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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
Abatacept (Orencia) (PDF) CP.PHAR.241 August 1, 2021 - NEW
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 June 1, 2020
Ado-trastuzumab (Kadcyla) (PDF) CP.PHAR.229 June 1, 2021
Adopted Clinical Practice and Preventive Health Guidelines (PDF) N/A June 1, 2020
Adult Rehabilitative Day Service (Psychosocial Rehabilitation Services)(PDF) CP.BH.AR.1800 March 1, 2019
Afamelanotide (Scenesse) (PDF) CP.PHAR.444 June 1, 2020
Aflibercept (Eylea) (PDF) CP.PHAR.184 June 1, 2020
Agalsidase beta (Fabrazyme) (PDF) CP.PHAR.158 August 1, 2021 - NEW
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 June 1, 2020
Alglucosidase (Lumizyme) (PDF) CP.PHAR.160 June 1, 2021
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) CP.MP.108 January 1, 2021
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 June 1, 2020
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 December 1, 2020
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) CP.PHAR.506 December 1, 2020
Apalutamide (Erleada) (PDF) CP.PHAR.376 August 1, 2021 - NEW
Applied Behavioral Analysis for Autism (PDF) CP.BH.104 June 1, 2019
Articular Cartilage Defect Repairs (PDF) CP.MP.26 April 1, 2021
Assistive Reproductive Technology (PDF) CP.MP.55 May 1, 2021
Atezolizumab (Tecentriq) (PDF) CP.PHAR.235 June 1, 2020
Avelumab (Bavencio) (PDF) CP.PHAR.333 June 1, 2020
axicabtagene ciloleucel (Yescarta®) (PDF) CP.PHAR.362 June 1, 2020
Azacitidine (Vidaza) (PDF) CP.PHAR.387 December 1, 2020
Balloon Sinus Ostial Dilation (PDF) CP.MP.119 November 1, 2020
Behavioral Assistance (Therapeutic Behavioral Services) (PDF) CP.BH.AR.1900 March 1, 2019
Belantamab mafodotin (Blenrep) (PDF) CP.PHAR.469 December 1, 2020
Belatacept (Nulojix) (PDF) CP.PHAR.201 December 1, 2020
Belimumab (Benlysta) (PDF) CP.PHAR.88 June 1, 2021
Belinostat (Beleodaq) (PDF) CP.PHAR.311 December 1, 2020
Bendamustine (Bendeka, Treanda) (PDF) CP.PHAR.307 December 1, 2020
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 March 1, 2021
Bimatoprost Implant (Durysta)(PDF) CP.PHAR.486 June 1, 2020
Binimetinib (Mektovi) (PDF) CP.PHAR.50 August 1, 2021 - NEW
Biofeedback (PDF) CP.MP.168 July 1, 2020
Biologic DMARDs (PDF) HIM.PA.SP60 August 1, 2021 - NEW
Bone-Anchored Hearing Aid (PDF) CP.MP.93 October 1, 2020
Bosutinib (Bosulif) (PDF) CP.PHAR.105 August 1, 2021 - NEW
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 September 1, 2020
Brexanolone (Zulresso) (PDF) CP.PHAR.417 June 1, 2020
Brexucabtagene Autoleucel (Tecartus) (PDF) CP.PHAR.472 September 1, 2020
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445  March 1, 2021
C1 Esterase Inhibitors (PDF) CP.PHAR.202 June 1, 2020
cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 August 1, 2021 - NEW
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 June 1, 2021
Canakinumab (Ilaris) (PDF) CP.PHAR.246 August 1, 2021 - NEW
Carfilzomib (Kyprolis) (PDF) CP.PHAR.309 December 1, 2020
Carrier Screening in Pregnancy (PDF) CP.MP.83 July 1, 2020
Casimersen (Amondys 45) (PDF) CP.PHAR.470 June 1, 2021
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 December 10, 2018
Cell-Free Fetal DNA Testing (PDF) CP.MP.84 March 16, 2017
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 June 1, 2021
Certolizumab (Cimzia) (PDF) CP.PHAR.247 August 1, 2021 - NEW
Cetuximab (Erbitux) (PDF) CP.PHAR.317 December 1, 2020
Child and Youth Support Services (PDF) CP.BH.AR.1700 March 1, 2019
Clinical Policy: Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 August 1, 2021 - NEW
Clinical Trials (PDF) CP.MP.94 December 1, 2017
Cochlear Implant Replacements (PDF) CP.MP.14 May 1, 2019
Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) CP.PHAR.505 December 1, 2020
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 September 1, 2020
