Next Gen Clinical Policies - ODM Provisional Approval

Medicaid Clinical - ODM

Policy Title	Policy #	Review Date
Air Ambulance (PDF)	CP.MP.175	22-Aug-22
Bariatric Surgery (PDF)	CP.MP.37	8/30/2022
Biofeedback (PDF)	CP.MP.168	6-Dec-22
Burn Surgery (PDF)	CP.MP.186	19-Dec-23
Caudal or Interlaminar Epidural Steroid Injections (PDF)	CP.MP.164	23-Aug-22
Cell-free Fetal DNA Testing (PDF) Cell-free Fetal DNA Testing Addendum (PDF)	CP.MP.84 CP.MP.84_Addendum	29-Oct-21
Cochlear Implant Replacements (PDF)	CP.MP.14	20-Aug-22
Cosmetic and Reconstructive Procedures (PDF)	CP.MP.31	4-Nov-22
Dental Anesthesia (PDF)	CP.MP.61	4-Nov-22
Diaphragmatic/Phrenic Nerve Stimulation (PDF) Diaphragmatic/Phrenic Nerve Stimulation Addendum (PDF)	CP.MP.203 CP.MP.203 Addendum	13-Jan-23
Durable Medical Equipment (PDF) Durable Medical Equipment Addendum (PDF)	CP.MP.107 CP.MP.107 Addendum	13-Jan-23
Experimental Technologies (PDF)	CP.MP.36	23-Aug-22
Fecal Incontinence Treatments (PDF)	CP.MP.137	22-Aug-22
Fertility preservation (PDF)	CP.MP.130	4-Oct-22
Gastric Electrical Stimulation (PDF)	CP.MP.40	23-Aug-22
Gender -Affirming Procedures (PDF)	CP.MP.95	1-Sep-22
Genetic Testing General Approach to Genetic Testing (PDF) Genetic Testing General Approach to Genetic Testing Addendum (PDF)	CP.MP.222 CP.MP.222 Addendum	10-Mar-22
Genetic Testing Hematologic Condition (non-cancerous) (PDF) Genetic Testing Hematologic Condition (non-cancerous) Addendum (PDF)	CP.MP.224 CP.MP.224 Addendum	12-Sep-22
Genetic Testing Hereditary Cancer Susceptibility (PDF) Genetic Testing Hereditary Cancer Susceptibility Addendum (PDF)	CP.MP.225 CP.MP.225 Addendum	10-Mar-22
Genetic Testing Pharmacogenetics (PDF) Genetic Testing Pharmacogenetics Addendum (PDF)	CP.MP.232 CP.MP.232 Addendum	10-Mar-22
Genetic Testing Prenatal Diagnosis (PDF) Genetic Testing Prenatal Diagnosis_Addendum (PDF)	CP.MP.235 CP.MP.235 Addendum	10-Mar-22
Home Birth (PDF)	CP.MP.136	22-Aug-22
Hyperhydrosis Treatments (PDF)	CP.MP.62	30-Aug-22
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)	CP.MP.180	19-Dec-22
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)	CP.MP.160 CP.MP.160_Addendum	5-Mar-22
Intradiscal Steroid Injections for Pain Management (PDF)	CP.MP.167	1-Sep-22
Laser Therapy for Skin Conditions (PDF) Laser Therapy for Skin Conditions Addendum (PDF)	CP.MP.123 CP.MP.123 Addendum	22-Aug-22
Low-Frequency ultrasound and noncontact normothermic wound therapy (PDF)	CP.MP.139	30-Aug-22
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)	CP.MP.144	19-Dec-22
Nerve Blocks and Neurolysis for Pain Management (PDF) Nerve Blocks and Neurolysis for Pain Management (PDF)	CP.MP.170 CP.MP.170_Addendum	1-Sep-22
Neuromusclar and Peroneal Nerve Electrical Stimulation (NMES)	CP.MP.48	22-Jul-22
Optic nerve decompression surgery (PDF)	CP.MP.128	28-Jul-22
Orthognathic Surgery (PDF)	CP.MP.202	4-Nov-22
Osteogenic Stimulation (PDF) Osteogenic Stimulation Addendum (PDF)	CP.MP.194 CP.MP.194_Addendum	4-Oct-22
Phototherapy for Neonatal Hyperbilirubinemia (PDF) Phototherapy for Neonatal Hyperbilirubinemia Addendum (PDF)	CP.MP.150 CP.MP.150_Addendum	4-Nov-22
Reduction Mammoplasty and Gynecomastia Surgery (PDF)	CP.MP.51	28-Jul-22
Repair of Nasal Valve Compromise (PDF) Repair of Nasal Valve Compromise Addendum (PDF)	CP.MP.210 CP.MP.210_Addendum	1-Jun-22
Sacroiliac Joint Interventions for Pain Management (PDF)	CP.MP.166	1-Sep-22
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF)	CP.MP.146	22-Aug-22
Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF)	CP.MP.165	1-Sep-22
Total Parenteral Nutrition and Intradialytic Parental Nutrition (PDF)	CP.MP.163	5-May-22
Transcatheter closure of patent foramen ovale (PDF)	CP.MP.151	19-Dec-22
Transplant Authorizations (PDF) Transplant Authorizations Addendum (PDF)	CC.UM.18 CC.UM.18_Addendum	01-30-23
Trigger Point Injections for Pain Management (PDF)	CP.MP.169	1-Sep-22

