1, 2022
Alglucosidase (Lumizyme) (PDF) CP.PHAR.160

Retire by August 1, 2022
Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft)(PDF) CP.PHAR.562 March 1, 2022
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) CP.MP.108 January 1, 2022
Allogenic processed thymus tissue-agdc (Rethymic) (PDF) CP.PHAR.563 June 1, 2022 - NEW
Allergy Testing and Therapy (PDF) CP.MP.100 August 1, 2022
Allergy Testing and Therapy (PDF) CP.MP.100

Retire by August 1, 2022
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) CP.PHAR.94 March 1, 2022
Amifampridine (Firdapse, Ruzurgi)(PDF) CP.PHAR.411 April 1, 2022
Amikacin (Arikayce) (PDF) CP.PHAR.401 April 1, 2022
Amisulpride (Barhemsys) (PDF) CP.PMN.236 November 1, 2021
Amivantamab-vmjw (Rybrevant) (PDF) CP.PHAR.544 October 1, 2021
Anifrolumab-fnia (Saphnelo) (PDF) CP.PHAR.551 December 1, 2021
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 June 1, 2022
Antithrombin III (ATryn, Thrombate III) (PDF) CP.PHAR.564 March 1, 2022
Antithrombin III (Thrombate III, Atryn) (PDF) CP.MP.179 December 1, 2021
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) CP.PHAR.506 December 1, 2021
Apalutamide (Erleada) (PDF) CP.PHAR.376 August 1, 2021 
Applied Behavioral Analysis for Autism (PDF) CP.BH.104 March 1, 2022
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) CP.PMN.19 March 1, 2022
Articular Cartilage Defect Repairs (PDF) CP.MP.26 April 1, 2022
Assistive Reproductive Technology (PDF) CP.MP.55  February 1, 2022
Atezolizumab (Tecentriq) (PDF) CP.PHAR.235 April 1, 2022
Avacopan (Tavneos) (PDF) CP.PHAR.515 March 1, 2022
Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) CP.PHAR.521 June 1, 2022
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 April 1, 2022
Avelumab (Bavencio) (PDF) CP.PHAR.333 April 1, 2022
Axicabtagene Ciloleucel (Yescarta®) (PDF) CP.PHAR.362 June 1, 2021
Azacitidine (Vidaza) (PDF) CP.PHAR.387 March 1, 2022
Baclofen (Gablofen, Lioresal, Lyvispah, Ozobax) (PDF) CP.PHAR.149 April 1, 2022
Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) CP.PHAR.532 August 1, 2022
Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016)

CP.PHAR.532

Retire by August 1, 2022
Bariatric Surgery (PDF) CP.MP.37 November 1, 2021
Behavioral Assistance (Therapeutic Behavioral Services) (PDF) CP.BH.AR.1900 March 1, 2019
Belantamab mafodotin (Blenrep) (PDF) CP.PHAR.469 June 1, 2022
Belatacept (Nulojix) (PDF) CP.PHAR.201 December 1, 2021
Belimumab (Benlysta) (PDF) CP.PHAR.88  June 1, 2022
Belinostat (Beleodaq) (PDF) CP.PHAR.311 December 1, 2021
Bendamustine (Bendeka, Treanda) (PDF) CP.PHAR.307 February 1, 2020
Benralizumab (Fasenra) (PDF) CP.PHAR.373 March 1, 2022
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 February 1, 2022
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 March 1, 2022
Bimatoprost Implant (Durysta)(PDF) CP.PHAR.486 June 1, 2022
Biofeedback (PDF) CP.MP.168 February 1, 2022
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 November 1, 2021
Bone-Anchored Hearing Aid (PDF) CP.MP.93 October 1, 2021
Bortezomib (Velcade) (PDF) CP.PHAR.410 March 1, 2022
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 April 1, 2022
Brexanolone (Zulresso) (PDF) CP.PHAR.417 June 1, 2022
Brexucabtagene Autoleucel (Tecartus) (PDF) CP.PHAR.472 March 1, 2022
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445  March 1, 2022
Bronchial Thermoplasty (PDF) CP.MP.110 July 1, 2022 - NEW
Burn Surgery (PDF) CP.MP.186 February 1, 2022
Burprenorphine (Brixadi) (PDF) CP.PHAR.498 December 1, 20221
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 March 1, 2022
C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (PDF) CP.PHAR.202 April 1, 2022
Cabotegravir, Cabotegravir-Rilpivirine (Apretude Cabenuva) (PDF) CP.PHAR.573 May 1, 2022
Cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 August 1, 2022
Cabazitaxel (Jevtana®) (PDF)