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 March 1, 2021
Cosyntropin (Cortrosyn) (PDF) CP.PHAR.203 March 1, 2021 
Crisis Intervention (PDF) CP.BH.AR.1500 March 1, 2019

Crizanlizumab-tmca (Adakveo) (PDF)

CP.PHAR.449 June 1, 2020
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 August 1, 2021 - NEW
Daratumumab (Darzalex) (PDF) CP.PHAR.310 March 1, 2021
Darbepoetin alfa (Aranesp) (PDF) CP.PHAR.236 August 1, 2021 - NEW
Daunorubicin-cytarabine (Vyxeos) (PDF) CP.PHAR.352 December 1, 2020
Deferoxamine (Desferal) (PDF) CP.PHAR.146 September 1, 2020
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 June 1, 2020
Dental Anesthesia (PDF) CP.MP.61 May 1, 2021
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 December 1, 2020
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 May 1, 2021
Disc Decompression Procedures (PDF) CP.MP.114 July 1, 2020
Discography (PDF) CP.MP.115 October 19, 2018
Donor lymphocyte infusion (PDF) CP.MP.101 December 1, 2020
Doxycycline (Doryx, Oracea, Acticlate) (PDF) CP.PMN.79 August 1, 2021 - NEW
Drugs of Abuse: Presumptive Testing (PDF) CP.MP.208 July 1, 2021
Dupilumab (Dupixent) (PDF) CP.PHAR.336 June 1, 2020
Durable Medical Equipment (DME) (PDF) CP.MP.107 May 1, 2021
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 August 1, 2021 - NEW
Eculizumab (Soliris) (PDF) CP.PHAR.97 June 1, 2020
Edaravone (Radicava) (PDF) CP.PHAR.343 June 1, 2021
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 August 1, 2021 - NEW
Electric Tumor Treatment Fields (PDF) CP.MP.145 May 1, 2021
Elosulfase alfa (Vimizim) (PDF) CP.PHAR.162 June 1, 2021
Elotuzumab (Empliciti) (PDF) CP.PHAR.308 December 1, 2020
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 June 1, 2020
Eptinezumab-jjmr (Vyepti) (PDF) CP.PHAR.489 March 1, 2021
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 August 1, 2021 - NEW
Eribulin mesylate (Halaven) (PDF) CP.PHAR.318 March 1, 2021
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 June 1, 2020
Esketamine (Spravato) (PDF) CP.PMN.199 August 1, 2021 - NEW
Esomeprazole-Naproxen (Vimovo) (PDF) CP.PMN.117 August 1, 2021 - NEW
Essure Removal (PDF) CP.MP.131 December 1, 2020
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 December 1, 2020
Eteplirsen  (Exondys 51) (PDF) CP.PHAR.288 June 1, 2020
Evinacumab-dgnb (Evkeeza) (PDF) CP.PHAR.511 August 1, 2021 - NEW
Experimental Technologies (PDF) CP.MP.36 March 15, 2017
Facet Joint Interventions (PDF) CP.MP.171 December 10, 2018
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215  October 1, 2020
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) CP.PHAR.216 June 1, 2020
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 December 1, 2020
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 December 1, 2020
Factor XIII A-Subunit, Recombinant (Tretten®) CP.PHAR.222 December 1, 2020
Family Support Partners (PDF) CP.BH.AR.1600 March 1, 2019
Famotidine-Ibuprofen (Duexis) (PDF) CP.PMN.120 August 1, 2021 - NEW
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 June 1, 2020
Fecal incontinence treatments (PDF) CP.MP.137 March 5, 2019
Ferric Derisomaltose (Monoferric)(PDF) CP.PHAR.480 August 1, 2021 - NEW
Ferriscan R2-MRI (PDF) CP.MP.53 December 1, 2020
Fertility Preservation (PDF) CP.MP.130 November 1, 2020
Fetal surgery in utero for prenatally diagnosed malformations (PDF) CP.MP.129 May 1, 2019
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) CP.PHAR.526 June 1, 2021
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) CP.PHAR.297 March 1, 2021
Fixed Wing Air Transportation (PDF) CP.MP.175 February 1, 2021
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 September 1, 2020
Functional MRI (PDF) CP.MP.43 March 15, 2017
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 June 1, 2021