Concert Genetics Policies
Policy Name	Policy #	Approval Date
Genet aorto conn (PDF)	BU_V2-2023-1	07-01-2023
Genet test Card dis (PDF)	BU_V2.2023-2	07-01-2023
Genet test Derm Cond (PDF)	BU_V2.2023-3	07-01-2023
Genet test Epilepsy Neuro dis (PDF)	BU_V2.2023-4	07-01-2023
Genet test exome genome seq (PDF)	BU_V2.2023-5	07-01-2023
Genet rest Eye Dis (PDF)	BU_V2-2023-6	07-01-2023
Genet test Gastroent non CA (PDF)	BU_V2.2023-7	07-01-2023
Genet test Hearing loss (PDF)	BU_V2-2023-8	07-01-2023
Genet test General app (PDF)	BU_V2-2023-9	07-01-2023
Genet test Hematol Cond non CA (PDF)	BU_V2-2023-10	07-01-2023
Genet test Hereditary CA (PDF)	BU_V2-2023-11	07-01-2023
Genet immune, auto and Rheu Dis (PDF)	BU_V2-2023-12	07-01-2023
Genet test Kidney Dis (PDF)	BU_V2-2023-13	07-01-2023
Genet test Lung Dis (PDF)	BU_V2-2023-14	07-01-2023
Genet Test Metabol Endo Mito Dis (PDF)	BU_V2-2023-15	07-01-2023
Genet test Inherited intel Dev Dis (PDF)	BU_V2-2023-16	07-01-2023
Genet tips NIPS (PDF)	BU_V2-2023-17	07-01-2023
Genet Oncology Algo test (PDF)	BU_V2-2023-18	07-01-2023
Genet Oncology CA Screen (PDF)	BU_V2-2023-19	07-01-2023
Genet Oncology Circ Tumor DNA (PDF)	BU_V2-2023-20	07-01-2023
Genet Oncology Cytogen test (PDF)	BU_V2-2023-21	07-01-2023
Genet test Pharmacogenetic (PDF)	BU_V2-2023-22	07-01-2023
Genet Preimplan Genetic test (PDF)	BU_V2-2023-23	07-01-2023
Genet Prenatal Preconcept Screen (PDF)	BU_V2-2023-24	07-01-2023
Genet Prenatal Pregnancy loss (PDF)	BU_V2-2023-25	07-01-2023
Genet Skeletal Dys Rare Bone Dis (PDF)	BU_V2-2023-26	07-01-2023
Genet Molecular Analysis Tumor(PDF)	BU_V2-2023-27	07-01-2023

BH Clinical - ODM Prov Apprl

Policy Title	Policy #	Reviewed Date
Applied Behavior Analysis (PDF) Applied Behavior Analysis Addendum (PDF)	CP.BH.104 CP.BH.104_Addendum	13-Jan-23
Biofeedback for Behavioral Health Disorders (PDF)	CP.BH.300	13-Jan-23
Deep Transcranial Magnetic Stimulation (PDF)	CP.BH.201	13-Jan-23
Institutions for Mental Disease (IMD) Policy (PDF) Institutions for Mental Disease (IMD) Policy Addendum (PDF)	CC.BH.UM.12 CC.BH.UM.12_ Addendum
Substance Use and Treatment Services (PDF)	CP.BH.100	13-Jan-23
Transcranial Magnetic Stimulation (PDF)	CP.BH.200	13-Jan-23

