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Next Gen Clinical Policies - ODM Provisional Approval

Medicaid Clinical - ODM

Policy TitlePolicy #Review Date
Air Ambulance (PDF)CP.MP.17522-Aug-22
Bariatric Surgery (PDF)CP.MP.378/30/2022
Biofeedback (PDF)CP.MP.1686-Dec-22
Burn Surgery (PDF)CP.MP.18619-Dec-23
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.16423-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.1420-Aug-22
Cosmetic and Reconstructive Procedures (PDF)CP.MP.314-Nov-22
Dental Anesthesia (PDF)CP.MP.614-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.3623-Aug-22
Fecal Incontinence Treatments (PDF)CP.MP.13722-Aug-22
Fertility preservation (PDF)CP.MP.1304-Oct-22
Gastric Electrical Stimulation (PDF)CP.MP.4023-Aug-22
Gender -Affirming Procedures (PDF)CP.MP.951-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.13622-Aug-22
Hyperhydrosis Treatments (PDF)CP.MP.6230-Aug-22
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.18019-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.1671-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.13930-Aug-22
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.14419-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.4822-Jul-22
Optic nerve decompression surgery (PDF)CP.MP.12828-Jul-22
Orthognathic Surgery (PDF)CP.MP.2024-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.5128-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.1661-Sep-22
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF)CP.MP.14622-Aug-22
Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF)CP.MP.1651-Sep-22
Total Parenteral Nutrition and Intradialytic Parental Nutrition (PDF)CP.MP.1635-May-22
Transcatheter closure of patent foramen ovale (PDF)CP.MP.15119-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.1691-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 TitlePolicy #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.30013-Jan-23
Deep Transcranial Magnetic Stimulation (PDF)CP.BH.20113-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.10013-Jan-23
Transcranial Magnetic Stimulation (PDF)CP.BH.20013-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)

CP.PHAR.553

Belzutifan (Welireg) (PDF)

CP.PHAR.592Beremagene geperpavec-svdt (Vyjuvek)

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.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.583Pacritinib (Vonjo) (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.629Retifanlimab-dlwr (Zynyz) (PDF)

CP.PHAR.233

RimabotulinumtoxinB (Myobloc) (PDF)

CP.PHAR.570Ropeginterferpm Alfa-2b-njft (BESREMi) (PDF)

CP.PHAR.329

Siltuximab (Sylvant) (PDF)

CH.PHAR.606Spesolimab-sbzo (Spevigo) (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)