Gastric Electrical Stimulation (PDF) CP.MP.40 March 15, 2017
Gemtuzumab (Mylotarg) (PDF) CP.PHAR.358 December 1, 2020
Gender reassignment surgery (PDF) CP.MP.95 February 1, 2021
Genetic Testing (PDF) CP.MP.89 May 1, 2021
Givosiran (Givlaari) (PDF) CP.PHAR.457 June 1, 2020
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 August 1, 2021 - NEW
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 June 1, 2020
Group Psychotherapy (PDF) CP.BH.AR.600 March 1, 2019
Heart-Lung Transplant (PDF) CP.MP.132 October 19, 2018
Home Birth (PDF) CP.MP.136 February 1, 2021
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 March 1, 2021
Hospice Clinical Coverage (PDF) CP.MP.54 March 15, 2017
Hyaluronate derivatives (PDF) CP.PHAR.05 December 1, 2020
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 July 1, 2021
Hyperhidrosis Treatments (PDF) CP.MP.62 March 1, 2021
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 June 1, 2020
Ibandronate sodium (PDF) CP.PHAR.189 June 1, 2020
Idursulfase (Elaprase) (PDF) CP.PHAR.156 June 1, 2021
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 June 1, 2021
Immune Globulins (PDF) CP.PHAR.103 June 1, 2020
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 January 1, 2021
Implantable Intrathecal Pain Pump (PDF) CP.MP.173 March 1, 2021
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 January 1, 2020
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 June 1, 2020
Individual/Group Pharmacologic Counseling by RN  (Medication Training and Support) (PDF) CP.BH.AR.1200 March 1, 2019
Inebilizumab (PDF) CP.PHAR.458 June 1, 2020
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 August 1, 2021 - NEW
Infusion SOC optimization (PDF) CP.MP.159 October 31, 2019
Inhaled Nitric Oxide (PDF) CP.MP.87 January 1, 2021
Inotuzumab Ozogamicin (Besponsa) (PDF) CP.PHAR.359 October 1, 2020
Intensity Modulated Radiation Therapy (PDF) CP.MP.69 February 1, 2021
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 June 1, 2020
Interpretation of Diagnosis (PDF) CP.BH.AR.800 March 1, 2019
Intestinal & Multivisceral Transplant (PDF) CP.MP.58 July 1, 2020
Intradiscal Steroid Injections (PDF) CP.MP.167 October 1, 2020
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 June 1, 2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 August 1, 2021 - NEW
Irinotecan Liposome (Onivyde) (PDF) CP.PHAR.304 March 1, 2020
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 June 1, 2020
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 June 1, 2021
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 December 1, 2020
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 August 1, 2021 - NEW
Lefamulin (Xenleta)(PDF) CP.PMN.219 March 1, 2021
Lenalidomide (Revlimid) (PDF) CP.PHAR.71 August 1, 2021 - NEW
Letermovir (Prevymis) (PDF) CP.PHAR.367 June 1, 2020
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 March 1, 2021
Levoleucovorin (Fusilev, Khapzory) (PDF) CP.PHAR.151 December 1, 2020
Lisocabtagene maraleucel (Breyanzi) (PDF) CP.PHAR.483 June 1, 2021
Lung Transplantation (PDF) CP.MP.57 July 1, 2020
Lurbinectedin (Zepzelca) (PDF) CP.PHAR.500 December 1, 2020
Lutetium Lu 177 Dotatate (Lutathera) (PDF) CP.PHAR.384 September 1, 2020
Lysis of Epidural Lesions (PDF) CP.MP.116 November 1, 2020
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
Mecasermin (Increlex) (PDF) CP.PHAR.150 December 1, 2020
Mechanical Stretch Devices (PDF) CP.MP.144 October 1, 2020
Medical Necessity Criteria (PDF) CP.MP.68 March 16, 2017
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 June 1, 2020
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 June 1, 2020
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 August 1, 2021 - NEW
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 June 1, 2020
Multi-Family Behavioral Health Counseling (PDF) CP.BH.AR.500 March 1, 2019
