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 Health & Wellness Clinical Policy Manual apply to Arkansas Health & Wellness members. Policies in the Arkansas Health & Wellness Clinical Policy Manual may have either a Arkansas Health & Wellness or a “Centene” heading.  Arkansas Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Arkansas Health & Wellness 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 Health & Wellness. In addition, Arkansas Health & Wellness 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 Health & Wellness. 

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 Health & Wellness Payment Policy Manual apply with respect to Arkansas Health & Wellness members. Policies in the Arkansas Health & Wellness Payment Policy Manual may have either a Arkansas Health & Wellness or a “Centene” heading.  In addition, Arkansas Health & Wellness 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 Health & Wellness. 

 

Ambetter Policies

Policy Title Policy Number Effective Date
Acupuncture (PDF) AR.MP.92 03/17/17
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) AR.MP.108 04/17/17
Ambulatory Surgery Center Optimization (PDF) AR.MP.158 04/16/18
Applied Behavioral Analysis for Autism (PDF) AR.MP.104 03/15/17
Articular Cartilage Defect Repairs (PDF) AR.MP.26 09/08/17
Assistive Reproductive Technology (PDF) AR.MP.55 09/08/17
Balloon Sinus Ostial Dilation (PDF) AR.MP.119 04/18/17
Biofeedback (PDF) AR.MP.168 11/07/17
Bone-Anchored Hearing Aid (PDF) AR.MP.93 12/01/17
Carrier Screening in Pregnancy (PDF) AR.MP.83 11/07/17
Cell-Free Fetal DNA Testing (PDF) AR.MP.84 03/16/17
Clinical Policy Committee (PDF) AR.CPC.01 04/17/17
Clinical Policy Web Posting (PDF) AR.CPC.02 04/17/17
Clinical Trials (PDF) AR.MP.94 12/01/17
Cochlear Implant Replacements (PDF) AR.MP.14 03/15/17
Cosmetic Reconstructive Surgery (PDF) AR.MP.31 03/15/17
Dental Anesthesia (PDF) AR.MP.61 03/15/17
Disc Decompression Procedures (PDF) AR.MP.114 04/17/17
Discography (PDF) AR.MP.115 04/18/17
Durable Medical Equipment (DME) (PDF) AR.MP.107
03/15/17
Electric Tumor Treatment Fields (PDF) AR.MP.145 09/08/17
Essure Removal (PDF) AR.MP.131
04/18/17
Experimental Policy (PDF) AR.MP.36
03/15/17
Fecal Incontinence Treatments (PDF) AR.MP.137
04/18/17
Ferriscan R2-MRI (PDF) AR.MP.53
03/15/17
Fetal Surgery in Utero (PDF) AR.MP.129
04/18/17
Flu and Strep Testing (PDF) AR.MP.112
04/17/17
Functional MRI (PDF) AR.MP.43
03/15/17
Gastric Electrical Stimulation (PDF) AR.MP.40
03/15/17
Gender Reassignment Surgery (PDF) AR.MP.95
04/17/17
Genetic Testing (PDF) AR.MP.89
03/16/17
Home Birth (PDF) AR.MP.216
04/18/17
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) AR.MP.150
12/31/17
Hospice Clinical Coverage (PDF) AR.MP.54
03/15/17
Hyperbaric Oxygen Therapy (PDF) AR.MP.27
03/15/17
Hyperemesis Gravidarum Treatment (PDF) AR.MP.34
03/15/17
Hyperhidrosis Treatments (PDF) AR.MP.62
09/08/17
Inhaled Nitric Oxide (PDF) AR.MP.87
03/16/17
Injections for Pain Management (PDF) AR.MP.118
04/18/17
Intensity-Modulated Radiotherapy (PDF) AR.MP.69
03/16/17
Intestinal & Multivisceral Transplant (PDF) AR.MP.58
03/15/17
Long Term Care Placement Criteria (PDF) AR.MP.71
03/16/17
Lung Transplantation (PDF) AR.MP.57
03/15/17
Lysis of Epidural Lesions (PDF) AR.MP.116
04/18/17
Medical Necessity Criteria (PDF) AR.MP.68
03/16/17
Multiple Sleep Latency Testing (PDF) AR.MP.24
06/13/17
Neonatal Abstinence Syndrome Guidelines (PDF) AR.MP.86
03/16/17
Neonatal Sepsis Management Guidelines (PDF) AR.MP.85
03/16/17
NICU Apnea Bradycardia Guidelines (PDF) AR.MP.82
03/16/17
NICU Discharge Guidelines (PDF) AR.MP.81
03/16/17
Nonmyeloablative allogeneic stem cell transplant (PDF) AR.MP.141
09/08/17
OB Home Health Programs (PDF) AR.MP.91
03/17/17
Optic Nerve Decompression Surgery (PDF) AR.MP.128
04/18/17
Outpatient Testing for Drugs of Abuse (PDF) AR.MP.50
03/15/17
Pain Management Procedures (PDF) AR.MP.63
03/16/17
Pancreas Transplantation (PDF) AR.MP.102
04/17/17
Panniculectomy (PDF) AR.MP.109
04/17/17
Pediatric Heart Transplant (PDF) AR.MP.138
04/18/17
Percutaneous LAA Device for Stroke Prevention (PDF) AR.MP.147
11/07/17
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) AR.MP.133
04/18/17
Radial Head Implant (PDF) AR.MP.148
12/08/17
Reduction Mammaplasty (PDF) AR.MP.51
03/15/17
Sacroiliac Joint Fusion (PDF) AR.MP.126
04/18/17
Sickle Cell Disease Observation (PDF) AR.MP.88
03/16/17
Spinal Cord Stimulation (PDF) AR.MP.117
04/18/17
Stereotactic Body Radiation Therapy (PDF) AR.MP.22
01/17/18
Therapy Services (PTOTST) (PDF) AR.MP.49
04/17/17
Transcatheter Closure of Patent Foramen Ovale (PDF) AR.MP.151 12/31/17