CP.PHAR.316

Retire by August 1, 2022
Cabozantinib (Cabometyx, Cometriq) (PDF) CP.PHAR.111 March 1, 2022
Canakinumab (Ilaris) (PDF) CP.PHAR.246 June 1, 2022
Caplacizumab-yhdp (Cablivi) CP.PHAR.416  August 1. 2022
Caplacizumab-yhdp (Cablivi) CP.PHAR.416  Retire by August 1, 2022
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 December 1, 2021
Carfilzomib (Kyprolis) (PDF) CP.PHAR.309 December 1, 2021
Casimersen (Amondys 45) (PDF) CP.PHAR.470 June 1, 2021
Casirivimab and Imdevimab (REGEN-COV) (PDF) CP.PHAR.520 August 1, 2022
Casirivimab and Imdevimab (REGEN-COV) (PDF)

CP.PHAR.520

Retire by August 1, 2022
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 November 1, 2021
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 December 1, 2021
Cerliponase Alfa (Brineura) (PDF) CP.PHAR.338 November 1, 2021
Cetuximab (Erbitux) (PDF) CP.PHAR.317 December 1, 2021
Child and Youth Support Services (PDF) CP.BH.AR.1700 March 1, 2019
Chlorambucil (Leukeran) (PDF) CP.PHAR.554 March 1, 2022
Chloramphenicol (PDF) CP.PHAR.388 March 1, 2022
Ciclopirox (Penlac) (PDF) CP.PMN.24 April 1, 2022
Ciltacabtagene Autoleucel (Carvykti) CP.PHAR.533  June 1, 2022
Clinical Trials (PDF) CP.MP.94 August 1, 2021
CNS Stimulants (PDF) CP.PMN.92 March 1, 2022
Cochlear Implant Replacements (PDF) CP.MP.14 September 1, 2020
Colchicine (Colcrys) (PDF) CP.PMN.123 March 1, 2022
Collagenase (Xiaflex) (PDF) CP.PHAR.82 November 1, 2021
Continuous Glucose Monitors (PDF) CP.PMN.214 December 1, 2021
Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) CP.PHAR.505 December 1, 2020
Copanlisib (Aliqopa) (PDF) CP.PHAR.357 December 1, 2021
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 June 1, 2022
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 December 1, 2021
Cosyntropin (Cortrosyn) (PDF) CP.PHAR.203 March 1, 2022
Crisis Intervention (PDF) CP.BH.AR.1500 March 1, 2019

Crizanlizumab-tmca (Adakveo) (PDF)

CP.PHAR.449 March 1, 2022
Cytomegalovirus Immune Globulin (Cytogam) (PDF) CP.PHAR.277 November 1, 2021
Dalteparin (Fragmin) (PDF) CP.PHAR.225 March 1, 2022
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 November 1, 2021
Daratumumab (Darzalex) (PDF) CP.PHAR.310 July 1, 2021
Darbepoetin Alfa (Aranesp) (PDF) CP.PHAR.236 June 1, 2022
Daunorubicin and Cytarabine (Vyxeos) (PDF) CP.PHAR.352 December 1, 2021
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) CP.BH.201

Retire by September 1, 2022
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) CP.BH.201 April 1, 2022
Deferoxamine (Desferal) (PDF) CP.PHAR.146 July 1, 2021
Degarelix (Firmagon) (PDF) CP.PHAR.170 December 1, 2021
Delafloxacin (Baxdela) (PDF) CP.PMN.115 March 1, 2022
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 June 1, 2022
Dental Anesthesia (PDF) CP.MP.61 December 1, 2021
Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) CP.PHAR.214 March 1, 2022
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 June 1, 2022
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 February 1, 2022
Digital Analysis of EEGs (PDF) CP.MP.105 December 1, 2021
Disc Decompression Procedures (PDF) CP.MP.114 July 1, 2021
Discography (PDF) CP.MP.115 August 1, 2021
Dolasetron (Anzemet) (PDF) CP.PMN.141 December 1, 2021
Donor Lymphocyte Infusion (PDF) CP.MP.101 December 1, 2021
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 March 1, 2022
Dostarlimab-gxly (Jemperli) (PDF) CP.PHAR.540 November 1, 2021
Dupilumab (Dupixent) (PDF) CP.PHAR.336 April 1, 2022
Durable Medical Equipment (DME) (PDF) CP.MP.107 February 1, 2022
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 August 1, 2022
Durvalumab (Imfinzi) (PDF)