Multiple Sleep Latency Testing (PDF) CP.MP.24 October 19, 2018
Nadofaragene Firadenovec (Instiladrin)(PDF) CP.PHAR.461 June 1, 2020
Naltrexone (Vivitrol) (PD) CP.PHAR.96 October 1, 2020
Natalizumab (Tysabri) (PDF) HIM.PA.SP17 June 1, 2021
Natalizumab (Tysabri) (PDF) CP.PHAR.259 December 1, 2020
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 March 16, 2017
Neonatal Sepsis Management Guidelines (PDF) CP.MP.85 March 16, 2017
Netupitant and Palonosetron (Akynzeo) (PDF) CP.PMN.158 September 1, 2020
Nerve Blocks for Pain Management (PDF) CP.MP.170 February 1, 2021
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 July 1, 2020
NICU Discharge Guidelines (PDF) CP.MP.81 June 30, 2020
Nivolumab (Opdivo) (PDF) CP.PHAR.121   June 1, 2020
No Coverage Criteria (PDF) CP.PMN.255 December 1, 2020
Non-Invasive Home Ventilator (PDF) CP.MP.184 December 1, 2020
Nonmyeloablative allogeneic stem cell transplant (PDF) CP.MP.141 April 1, 2021
nusinersen (Spinraza®) (PDF) CP.PHAR.327 June 1, 2020
OB Home Health Programs (PDF) CP.MP.91 May 1, 2021
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 June 1, 2020
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) CP.PHAR.40 September 1, 2020
Ofatumumab (Arzerra, Kesimpta) (PDF) CP.PHAR.306 August 1, 2021 - NEW
Omalizumab (PDF) CP.PHAR.01 June 1, 2021
Omecetaxine (Synribo) (PDF) CP.PHAR.108 August 1, 2021 - NEW
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 August 1, 2021 - NEW
Onasemnogene abeparvovec (Zolgensma) (PDF) CP.PHAR.421 December 1, 2020
Optic Nerve Decompression Surgery (PDF) CP.MP.128 October 11, 2020
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 July 1, 2020
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 July 1, 2021
Oxygen Use and Concentrators (PDF) CP.MP.190 January 1, 2021
Ozanimod(PDF) CP.PHAR.462 June 1, 2020
Pain Management Procedures (PDF) CP.MP.63 March 16, 2017
Palivizumab (Synagis) (PDF) CP.PHAR.16 August 1, 2021 - NEW
Pancreas Transplantation (PDF) CP.MP.102 April 1, 2021
Panitumumab (Vectibix) (PDF) CP.PHAR.321 December 1, 2020
Panniculectomy (PDF) CP.MP.109 August 1, 2021 - NEW
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 September 1, 2020
Pasireotide (Signifor, Signifor LAR) (PDF) CP.PHAR.332 December 1, 2020
Patisiran (Onpattro) (PDF) CP.PHAR.395 December 1, 2020
Peanut Allergen Powder-dnfp (Palforzia)(PDF) CP.PMN.220 June 1, 2020
Pediatric Heart Transplant (PDF) CP.MP.138 May 1, 2021
Pediatric Liver Transplant (PDF) CP.MP.120 March 1, 2021
Peer Support (PDF) CP.BH.AR.1300 March 1, 2019
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 June 1, 2020
Pegaptanib (Macugen) (PDF) CP.PHAR.185 December 1, 2020
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) CP.PHAR.296 July 1, 2021
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 March 1, 2021
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 June 1, 2020
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 June 1, 2020
Percutaneous LAAD Stroke Prevention (PDF) CP.MP.147 July 1, 2020
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 August 1, 2021 - NEW
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) CP.PHAR.501 December 1, 2020
Pharmacologic Management (PDF) CP.BH.AR.1000 March 1, 2019
Phendimetrazine (PDF) HIM.PA.114 August 1, 2021 - NEW
Pitolisant (Wakix) (PDF) CP.PMN.221 August 1, 2021 - NEW
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 September 1, 2020
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 March 15, 2021
Pomalidomide (Pomalyst) (PDF) CP.PHAR.116 August 1, 2021 - NEW
Ponatinib (Iclusig) (PDF) CP.PHAR.112 August 1, 2021 - NEW
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 October 1, 2020
Pralatrexate (Folotyn) (PDF) CP.PHAR.313 December 1, 2020
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
Radial Head Implant (PDF) CP.MP.148 July 1, 2020