Urinary Incontinence Devices and Treatments (PDF) AR.MP.142
09/08/17
Vagus Nerve Stimulation for Epilepsy (PDF) AR.MP.12
03/15/17
Ventricular Assist Devices (PDF) AR.MP.46
09/08/17
Ventriculectomy and Cardiomyoplasty (PDF) AR.MP.56
04/17/17
Zika Virus Testing (PDF) AR.MP.111
04/17/17
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 7/1/2014
Add on Code Billed Without Primary Code (PDF) CC.PP.030 10/18/2016
ADHD Assessment and Treatment (PDF) CP.MP.124 4/1/2017
Allergy Testing (PDF) CP.MP.100 8/12/2016
Ambulatory EEG (PDF) CP.MP.96 8/12/2016
Assistant Surgeon (PDF) CC.PP.029 2/7/2017
Bevacizumab (PDF) CP.PHAR.93 2/10/2017
Bilateral Procedures (PDF) CC.PP.037 2/7/2017
Bronchial Thermoplasty (PDF) CP.MP.110 4/1/2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 5/21/2018
Cerumen Removal (PDF) CC.PP.008 8/12/2016
Clean Claims (PDF) CC.PP.021 10/18/2016
CLIA Number (PDF) CC.PP.022 10/18/2016
Coding Overview (PDF) CC.PP.011 10/18/2016
Cosmetic Procedures (PDF) CC.PP.024 10/18/2016
Diagnosis of Vaginitis (PDF) CP.MP.97 4/1/2017
Digital Analysis of EEGs (PDF) CP.MP.105 2/10/2017
Distinct Procedural Modifiers (PDF) CC.PP.020 10/18/2016
DNA Analysis of Stool (PDF) CP.MP.125 6/17/2017
Duplicate Primary Code Billing (PDF) CC.PP.044 2/7/2017
E&M Medical Decision-Making (PDF) CC.PP.051 7/25/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 5/21/2018
EM Bundling Edits (PDF) CC.PP.010 8/12/2016
Endometrial Ablation (EA) (PDF) CP.MP.106 2/10/2017
EpiFix Wound Treatment (PDF) CP.MP.140 11/1/2017
Evoked Potentials (PDF) CP.MP.134 6/17/2017
Fecal Calprotectin Assay (PDF) CP.MP.135 6/17/2017
FeNo Testing (PDF) CP.MP.103 4/1/2017
Global Maternity Billing (PDF) CC.PP.016 10/18/2016
H Pylori Testing (PDF) CP.MP.153 5/21/2018
Holter Monitors (PDF) CP.MP.113 4/1/2017
Homocysteine Testing (PDF) CP.MP.121 4/1/2017
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 10/18/2016
Inpatient Consultation (PDF) CC.PP.038 2/7/2017
Inpatient Only Procedures (PDF) MP.PP.018 10/18/2016
IV Hydration (PDF) CC.PP.012 10/18/2016
Laser Skin Treatment (PDF) CP.MP.123 4/1/2017
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 11/1/2017
Maximum Units (PDF) CC.PP.007 8/12/2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 5/21/2018
Mechanical Stretch Devices (PDF) CP.MP.144 11/1/2017
Moderate Conscious Sedation (PDF) CC.PP.015 10/18/2016
Modifier -25 clinical validation (PDF) CC.PP.013 10/18/2016
Modifier -59 clinical validation (PDF) CC.PP.014 10/18/2016
Modifier DOS Validation (PDF) CC.PP.034 10/18/2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 10/18/2016