CP.PHAR.339

Retire by August 1, 2022
Duvelisib (Copiktra) (PDF) CP.PHAR.400 March 1, 2022
Ecallantide (Kalbitor) (PDF) CP.PHAR.177 April 1, 2022
Eculizumab (Soliris) (PDF) CP.PHAR.97 August 1, 2022
Eculizumab (Soliris) (PDF)

CP.PHAR.97

Retire by August 1, 2022
Edaravone (Radicava) (PDF) CP.PHAR.343 June 1, 2022
EEG in Evaluation of Headache (PDF) CP.MP.155 December 1, 2021
Efinaconazole (Jublia) (PDF) CP.PMN.25 April 1, 2022
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 June 1, 2022
Electric Tumor Treatment Fields (PDF) CP.MP.145 February 1, 2022
Elexacaftor-ivacaftor-tezacaftor (Trikafta) (PDF) CP.PHAR.440 March 1, 2022
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 June 1, 2022
Elotuzumab (Empliciti) (PDF) CP.PHAR.308 December 1, 2021
Eltrombopag (Promacta) (PDF) CP.PHAR.180 March 1, 2022
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 March 1, 2022
Endometrial Ablation (PDF) CP.MP.106

Retire by September 1, 2022
Endometrial Ablation (PDF) CP.MP.106 June 1, 2022
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 March 1, 2022
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 November 1, 2021
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 March 1, 2022
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 June 1, 2022
Epoprostenol (Flolan, Veletri) (PDF) CP.PHAR.192 March 1, 2022
Eptinezumab-jjmr (Vyepti) (PDF) CP.PHAR.489 December 1, 2021
Eribulin Mesylate (Halaven) (PDF) CP.PHAR.318 February 1, 2022
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 April 1, 2022
Essure Removal (PDF) CP.MP.131 December 1, 2021
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 July 1, 2021
Eteplirsen  (Exondys 51) (PDF) CP.PHAR.288 July 1, 2021
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) CP.PHAR.63 March 1, 2022
Evinacumab-dgnb (Evkeeza) (PDF) CP.PHAR.511 March 1, 2022
Evoked Potential Testing (PDF) CP.MP.134 October 1, 2021
Evolocumab (Repatha) (PDF) CP.PHAR.123

March 1, 2022
Experimental Technologies (PDF) CP.MP.36 April 1, 2022
Facet Joint Interventions (PDF) CP.MP.171  
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF) CP.PHAR.220 March 1, 2022
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215  June 1, 2022
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) CP.PHAR.216 June 1, 2022
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 June 1, 2022
Factor IX Complex, Human (Profilnine) (PDF) CP.PHAR.219 March 1, 2022
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 June 1, 2022
Factor XIII A-Subunit, Recombinant (Tretten®) CP.PHAR.222 June 1, 2022
Family Support Partners (PDF) CP.BH.AR.1600 March 1, 2019
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 March 1, 2022
Fecal Incontinence Treatments (PDF) CP.MP.137 September 1, 2021
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 March 1, 2022
Ferric Derisomaltose (Monoferric)(PDF) CP.PHAR.480 June 1, 2022
Ferric Gluconate (Ferrlecit) (PDF) CP.PHAR.166 March 1, 2022
Ferriscan R2-MRI (PDF) CP.MP.53 December 1, 2021
Ferumoxytol (Feraheme) (PDF) CP.PHAR.165 March 1, 2022
Fertility Preservation (PDF) CP.MP.130 November 1, 2021
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 December 1, 2021
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) CP.PHAR.526 June 1, 2022
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) CP.PHAR.297 April 1, 2022
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 March 1, 2022
Fosdenopterin (Nulibry) (PDF) CP.PHAR.471  June 1, 2022
Fostemsavir (Rukobia) (PDF) CP.PHAR.516 April 1, 2022
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 July 1, 2021
Functional MRI (PDF) CP.MP.43 April 1, 2022
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 June 1, 2022
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) CP.MP.209 May 1, 2022
Gastric Electrical Stimulation (PDF) CP.MP.40 April 1, 2022
Gemtuzumab (Mylotarg) (PDF) CP.PHAR.358  
Gender reassignment surgery (PDF) CP.MP.95 January 1, 2022
Gilteritinib (Xospata) (PDF) CP.PHAR.412 March 1, 2022
Givosiran (Givlaari) (PDF) CP.PHAR.457 April 1, 2022
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 July 1, 2021
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 February 1, 2022
Goserelin Acetate (Zoladex) (PDF) CP.PHAR.171 December 1, 2021
Granisetron (Kytril, Sancuso, Sustol) (PDF) CP.PMN.74 March 1, 2022
Group Psychotherapy (PDF) CP.BH.AR.600 March 1, 2019
Heart-Lung Transplant (PDF) CP.MP.132 July 1, 2022 - NEW
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 December 1, 2021
Hemin (Panhematin) (PDF) CP.PHAR.181 March 1, 2022
Histrelin (Vantas, Supprelin LA) (PDF) CP.PHAR.172 December 1, 2021
Holter Monitors (PDF) CP.MP.113 February 1, 2022
Home Birth (PDF) CP.MP.136 March 1, 2022
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 December 1, 2021
Homocysteine Testing (PDF) CP.MP.121 May 1, 2022
Hospice Clinical Coverage (PDF) CP.MP.54 February 1, 2022
Human Growth Hormone (Somapacitan, Somatropin) (PDF) CP.PHAR.517 April 1, 2022
Hyaluronate Derivatives (PDF) CP.PHAR.05 December 1, 2021
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 April 1, 2022
Hyperhidrosis Treatments (PDF) CP.MP.62 March 1, 2022
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 June 1, 2022
Ibandronate Injection (Boniva) (PDF) CP.PHAR.189 March 1, 2022
Ibrutinib (Imbruvica)  (PDF) CP.PHAR.126 April 1, 2022
Icatibant (Firazyr®) (PDF) CP.PHAR.178 April 1, 2022
Idecabtagene vicleucel (Abecma) (PDF) CP.PHAR.481  June 1, 2022
Idursulfase (Elaprase) (PDF) CP.PHAR.156 June 1, 2022
Iloprost (Ventavis) (PDF) CP.PHAR.193 March 1, 2022
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 August 1, 2022
Imiglucerase (Cerezyme) (PDF)