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 August 1, 2020
Ramucirumab (Cyramza) (PDF) CP.PHAR.119  December 1, 2020
Ranibizumab (Lucentis) (PDF) CP.PHAR.186 December 1, 2020
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 December 10, 2018
Rifamycin (Aemcolo) (PDF) CP.PMN.196 June 1, 2021
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 August 1, 2021 - NEW
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 June 1, 2020
Risdiplam (Evrysdi) (PDF) CP.PHAR.477 September 1, 2020
Romidepsin (Istodax) (PDF) CP.PHAR.314 December 1, 2020
Romiplostim (Nplate®) (PDF) CP.PHAR.179 December 1, 2020
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 March 1, 2021
Sacroiliac Joint Fusion (PDF) CP.MP.126 April 18, 2017
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 October 1, 2020
Sapropterin (Kuvan) (PDF) CP.PHAR.43 August 1, 2021 - NEW
Sargramostim (Leukine) (PDF) CP.PHAR.295 September 1, 2020
Satralizumab(PDF) CP.PHAR.463 March 1, 2021
Sclerotherapy (PDF) CP.MP.146 October 1, 2020
Sebelipase alfa (Kanuma) (PDF) CP.PHAR.159 June 1, 2021
Selective Dorsal Rhizotomy (PDF) CP.MP.174 May 1, 2021
Selective Nerve Root Blocks and Transforaminal Epidural (PDF) CP.MP.165 October 1, 2020
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 August 1, 2021 - NEW
Siltuximab (Sylvant) (PDF)  CP.PHAR.329 March 1, 2021
Skilled Nursing Facility Leveling (PDF) CP.MP.206 March 1, 2021
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 June 1, 2020
Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (PDF) CP.PMN.42 August 1, 2021 - NEW
Sonidegib (Odomzo) (PDF) CP.PHAR.272 August 1, 2021 - NEW
Sorafenib (Nexavar) (PDF) CP.PHAR.69 August 1, 2021 - NEW
Spinal Cord Stimulation (PDF) CP.MP.117 April 18, 2017
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 March , 2021
Substance Abuse Assessment (PDF) CP.BH.AR.1100 March 1, 2019
Sunitinib (Sutent) (PDF) CP.PHAR.73 August 1, 2021 - NEW
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, 2020
Taliglucerase alfa (Elelyso) (PDF) CP.PHAR.157 June 1, 2021
Tandem Transplant (PDF) CP.MP.162 May 1, 2019
Temozolomide (Temodar) CP.PHAR.77 August 1, 2021 - NEW
Teprotumumab (Tepezza)(PDF) CP.PHAR.465 December 1, 2020
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 December 1, 2020
Therapy Services (PT/OT/ST) (PDF) CP.MP.49 April 1, 2021
Thymus Transplantation (PDF) CP.MP.189 October 1, 2020
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 June 1, 2020
Tocilizumab (Actemra) (PDF) CP.PHAR.263 August 1, 2021 - NEW
Topotecan (Hycamtin) (PDF) CP.PHAR.64 June 1, 2021
Toremifene (Fareston) (PDF) CP.PMN.126 August 1, 2021 - NEW
Total Artificial Heart (PDF) CP.MP.127 January 1, 2021
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 January 1, 2020
Trametinib (Mekinist) (PDF) CP.PHAR.240 August 1, 2021 - NEW
Transcatheter closure of patent foramen ovale (PDF) CP.MP.151 January 1, 2021
Transcranial Magnetic Stimulation(PDF) CP.MP.172 May 1, 2019
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 March 1, 2021
Treatment Plan (PDF) CP.BH.AR.700 March 1, 2019
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) CP.PHAR.199  June 1, 2020
Trigger Point Injections for Pain Management (PDF) CP.MP.169 February 1, 2021
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 May 1, 2021
Ustekinumab (Stelara) (PDF) CP.PHAR.264 August 1, 2021 - NEW
Vagus Nerve Stimulation for Epilepsy (PDF) CP.MP.12 February 1, 2021
Valoctocogene Roxaparvovec(PDF) CP.PHAR.466 June 1, 2020
Valrubicin (Valstar) (PDF) CP.PHAR.439 December 1, 2020
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 August 1, 2021 - NEW
Velaglucerase alfa (VPRIV) (PDF) CP.PHAR.163 June 1, 2021
Ventricular Assist Devices (PDF) CP.MP.46 July 1, 2021
Verteporfin (Visudyne) (PDF) CP.PHAR.187 December 1, 2020