CP.PHAR.230	AbobotulinumtoxinA (Dysport) (PDF)
CP.PHAR.242	Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz), Adalimumab-aacf (Idacio), Adalimumab-aaty (Yuflyma), Adalimumab-aqvh (PDF)
CP.PHAR.468	Aducanumab-avwa (Aduhelm) (PDF)
CP.PHAR.184	Aflibercept (Eylea) (PDF)
CP.PHAR.158	Agalsidase Beta (Fabrazyme) (PDF)
CP.PHAR.243	Alemtuzumab (Lemtrada) (PDF)
CP.PHAR.160	Alglucosidase Alfa (Lumizyme) (PDF)
CP.PHAR.551	Anifrolumab-fnia (Saphnelo) (PDF)
CP.PHAR.506	Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)
CP.PHAR.362	Axicabtagene ciloleucel (Yescarta) (PDF)
CP.PHAR.88	Belumumab (Benlysta) (PDF)
CH.PHAR.553	Belzutifan (Welireg) (PDF)
CP.PHAR.300	Bezlotoxumab (Zinplava) (PDF)
CP.PHAR.486	Bimatoprost Implant (Durysta) (PDF)
CP.PHAR.417	Brexanolone (Zulresso) (PDF)
CP.PHAR.472	Brexucabtagene autoleucel (Tecartus) (PDF)
CP.PHAR.445	Brolucizumab (Beovu) (PDF)
CP.PHAR.416	Caplacizumab-yhdp (Cablivi) (PDF)
CP.PHAR.470	Casimersen (Amondys 45) (PDF)
CP.PHAR.449	Crizanlizumab-tmca (Adakveo) (PDF)
CP.PHAR.146	Deferoxamine (Desferal) (PDF)
CP.PHAR.58	Denosumab (Prolia, Xgeva) (PDF)
CP.PHAR.336	Dupilumab (Dupixent) (PDF)
CP.PHAR.97	Eculizumab (Soliris) (PDF)
CP.PHAR.343	Edaravone (Radicava, Radivaca ORS) (PDF)
CP.PHAR.555	Efgartigimod Alfa-fcab, Efgartigimod/Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo) (PDF)
CP.PHAR.419	Elapegademase-lvlr (Revcovi) (PDF)
CP.PHAR.489	Eptinezumab-jjmr (Vyepti) (PDF)
CP.PHAR.379	Etelcalcetide (Parsabiv) (PDF)
CP.PHAR.288	Eteplirsen (Exondys 51) (PDF)
CP.PHAR.511	Evinacumab-dgnb (Evkeeza) (PDF)
CP.PHAR 234	Ferric Carboxymaltose (Injectafer) (PDF)
CP.PHAR.453	Golodirsen (Vyondys 53) (PDF)
CP.PHAR.172	Histrelin Acetate (Vantas, Supprelin LA) (PDF)
CP.PHAR.517	Human Growth Hormone (Somapacitan, Somatrogon, Somatropin) (PDF)
CP.PHAR.05	Hyaluronate Derivatives (PDF)
CP.PHAR.189	Ibandronate injection (Boniva) (PDF)
CP.PHAR.481	Idecabtagene Vicleucel (Abecma) (PDF)
CP.PHAR.103	Immune Globulins (PDF)
CP.PHAR.568	Inclisiran (Leqvio) (PDF)
CP.PHAR.231	IncobotulinumtoxinA (Xeomin) (PDF)
CP.PHAR.254	Infliximab, Infliximab-axxq. Inflismab-dyyb, Infiximab-abda (PDF)
CP.PHAR.596	Lecanemab-irmb (Leqembi)(PDF)
CP.PHAR. 367	Letermovir (Prevymis) (PDF)
CP.PHAR.173	Leuprolide Acetate, Leuprolide Mesylate (PDF)
CP.PHAR.483	Lisocabtagene Maraleucel (Breyanzi) (PDF)
CP.PHAR.539	Loncastuximab Tesirine-lpyl (Zynlonta) (PDF)
CP.PHAR.558	Mitapivat (Pyrunkynd) (PDF)
CP.PHAR.258	Mitoxantrone (PDF)
CP.PHAR.559	Mobocertinib (Exkivity) (PDF)
CP.PHAR.259	Natalizumab (Tysabri) (PDF)
CP.PHAR.327	Nusinersen (Spinraza) (PDF)
CP.PHAR.335	Ocrelizumab (Ocrevus) (PDF)
CP.PHAR.528	Odevixibat (Bylvay) (PDF)
CP.PHAR 360	Olaparib (Lynparza) (PDF)
CP.PHAR.232	OnabotulinumtoxinA (Botox) (PDF)
CP.PHAR.536	Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)
CP.PHAR.16	Palivizumab (Synagis) (PDF)
CP.PHAR.332	Pasireotide (Signifor, Signifor LAR) (PDF)
CP.PHAR.395	Patisiran (Onpattro) (PDF)
CP.PHAR.185	Pegaptanib (Macguen) (PDF)
CP.PHAR.115	Pegloticase (Krystexxa) (PDF)
CP.PHAR.186	Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF)
CP.PHAR.415	Ravulizumab-cwvz (Ultomiris) (PDF)
CP.PHAR.223	Resilizumab (Cinqair) (PDF)
CP.PHAR.233	RimabotulinumtoxinB (Myobloc) (PDF)
CP.PHAR.329	Siltuximab (Sylvant) (PDF)
CP.PHAR 409	Talazoparib (Talzenna) (PDF)
CP.PHAR.465	Teprotumumab (Tepezza) (PDF)
CP.PHAR.361	Tisagenlecleucel (Kymriah) (PDF)
CP.PHAR.591	Tofersen (Qalsody) (PDF)
CP.PHAR. 175	Triptorelin Pamoate (Trelstar, Triptodur) (PDF)

CP.PHARM.621	Ublituximab-xiiy (Briumvi (PDF)
CP.PHAR.443	Upadacitinib (Rinvoq) (PDF)
CP.PHAR.265	Vedolizumab (Entyvio) (PDF)
CP.PHAR.187	Verteporfin (Visudyne) (PDF)
CP.PHAR.484	Viltolarsen (Vilteplso) (PDF)
CP.PHAR.372	Voretigene neparvovec-rzyl (Luxturna) (PDF)

Next Gen Clinical Policies - ODM Provisional Approval

Medicaid Clinical Policies

Concert Genetics Policies

Behavioral Health Clinical - ODM Prov Apprl

Pharmacy Clinical Policies - ODM Prov. Approval