CP.PHAR.154

Retire by August 1, 2022
Immune Globulins (PDF) CP.PHAR.103 March 1, 2022
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 January 1, 2022
Implantable Intrathecal Pain Pump (PDF) CP.MP.173 June 1, 2022
Implantable Loop Recorder (PDF) CP.MP.243 Retire by September 1, 2022
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 June 1, 2022
Inclisiran (Leqvio) (PDF) CP.PHAR.568 March 1, 2022
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 June 1, 2022
Individual/Group Pharmacologic Counseling by RN  (Medication Training and Support) (PDF) CP.BH.AR.1200 March 1, 2019
Inebilizumab (PDF) CP.PHAR.458 August 1, 2022
Inebilizumab (PDF)

CP.PHAR.458

Retire by August 1, 2022
Infertility and Fertility Preservation (PDF) CP.PHAR.131 December 1, 2021
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 October 1, 2021 
Inhaled Nitric Oxide (PDF) CP.MP.87 June 1, 2022
Inotuzumab Ozogamicin (Besponsa) (PDF) CP.PHAR.359 December 1, 2021
Intensity Modulated Radiation Therapy (PDF) CP.MP.69 February 1, 2022
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 March 1, 2022
Interpretation of Diagnosis (PDF) CP.BH.AR.800 March 1, 2019
Intestinal & Multivisceral Transplant (PDF) CP.MP.58 July 1, 2022 - NEW
Intradiscal Steroid Injections (PDF) CP.MP.167 October 1, 2021
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 March 1, 2022
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 August 1, 2022
Ipilimumab (Yervoy) (PDF)
CP.PHAR.319

Retire by August 1, 2022
Irinotecan Liposome (Onivyde) (PDF) CP.PHAR.304 December 1, 2021
Iron Sucrose (Venofer) (PDF) CP.PHAR.167 March 1, 2022
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 June 1, 2022
Isavuconazonium (Cresemba)
CP.PMN.154

