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

Pharmacy Clinical Policies

Policy Title	Policy #	Review Date
AbobotulinumtoxinA (Dysport) (PDF)	CP.PHAR.230	May-22
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.242	Aug-23
Aducanumab-avwa (Aduhelm) (PDF)	CP.PHAR.468	May-22
Aflibercept (Eylea) (PDF)	CP.PHAR.184	Feb-23
Agalsidase Beta (Fabrazyme) (PDF)	CP.PHAR.158	May-22
Alemtuzumab (Lemtrada) (PDF)	CP.PHAR.243	May-22
Alglucosidase Alfa (Lumizyme) (PDF)	CP.PHAR.160	May-22
Anifrolumab-fnia (Saphnelo) (PDF)	CP.PHAR.551	Nov-22
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)	CP.PHAR.506	Nov-22
Axicabtagene ciloleucel (Yescarta) (PDF)	CP.PHAR.362	Feb-23
Belumumab (Benlysta) (PDF)	CP.PHAR.88	May-22
Bezlotoxumab (Zinplava) (PDF)	CP.PHAR.300	Feb-23
Bimatoprost Implant (Durysta) (PDF)	CP.PHAR.486	May-22
Brexanolone (Zulresso) (PDF)	CP.PHAR.417	May-22
Brexucabtagene autoleucel (Tecartus) (PDF)	CP.PHAR.472	Feb-23
Brolucizumab (Beovu) (PDF)	CP.PHAR.445	Feb-23
Caplacizumab-yhdp (Cablivi) (PDF)	CP.PHAR.416	Aug-22
Casimersen (Amondys 45) (PDF)	CP.PHAR.470	Feb-23
Crizanlizumab-tmca (Adakveo) (PDF)	CP.PHAR.449	Feb-23
Deferoxamine (Desferal) (PDF)	CP.PHAR.146	Aug-22
Denosumab (Prolia, Xgeva) (PDF)	CP.PHAR.58	Feb-23
Dupilumab (Dupixent) (PDF)	CP.PHAR.336	Feb-23
Eculizumab (Soliris) (PDF)	CP.PHAR.97	Feb-23
Edaravone (Radicava, Radivaca ORS) (PDF)	CP.PHAR.343	May-22
Efgartigimod Alfa-fcab, Efgartigimod/Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo) (PDF)	CP.PHAR.555	Aug-23
Elapegademase-lvlr (Revcovi) (PDF)	CP.PHAR.419	May-22
Eptinezumab-jjmr (Vyepti) (PDF)	CP.PHAR.489	Nov-22
Etelcalcetide (Parsabiv) (PDF)	CP.PHAR.379	Aug-22
Eteplirsen (Exondys 51) (PDF)	CP.PHAR.288	Feb-23
Evinacumab-dgnb (Evkeeza) (PDF)	CP.PHAR.511	Feb-23
Ferric Carboxymaltose (Injectafer) (PDF)	CP.PHAR 234	Aug-23
Golodirsen (Vyondys 53) (PDF)	CP.PHAR.453	Feb-23
Histrelin Acetate (Vantas, Supprelin LA) (PDF)	CP.PHAR.172	Nov-22
Human Growth Hormone (Somapacitan, Somatrogon, Somatropin) (PDF)	CP.PHAR.517	Aug-23
Hyaluronate Derivatives (PDF)	CP.PHAR.05	Nov-22
Ibandronate injection (Boniva) (PDF)	CP.PHAR.189	Feb-23
Idecabtagene Vicleucel (Abecma) (PDF)	CP.PHAR.481	May-22
Immune Globulins (PDF)	CP.PHAR.103	Aug-23
IncobotulinumtoxinA (Xeomin) (PDF)	CP.PHAR.231	May-22
Infliximab, Infliximab-axxq. Inflismab-dyyb, Infiximab-abda (PDF)	CP.PHAR.254	May-22
Letermovir (Prevymis) (PDF)	CP.PHAR. 367	Aug-23
Leuprolide Acetate, Leuprolide Mesylate (PDF)	CP.PHAR.173	Nov-22
Lisocabtagene Maraleucel (Breyanzi) (PDF)	CP.PHAR.483	Nov-22
Loncastuximab Tesirine-lpyl (Zynlonta) (PDF)	CP.PHAR.539	Aug-22
Mitoxantrone (PDF)	CP.PHAR.258	May-22
Natalizumab (Tysabri) (PDF)	CP.PHAR.259	May-22
Nusinersen (Spinraza) (PDF)	CP.PHAR.327	Feb-23
Ocrelizumab (Ocrevus) (PDF)	CP.PHAR.335	May-22
Odevixibat (Bylvay) (PDF)	CP.PHAR.528	Aug-23
Olaparib (Lynparza) (PDF)	CP.PHAR 360	Aug-23
OnabotulinumtoxinA (Botox) (PDF)	CP.PHAR.232	May-22
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)	CP.PHAR.536	May-22
Palivizumab (Synagis) (PDF)	CP.PHAR.16	May-22
Pasireotide (Signifor, Signifor LAR) (PDF)	CP.PHAR.332	Nov-22
Patisiran (Onpattro) (PDF)	CP.PHAR.395	Nov-22
Pegaptanib (Macguen) (PDF)	CP.PHAR.185	Feb-22
Pegloticase (Krystexxa) (PDF)	CP.PHAR.115	Feb-23
Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF)	CP.PHAR.186	Feb-23
Ravulizumab-cwvz (Ultomiris) (PDF)	CP.PHAR.415	Feb-23
Resilizumab (Cinqair) (PDF)	CP.PHAR.223	Feb-23
RimabotulinumtoxinB (Myobloc) (PDF)	CP.PHAR.233	May-22
Siltuximab (Sylvant) (PDF)	CP.PHAR.329	Feb-23
Talazoparib (Talzenna) (PDF)	CP.PHAR 409	Aug-23
Teprotumumab (Tepezza) (PDF)	CP.PHAR.465	Feb-23
Tisagenlecleucel (Kymriah) (PDF)	CP.PHAR.361	Feb-23
Triptorelin Pamoate (Trelstar, Triptodur) (PDF)	CP.PHAR. 175	Nov-22
Upadacitinib (Rinvoq) (PDF)	CP.PHAR.443	Aug-23
Vedolizumab (Entyvio) (PDF)	CP.PHAR.265	May-22
Verteporfin (Visudyne) (PDF)	CP.PHAR.187	Feb-23
Viltolarsen (Vilteplso) (PDF)	CP.PHAR.484	Feb-23
Voretigene neparvovec-rzyl (Luxturna) (PDF)	CP.PHAR.372	Feb-23

Next Gen Clinical Policies - ODM Provisional Approval

Medicaid Clinical Policies

Concert Genetics Policies

Behavioral Health Clinical - ODM Prov Apprl

Pharmacy Clinical Policies - ODM Prov. Appr.