Multiple CPT Code Replacement (PDF) CC.PP.033 10/18/2016
NCCI Unbundling (PDF) CC.PP.031 10/18/2016
Never Paid Events (PDF) CC.PP.017 10/18/2016
New Patient (PDF) CC.PP.036 2/7/2017
Outpatient Consultation (PDF) CC.PP.039 2/7/2017
Paclitaxel (PDF) CP.PHAR.176 5/16/2016
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 10/18/2016
Post-Operative Visits (PDF) CC.PP.042 2/7/2017
Pre-Operative Visits (PDF) CC.PP.041 2/7/2017
Professional Component (PDF) CC.PP.027 10/18/2016
PROM Testing (PDF) CP.MP.149 11/8/2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 2/10/2017
Pulse Oximetry (PDF) CC.PP.025 10/18/2016
Rituximab (PDF) CP.PHAR.260 2/10/2017
Robotic Surgery (PDF) CC.PP.050 11/1/2017
Same Day Visits (PDF) CC.PP.040 2/7/2017
Status "B" Bundled Services (PDF) CC.PP.046 2/7/2017
Status P Bundled Services (PDF) CC.PP.049 6/17/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 10/18/2016
Thyroid Testing in Pediatrics (PDF) CP.MP.154 5/21/2018
Transgender Related Services (PDF) CC.PP.047 2/22/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 2/10/2017
Unbundled Professional Services (PDF) CC.PP.043 4/6/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 4/6/2017
Unlisted Procedure Codes (PDF) CC.PP.009 8/12/2016
Urine Specimen Validity Testing (PDF) CC.PP.056 11/8/2017
Urodynamic Testing (PDF) CP.MP.98 8/12/2016
Vitamin D Testing in Children (PDF) CP.MP.157 5/21/2018
Wheelchair Accessories (PDF) CC.PP.502 8/12/2016
Wheelchair Seating (PDF) CP.MP.99 8/12/2016
Wireless Motility Capsule (PDF) CP.MP.143 11/1/2017
Policy Title Policy Number Effective Date
Abaloparatide (Tymlos) (PDF) AR.PHAR.345
11/07/17
Abatacept (Orencia) (PDF) AR.PHAR.241
12/08/17
AbobotulinumtoxinA (Dysport) (PDF) AR.PHAR.230
11/07/17
Acne treatment options except isotretinoin (PDF) HIM.PA.71
03/01/16
Adalimumab (Humira) (PDF) AR.PHAR.242
12/08/17
Aflibercept (Eylea) (PDF) AR.PHAR.184
07/01/16
Alemtuzumab (Lemtrada) (PDF) AR.PHAR.243
12/08/17
Alpha-1 Proteinase Inhibitors (PDF) AR.PHAR.94
07/24/15
Ambrisentan (PDF) AR.PHAR.190
07/01/16
Anakinra (Kineret) (PDF) AR.PHAR.244
12/08/17
Anzemet (PDF) HIM.PA.85
03/01/16
Apremilast (Otezla) (PDF) AR.PHAR.245
12/08/17
aprepitant (Emend) (PDF) HIM.PA.62
03/01/16
Atezolizumab (Tecentriq) (PDF) AR.PHAR.235
09/08/17
atomoxetine (Strattera) PDF) HIM.PA.66
03/01/16
Atypical antipsychotics (PDF) HIM.PA.59
03/01/16
Avelumab (Bavencio) (PDF) AR.PHAR.333
09/08/17
Axitinib (Inlyta) (PDF) AR.PHAR.100
09/08/17
Aztreonam (Cayston) (PDF) AR.PHAR.209
09/08/17
Benlysta (belimumab) (PDF) AR.PHAR.88
07/24/15
Bexarotene (Targretin) Capsules (PDF) AR.PHAR.75 11/07/17