August 1, 2022
Isavuconazonium (Cresemba) CP.PMN.154 Retire by August 1, 2022
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 March 1, 2022
Lanadelumab-fylo (Takhzyro) (PDF) CP.PHAR.396 April 1, 2022
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 December 1, 2021
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 June 1, 2022
Larotrectinib (Vitrakvi) (PDF)
CP.PHAR.414 March 1, 2022
Laser Skin Treatment (PDF) CP.MP.123 May 1, 2022
Lasmiditan (Reyvow) (PDF) CP.PMN.218 March 1, 2022
Ledipasvir-Sofosbuvir (Harvoni) (PDF) CP.PHAR.279 March 1, 2022
Letermovir (Prevymis) (PDF) CP.PHAR.367 March 1, 2022
Leucovorin Injection (PDF) CP.PHAR.393 December 1, 2021
Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) CP.PHAR.173 March 1, 2022
Levoleucovorin (Fusilev, Khapzory) (PDF) CP.PHAR.151 December 1, 2021
Lifitegrast (Xiidra) (PDF) CP.PMN.73 April 1, 2022
Linezolid (Zyvox) (PDF) CP.PMN.27 March 1, 2022
Liposuction for Lipedema (PDF) CP.MP.244 October 1, 2022 - NEW
Lisocabtagene maraleucel (Breyanzi) (PDF) CP.PHAR.483 June 1, 2022
Loncastuximab tesirine-lpyl (Zynlonta) (PDF) CP.PHAR.539 November 1, 2021
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 May 1, 2022
Lumacaftor-ivacaftor (Orkambi)  CP.PHAR.213 March 1, 2022
Lumasiran (Oxlumo) (PDF) CP.PHAR.473 March 1, 2022
Lung Transplantation (PDF) CP.MP.57 April 1, 2022
Lurbinectedin (Zepzelca) (PDF) CP.PHAR.500 July 1, 2021
Lutetium Lu 177 Dotatate (Lutathera) (PDF) CP.PHAR.384 July 1, 2021
Lysis of Epidural Lesions (PDF) CP.MP.116 July 1, 2022 - NEW
Margetuximab-cmkb (Margenza) (PDF) CP.PHAR.522 March 1, 2022
Marital/Family BH Counseling with Beneficiary Present (PDF) CP.BH.AR.400 March 1, 2019
Marital/Family BH Counseling without Beneficiary Present (PDF) CP.BH.AR.300 March 1, 2019
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 December 1, 2021
Mecasermin (Increlex) (PDF) CP.PHAR.150 July 1, 2021
Mechanical Stretch Devices (PDF) CP.MP.144 February 1, 2022
Mepolizumab (Nucala) (PDF) CP.PHAR.200 April 1, 2022
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238  June 1, 2022
Metreleptin (Myalept) (PDF) CP.PHAR.425 November 1, 2021
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) CP.PHAR.495 November 1, 2021
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 August 1, 2022
Mitoxantrone (Novantrone) (PDF)

CP.PHAR.258

Retire by August 1, 2022
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 December 1, 2021
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 April 1, 2022
Moxetumomab Pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 December 1, 2021
Multi-Family Behavioral Health Counseling (PDF) CP.BH.AR.500 March 1, 2019
Multiple Sleep Latency Testing (PDF) CP.MP.24 June 1, 2022
Nadofaragene Firadenovec (Instiladrin)(PDF) CP.PHAR.461 March 1, 2022
Naltrexone (Vivitrol) (PDF) CP.PHAR.96 March 1, 2022
Natalizumab (Tysabri) (PDF) CP.PHAR.259 June 1, 2022
Naxitamab-gqgk (Danyelza) (PDF) CP.PHAR.523 March 1, 2022
Necitumumab (Portrazza) (PDF) CP.PHAR.320 December 1, 2021
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 July 1, 2022
Neonatal Sepsis Management Guidelines (PDF) CP.MP.85 December 1, 2021
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 August 1, 2021
Neuromuscular Electrical Stimulation (PDF) CP.MP.48 June 1, 2022
Netupitant and Palonosetron (Akynzeo) (PDF) CP.PMN.158 December 1, 2021
Nerve Blocks for Pain Management (PDF) CP.MP.170 February 1, 2022
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 August 1, 2021
NICU Discharge Guidelines (PDF) CP.MP.81 November 1, 2021 
Nivolumab (Opdivo) (PDF) CP.PHAR.121   April 1, 2022
No Coverage Criteria (PDF) CP.PMN.255 March 1, 2022
Non-Invasive Home Ventilator (PDF) CP.MP.184 October 1, 2021
Nonmyeloablative allogeneic stem cell transplant (PDF) CP.MP.141 July 1, 2022
Nusinersen (Spinraza®) (PDF) CP.PHAR.327 March 1, 2022
OB Home Health Programs (PDF) CP.MP.91 February 1, 2022
Obinutuzumab (Gazyva) (PDF) CP.PHAR.305 February 1, 2022
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 August 1, 2022
Ocrelizumab (Ocrevus) (PDF)