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 June 1, 2021
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 June 1, 2020
Viltolarsen (Viltepso) (PDF) CP.PHAR.484 September 1, 2020
Vismodegib (Erivedge) (PDF) CP.PHAR.273 August 1, 2021 - NEW
Wheelchair seating (PDF) CP.MP.99 October 1, 2018
Ziv-aflibercept (Zaltrap) (PDF) CP.PHAR.325 December 1, 2020
Zika Virus Testing (PDF) CP.MP.111 July 1, 2020
Zoledronic acid (PDF) CP.PHAR.59 June 1, 2020
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
ADHD Assessment and Treatment (PDF) CP.MP.124 May 1, 2021
Allergy Testing (PDF) CP.MP.100 May 1, 2021
Ambulatory EEG (PDF) CP.MP.96 August 12, 2016
Antithrombin III (Thrombate III, Atryn) (PDF) CP.MP.179 December 1, 2020
Assistant Surgeon (PDF) CC.PP.029 February 7, 2017
Bariatric Surgery (PDF) CP.MP.37 March 1, 2021
Bevacizumab (PDF) CP.PHAR.93 February 10, 2017
Bilateral Procedures (PDF) CC.PP.037 February 7, 2017
Bronchial Thermoplasty (PDF) CP.MP.110 April 1, 2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 March 1, 2021
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
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 June 1, 2021
Digital Analysis of EEGs (PDF) CP.MP.105 March 1/2021
Distinct Procedural Modifiers (PDF) CC.PP.020 October 18, 2016
DNA Analysis of Stool (PDF) CP.MP.125 January 1, 2021
Duplicate Primary Code Billing (PDF) CC.PP.044 February 7, 2017
E&M Medical Decision-Making (PDF) CC.PP.051 July 25, 2017
EEG in Evaluation of Headache (PDF) CP.MP.155 December 1, 2020
EM Bundling Edits (PDF) CC.PP.010 August 12, 2016
Endometrial Ablation (PDF) CP.MP.106 December 10, 2018
EpiFix Wound Treatment (PDF) CP.MP.140 November 1, 2017
Evoked Potentials (PDF) CP.MP.134 May 1, 2021
Fecal Calprotectin Assay (PDF) CP.MP.135 June 17, 2017
FeNo Testing (PDF) CP.MP.103 January 1, 2021
Global Maternity Billing (PDF) CC.PP.016 October 18, 2016
H Pylori Testing (PDF) CP.MP.153 December 1, 2020
Holter Monitors (PDF) CP.MP.113 April 1, 2017
Homocysteine Testing (PDF) CP.MP.121 May 1, 2021
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 Skin Treatment (PDF) CP.MP.123 April 1, 2017
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 March 16, 2017
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 February 1, 2021
Maximum Units (PDF) CC.PP.007 August 12, 2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 December 1, 2020
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
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 February 1, 2021
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
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 March 15, 2021
Paclitaxel (PDF) CP.PHAR.176 May 16, 2016
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 June 30, 2020
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
PROM Testing (PDF) CP.MP.149 November 8, 2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 April 1, 2021
Pulse Oximetry (PDF) CC.PP.025 October 18, 2016
Renal Hemodialysis (PDF) CC.PP.067 March 15, 2021
Rituximab (PDF) CP.PHAR.260 February 10, 2017
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 March 16, 2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 October 18, 2016
Supportive Living (PDF) ARTC.PP.1000 July 20, 2020
Thyroid Testing in Pediatrics (PDF) CP.MP.154 December 1, 2020
Transcranial Magnetic Stimulation (PDF) CP.BH.200 February 1, 2021
Transgender Related Services (PDF) CC.PP.047 February 22, 2017
Ultrasound in Pregnancy (PDF) CP.MP.38 February 10, 2017
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 March 1, 2021
Vitamin D Testing in Children (PDF) CP.MP.157 March 1, 2021
Wheelchair Accessories (PDF) CC.PP.502 August 12, 2016
Wireless Motility Capsule (PDF) CP.MP.143 March 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 - Attachment F (PDF) CC.BH.UM.28 Attachment F February 15, 2021