Bosentan (PDF) AR.PHAR.191 07/01/16

Bosulif (PDF) AR.PHAR.105 03/01/16

Brand Name Override and Non-formulary Medication Policy (PDF) HIM.PA.103
03/01/16
Brigatinib (Alunbrig) (PDF) AR.PHAR.342
11/07/17
Butorphanol Nasal Spray (PDF) HIM.PA.46
03/01/16
C1 Esterase Inhibitors (PDF) AR.PHAR.202
07/01/16
Cabozantinib (Cometriq, Cabometyx) (PDF) AR.PHAR.111
09/08/17
Capecitabine (Xeloda) (PDF) AR.PHAR.60
11/07/17
Caprelsa (vandetanib) (PDF) AR.PHAR.80
07/24/15
Carglumic acid (Carbaglu) (PDF) AR.PHAR.206
09/08/17
Cerliponase alfa (Brineura) (PDF) AR.PHAR.338
11/07/17
Certolizumab (Cimzia) (PDF) AR.PHAR.247
12/08/17
Cinacalcet (Sensipar (PDF) AR.PHAR.61
09/08/17
Cosyntropin (Cortrosyn) (PDF) AR.PHAR.203
09/08/17
Crizotinib (PDF) AR.PHAR.90
12/08/17
Dabrafenib (Tafinlar) (PDF) AR.PHAR.239
11/07/17
Daclatasvir (Daklinza) (PDF) AR.PHAR.274
12/08/17
Daclizumab (Zinbryta) (PDF) AR.PHAR.269
12/08/17
Dalfampridine (Ampyra) (PDF) AR.PHAR.248
12/08/17
Dalteparin (Fragmin) (PDF) AR.PHAR.225
0908/17
Darbopoetin Alfa (PDF) AR.PHAR.236
10/30/16
Dasabuvir Ombitasvir Paritaprevir Ritonavir (PDF) AR.PHAR.278
12/08/17
Dasatinib (Sprycel) (PDF) AR.PHAR.72
11/07/17
Denosumab (PDF) AR.PHAR.58
12/08/17
Desferal (deferoxamine) (PDF) AR.PHAR.146
03/01/16
Desmopressin Acetate (DDAVP Injection) (PDF) AR.PHAR.214
09/08/17
Deutetrabenazine (Austedo) (PDF) AR.PHAR.341
11/07/17
Dimethyl Fumarate (Tecfidera) (PDF) AR.PHAR.249
12/08/17
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) HIM.PA.58
03/01/16
Dornase Alfa (Pulmozyme) (PDF) AR.PHAR.212
09/08/17
Dupilumab (Dupixent) (PDF) AR.PHAR.336
09/08/17
Durvalumab (Imfinzi) (PDF) AR.PHAR.339
11/07/17
Ecallantide (Kalbitor) (PDF) AR.PHAR.177
07/01/16
Eculizumab (Soliris) (PDF) AR.PHAR.97
09/08/17
Edaravone (Radicava) (PDF) AR.PHAR.343
11/07/17
Egrifta (PDF) AR.PHAR.109
04/01/16
Elbasvir Grazoprevir (PDF) AR.PHAR.275
12/08/17
Eltrombopag (Promacta) (PDF) AR.PHAR.180
07/01/16
Enfuvirtide (PDF) AR.PHAR.41
07/24/15
Enoxaparin (Lovenox) (PDF) AR.PHAR.224
09/08/17
Epoetin alfa (PDF) AR.PHAR.237
07/01/16
Epoprostenol (PDF) AR.PHAR.192
07/01/16
Etanercept (Enbrel) (PDF) AR.PHAR.250
12/08/17
Everolimus (Afinitor, Afinitor Disperz) (PDF) AR.PHAR.63
09/08/17
Exjade (deferasirox) (PDF) AR.PHAR.145
03/01/16
ezogabine (Potiga) (PDF) HIM.PA.60
03/01/16
Factor VIII (Human, Recombinant) (PDF) AR.PHAR.215
09/08/17
Factor VIII von Willebrand Factor Complex (PDF) AR.PHAR.216
09/08/17
famciclovir (Famvir) (PDF) HIM.PA.63
03/01/16
Ferriprox (deferiprone) (PDF) AR.PHAR.147
03/01/16
Fingolimod (Gilenya) (PDF) AR.PHAR.251
12/08/17
Fondaparinux (Arixtra) (PDF) AR.PHAR.226
09/08/17
Glatiramer (Copaxone, GlatopaTM) (PDF) AR.PHAR.252
12/08/17
Glecaprevir Pibrentasvir (Mavyret) (PDF) AR.PHAR.348
12/08/17
Global Biopharm Policy (PDF) AR.PHAR.57
12/08/17
Golimumab (SimponiSimponi Aria) (PDF) AR.PHAR.253
11/07/17
guanfacine ER (INTUNIV) (PDF) HIM.PA.98
03/01/16
HIV Medications (PDF) HIM.PA.78
03/01/16
Hyaluronate derivatives (PDF) AR.PHAR.05
12/08/17
Hydroxyprogesterone Caproate (Makena) (PDF) AR.PHAR.14
03/01/16
Ibandronate sodium (PDF) AR.PHAR.189
07/01/16
Icatibant (PDF) AR.PHAR.178
07/01/16
Iloprost (PDF) AR.PHAR.193
07/01/16
Imatinib (Gleevec) (PDF) AR.PHAR.65
11/07/17
Immune Globulin Injections (PDF) AR.PHAR.103
03/01/16
Immunization Coverage (PDF) AR.PHAR.28
07/24/15
IncobotulinumtoxinA (Xeomin) (PDF) AR.PHAR.231
11/07/17
Infliximab (PDF) AR.PHAR.254
11/07/17
Inhaled Corticosteroids (PDF) HIM.PA.73
03/01/16
Inhaled Long Acting Beta Agonists and Combination Products (PDF) HIM.PA.74
03/01/16
Interferon beta-1a (Avonex, Rebif) (PDF) AR.PHAR.255