CP.PHAR.335

Retire by August 1, 2022
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) CP.PHAR.40 March 1, 2022
Ofatumumab (Arzerra, Kesimpta) (PDF) CP.PHAR.306 June 1, 2022
Off-Label Use (PDF) CP.PMN.53 March 1, 2022
Olaparib (Lynparza) (PDF) CP.PHAR.360 April 1, 2022
Olaratumab (Lartruvo) (PDF) CP.PHAR.326 December 1, 2021
Omadacycline (Nuzyra) (PDF) CP.PMN.188 March 1, 2022
Omalizumab (Xolair) (PDF) CP.PHAR.01 March 1, 2022
Omecetaxine (Synribo) (PDF) CP.PHAR.108 June 1, 2022
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 June 1, 2022 - NEW
Onasemnogene Abeparvovec (Zolgensma) (PDF) CP.PHAR.421 June 1, 2022
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) CP.PHAR.536 June 1, 2022
Optic Nerve Decompression Surgery (PDF) CP.MP.128 October 1, 2021
Orthognathic Surgery (PDF) CP.MP.202  December 1, 2021
Osteogenic Stimulation (PDF) CP.MP.194  November 1, 2021
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 July 1, 2022 - NEW
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 May 1, 2022
Oxygen Use and Concentrators (PDF) CP.MP.190 March 1, 2022
Ozanimod(PDF) CP.PHAR.462 June 1, 2021
Pancreas Transplantation (PDF) CP.MP.102 April 1, 2022
Panitumumab (Vectibix) (PDF) CP.PHAR.321 December 1, 2021
Panniculectomy (PDF) CP.MP.109 January 1, 2022 
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 October 1, 2021
Pasireotide (Signifor, Signifor LAR) (PDF) CP.PHAR.332 December 1, 2021
Patisiran (Onpattro) (PDF) CP.PHAR.395 February 1, 2022
Peanut Allergen Powder-dnfp (Palforzia)(PDF) CP.PMN.220 March 1, 2021
Pediatric Heart Transplant (PDF) CP.MP.138 July 1, 2022
Pediatric Liver Transplant (PDF) CP.MP.120 July 1, 2022
Pediatric Oral Function Therapy (PDF) CP.MP.188 July 1, 2022 - NEW
Peer Support (PDF) CP.BH.AR.1300 March 1, 2019
Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF) CP.PHAR.353 February 1, 2022
Pegaptanib (Macugen) (PDF) CP.PHAR.185 March 1, 2022
Pegcetacoplan (Empaveli) (PDF) CP.PHAR.524 March 1, 2022
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) CP.PHAR.296 March 1, 2022
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 December 1, 2021
Pegvisomant (Somavert) (PDF) CP.PHAR.389 December 1, 2021
Pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 June 1, 2022
Pembrolizumab (Keytruda®) (PDF)

CP.PHAR.322

Retire by June 1, 2022
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 April 1, 2022
Percutaneous LAAD Stroke Prevention (PDF) CP.MP.147 July 1, 2022 - NEW
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 June 1, 2022
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) CP.PHAR.501 July 1, 2021
Pharmacologic Management (PDF) CP.BH.AR.1000 March 1, 2019
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 August 1, 2021
Pitolisant (Wakix) (PDF) CP.PMN.221 March 1, 2022
Plasminogen (Ryplazim) (PDF) CP.PHAR.513 December 1, 2021
Plerixafor (Mozobil) (PDF) CP.PHAR.323 November 1, 2021
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 July 1, 2021
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 May 1, 2022
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 October 1, 2021
Post-Acute Care (PDF) CP.MP.213 April 1, 2022
Potassium Salts (Klor-Con) (PDF) HIM.PA.143 March 1, 2022
Pralatrexate (Folotyn) (PDF) CP.PHAR.313 December 1, 2021
Protein C Concentrate, Human (Ceprotin) PDF) CP.PHAR.330 March 1, 2022
Psychiatric Diagnosis Evaluation (PDF) CP.BH.AR.100 March 1, 2019
Psychoeducation Services (PDF) CP.BH.AR.2100 March 1, 2019
Psychological Evaluation of Psych Testing (PDF) CP.BH.AR.900 March 1, 2019
Psychotherapy (PDF) CP.BH.AR.200 March 1, 2019
Pyrimethamine (Daraprim) (PDF) CP.PMN.44 April 1, 2022
Radial Head Implant (PDF) CP.MP.148 July 1, 2022 - NEW
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 April 1, 2022
Ramucirumab (Cyramza) (PDF) CP.PHAR.119  April 1, 2022
Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF) CP.PHAR.186 June 1, 2022 - NEW
Ravulizumab-cwvz (Ultomiris) (PDF) CP.PHAR.415 April 1, 2022
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 November 1, 2021
Repair of Nasal Valve Compromise (PDF) CP.MP.210 July 1, 2022 - NEW
Reslizumab (Cinqair) (PDF) CP.PHAR.223 March 1, 2022
Rifabutin (Mycobutin), Rifabutin, omeprazole, amoxicillin (Talicia) (PDF) CP.PMN.223 March 1, 2022
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 June 1, 2022
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 June 1, 2022
Rimegepant (Nurtec ODT) (PDF) CP.PHAR.490 April 1, 2022
Risdiplam (Evrysdi) (PDF) CP.PHAR.477 March 1, 2022
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 August 1, 2022
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260

Retire by August 1, 2022
Rivaroxaban (Xarelto) (PDF) CP.PMN.247 March 1, 2022
Rolapitant (Varubi) (PDF) CP.PMN.102 December 1, 2021
Romidepsin (Istodax) (PDF) CP.PHAR.314 February 1, 2022
Romiplostim (Nplate®) (PDF) CP.PHAR.179 March 1, 2022
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 March 1, 2022
Ropeginterferon alfa-2b-njft (Besremi)(PDF) CP.PHAR.570 March 1, 2022
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 August 1, 2022
Sacituzumab Govitecan-hziy (Trodelvy) (PDF)

CP.PHAR.475

Retire by August 1, 2022
Sacroiliac Joint Fusion (PDF) CP.MP.126 August 1, 2021
Sacroiliac Joint Interventions (PDF) CP.MP.166 October 1, 2021
Sargramostim (Leukine) (PDF) CP.PHAR.295 December 1, 2021
Satralizumab-mwge (Enspryng) (PDF) CP.PHAR.463 March 1, 2022
Sclerotherapy (PDF) CP.MP.146 Retire by September 1, 2022
Sclerotherapy (PDF) CP.MP.146 September 1, 2021
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 June 1, 2022
Selective Dorsal Rhizotomy (PDF) CP.MP.174 January 1, 2022
Selective Nerve Root Blocks and Transforaminal Epidural (PDF) CP.MP.165 October 1, 2021
Selinexor (Xpovio) (PDF) CP.PHAR.431 March 1, 2022
Selumetinib (Koselugo) (PDF) CP.PHAR.464 March 1, 2022
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 August 1, 2021 
Siltuximab (Sylvant) (PDF)  CP.PHAR.329 March 1, 2022
Skilled Nursing Facility Leveling (PDF) CP.MP.206 April 1, 2022
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 June 1, 2022
Sofosbuvir (Sovaldi) (PDF) CP.PHAR.281 March 1, 2022
Sotrovimab (VIR-7831) (PDF) CP.PHAR.541 Pending FDA Approval
Spinal Cord Stimulation (PDF) CP.MP.117 April 1, 2022
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 March , 2022
Substance Abuse Assessment (PDF) CP.BH.AR.1100 March 1, 2019
SUD (PDF) CP.BH.100 June 1, 2022
Supportive Employment (PDF) CP.BH.AR.2000 March 1, 2019
Supportive Housing (PDF) CP.BH.AR.1400 March 1, 2019
Tafasitamab-cxix (Monjuvi) (PDF) CP.PHAR.508 December 1, 2021
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 December 1, 2021
Talimogene laherparepvec (Imlygic) (PDF) CP.PHAR.542 November 1, 2021
Tandem Transplant (PDF) CP.MP.162 April 1, 2022
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 March 1, 2022
Tavaborole (Kerydin) (PDF) CP.PMN.105 April 1, 2022
Tebentafusp-(Kimmtrak) (PDF) CP.PHAR.575  June 1, 2022
Tedizolid (Sivextro) (PDF) CP.PMN.62 March 1, 2022
Teduglutide (Gattex) (PDF) CP.PHAR.114 April 1, 2022
Temozolomide (Temodar) (PDF) CP.PHAR.77 June 1, 2022
Temsirolimus (Torisel) (PDF) CP.PHAR.324 December 1, 2021
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 March 1, 2022
Teriparatide (Forteo) (PDF) CP.PHAR.188 March 1, 2022
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 June 1, 2022 - NEW
Tezacaftor-Ivacaftor (Symdeko) (PDF) CP.PHAR.377 March 1, 2022
Tezepelumab (Tezspire) (PDF) CP.PHAR.576  June 1, 2022
Thyrotropin alfa (Thyrogen) (PDF) CP.PHAR.95 November 1, 2021
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 May 1, 2022
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF) CP.PHAR.211 March 1, 2022
Tocilizumab (Actemra) (PDF) CP.PHAR.263 December 1, 2021
Topical Immunomodulator (PDF) CP.PMN.107 March 1, 2022
Topotecan (Hycamtin) (PDF) CP.PHAR.64 August 1, 2022
Topotecan (Hycamtin) (PDF)