12/08/17
Interferon beta-1b (Betaseron, Extavia) (PDF) AR.PHAR.256
12/08/17
Interferon Gamma 1-b b (Actimmune) (PDF) AR.PHAR.52
09/08/17
isotretinoin (Claravis, Sotret, Amnesteem, Myorisan) (PDF) HIM.PA.50
03/01/16
Ivacaftor (Kalydeco) (PDF) AR.PHAR.210
09/08/17
Ixekizumab (Taltz) (PDF) AR.PHAR.257
12/08/17
lacosamide (Vimpat) (PDF) HIM.PA.49
03/01/16
LedipasvirSofosbuvir (Harvoni) (PDF) AR.PHAR.279
09/08/17
Lenalidomide (PDF) AR.PHAR.71
10/30/16
Long Acting Injectable Atypical Antipsychotics (PDF) HIM.PA.99
03/01/16
lubiprostone (Amitiza) (PDF) HIM.PA.79
03/01/16
Lumacaftor-Ivacaftor (Orkambi) (PDF) AR.PHAR.213
09/08/17
Macitentan (PDF) AR.PHAR.194
07/01/16
Mepolizumab (Nucala) (PDF) AR.PHAR.200
09/08/17
Midostaurin (Rydapt) (PDF) AR.PHAR.344
11/07/17
Mifepristone (Korlym) (PDF) AR.PHAR.101
09/08/17
Mitoxantrone (PDF) AR.PHAR.258
12/08/17
Naltrexone (Vivitrol) (PDF) AR.PHAR.96
07/01/16
nasal steroids (PDF) HIM.PA.93
03/01/16
Natalizumab (Tysabri) (PDF) AR.PHAR.259
11/07/17
Nilotinib (Tasigna) (PDF) AR.PHAR.76
11/07/17
Nivolumab (Opdivo) (PDF) AR.PHAR.121
09/08/17
Non-formulary and formulary contraceptives (PDF) HIM.PA.100
07/25/15
Nucynta (PDF) HIM.PA.86
03/01/16
Ocrelizumab (Ocrevus) (PDF) AR.PHAR.335
09/08/17
Ocreotide acetate (PDF) AR.PHAR.40
07/24/15
Omalizumab (Xolair) (PDF) AR.PHAR.01
11/07/17
Ombitasvir Paritaprevir Ritonavir (PDF) AR.PHAR.276
12/08/17
OnabotulinumtoxinA (Botox) (PDF) AR.PHAR.232
11/07/17
Opioid Analgesics (PDF) HIM.PA.139
01/01/18
Overactive Bladder Agents (PDF) HIM.PA.40
03/01/16
Palivizumab (Synagis ) (PDF) AR.PHAR.16
12/08/17
Paricalcitol (Generic and Zemplar) (PDF) AR.PHAR.270
12/08/17
Pegaptanib (Macugen) (PDF) AR.PHAR.185
07/01/16
Peginterferon beta-1a (Plegridy) (PDF) AR.PHAR.271
12/08/17
Pegloticase (Krystexxa) (PDF) AR.PHAR.115
06/01/13
Pertuzumab (PDF) AR.PHAR.227
10/30/16
Pomalyst (PDF) AR.PHAR.116
04/01/16
Ponatinib (PDF) AR.PHAR.112
10/30/16
Praluent (PDF) AR.PHAR.124
03/01/16
Provenge (PDF) AR.PHAR.120
04/01/16
Ramucirumab (Cyramza) (PDF) AR.PHAR.119
09/08/17
Ranibizumab (Lucentis) (PDF) AR.PHAR.186
07/01/16
rasagiline (Azilect) (PDF) HIM.PA.89
03/01/16
Repatha (PDF) AR.PHAR.123
03/01/16
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) AR.PHAR.168
09/08/17
Reslizumab (Cinqair) (PDF) AR.PHAR.223 09/08/17