CP.PHAR.64

Retire by August 1, 2022
Total Artificial Heart (PDF) CP.MP.127 January 1, 2022
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 June 1, 2022
Trabectedin (Yondelis) (PDF) CP.PHAR.204 March 1, 2022
Tralokinumab-ldrm (Adbry) (PDF) CP.PHAR.577  June 1, 2022
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 January 1, 2022
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 June 1, 2022
Treatment Plan (PDF) CP.BH.AR.700 March 1, 2019
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199 March 1, 2022
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 April 1, 2022
Trigger Point Injections for Pain Management (PDF) CP.MP.169 October 1, 2021
Triptorelin pamoate (Trelstar, Triptodur) (PDF) CP.PHAR.175 December 1, 2021
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 January 1, 2022
Ustekinumab (Stelara) (PDF) CP.PHAR.264 February 1, 2022
Vagus Nerve Stimulation for Epilepsy (PDF) CP.MP.12 October 1, 2021
Valganciclovir (Valcyte) (PDF) CP.PCH.06 March 1, 2022
Valoctocogene Roxaparvovec(PDF) CP.PHAR.466 Pending FDA Approval
Valproate (Depacon) (PDF) CP.PHAR.429 November 1, 2021
Valrubicin (Valstar) (PDF) CP.PHAR.439 December 1, 2021
Vandetanib (Caprelsa) (PDF)  CP.PHAR.80 April 1, 2022
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 February 1, 2022
Velaglucerase alfa (VPRIV) (PDF) CP.PHAR.163 December 1, 2021
Vemurafenib (Zelboraf) (PDF) CP.PHAR.91 March 1, 2022
Ventricular Assist Devices (PDF) CP.MP.46 July 1, 2022
Verteporfin (Visudyne) (PDF) CP.PHAR.187 March 1, 2022
Vestronidase Alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 June 1, 2022
Viltolarsen (Viltepso) (PDF) CP.PHAR.484 July 1, 2021
Vincristine Liposome (Marqibo) (PDF) CP.PHAR.315 February 1, 2022
Vorinostat (Zolinza) (PDF) CP.PHAR.83 March 1, 2022
Vosoritide (Voxzogo) (PDF) CP.PHAR.525 March 1, 2022
Wheelchair seating (PDF) CP.MP.99 May 1, 2022
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 March 1, 2022
Ziv-aflibercept (Zaltrap) (PDF) CP.PHAR.325 December 1, 2021
Zika Virus Testing (PDF) CP.MP.111 July 1, 2020
Zoledronic Acid (PDF) CP.PHAR.59 March 1, 2021
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 July 1, 2014
Acupuncture (PDF) CP.MP.92 February 1, 2021
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
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
EpiFix Wound Treatment (PDF) CP.MP.140 November 1, 2017
Fecal Calprotectin Assay (PDF) CP.MP.135 June 17, 2017
Global Maternity Billing (PDF) CC.PP.016 October 18, 2016
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
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 - NEW
Maximum Units (PDF) CC.PP.007 August 12, 2016
Mechanical Stretch Devices (PDF) CP.MP.144 November 1, 2017
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
Monitored Anesthesia Care (PDF) CP.MP.161 December 15, 2018
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 August 1, 2022 - NEW
Paclitaxel (PDF)

CP.PHAR.176

Retire by August 1, 2022
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
Proton and Neutron Beam Therapy (PDF) CP.MP.70 January 1, 2022
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
Sickle Cell Disease Observation (PDF) CP.MP.88 September 11, 2021
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 October 18, 2016
Supportive Living (PDF) ARTC.PP.1000 July 20, 2020
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 August 1, 2022
Testing for Select Genitourinary Conditions (PDF)

CP.MP.97

Retire by August 1, 2022
Thyroid Testing in Pediatrics (PDF) CP.MP.154 December 1, 2021
Transcranial Magnetic Stimulation (PDF)

CP.BH.200

Retire by September 1, 2022
Transcranial Magnetic Stimulation (PDF) CP.BH.200 July 1, 2022
Transgender Related Services (PDF) CC.PP.047 February 22, 2017
Ultrasound in Pregnancy (PDF) CP.MP.38 May 1, 2022
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, 2022
Wheelchair Accessories (PDF) CC.PP.502 August 12, 2016
Wireless Motility Capsule (PDF) CP.MP.143 December 1, 2021
 
Policy Title Policy Number Effective Date
Behavioral Health Covered Benefits and Services (PDF) CC.BH.UM.28 February 15, 2021
Behavioral Health Covered Benefits and Services —Amendment (PDF) CC.BH.UM.28 - Amendment January 1, 2022
Behavioral Health Covered Benefits and Services — Attachment F (PDF) CC.BH.UM.28 Attachment F February 15, 2021
Behavioral Health Covered Benefits and Services — Attachment F - Amendment (PDF) CC.BH.UM.28 Attachment F - Amendment
January 1, 2022