Ribociclib (Kisqali) (PDF) AR.PHAR.334
09/08/17
rifaximin (Xifaxan) (PDF) HIM.PA.68
03/01/16
Rilonacept (Arcalyst) (PDF) AR.PHAR.266 11/07/17

RimabotulinumtoxinB (Myobloc) (PDF) AR.PHAR.233
11/07/17
Riociguat (PDF) AR.PHAR.195
07/01/16
Risperidone (PDF) HIM.PA.81
03/01/16
romiplostim (Nplate) (PDF) AR.PHAR.179
07/01/16
rufinamide (Banzel) (PDF) HIM.PA.90
03/01/16
Ruxolitinib (Jakafi) (PDF) AR.PHAR.98
09/08/17
Sapropterin (Kuvan) (PDF) AR.PHAR.43
09/08/17
Secukinumab (Cosentyx) (PDF) AR.PHAR.261
12/08/17
Selexipag (PDF) AR.PHAR.196
07/01/16
Sildenafil (PDF) AR.PHAR.197
07/01/16
Simeprevir (Olysio) (PDF) AR.PHAR.280
12/08/17
sodium oxybate (Xyrem) (PDF) HIM.PA.69
03/01/16
Sofosbuvir & Velpatasvir (Epclusa) (PDF) AR.PHAR.268
12/08/17
Sofosbuvir (Sovaldi) (PDF) AR.PHAR.281
09/08/17
Sofosbuvir Velpatasvir Voxilaprevir (Vosevi) (PDF) AR.PHAR.347
12/08/17
Somatropin (Recombinant Human Growth Hormone) (PDF) AR.PHAR.55
11/07/17
Sonidegib (Odomzo) (PDF) AR.PHAR.272
12/08/17
Sorafenib (PDF) AR.PHAR.69
10/30/16
Stivarga (regorafenib) (PDF) AR.PHAR.107
03/01/16
Sunitinib (PDF) AR.PHAR.73
12/08/17
Sylatron (peginterferon alfa-2b) (PDF) AR.PHAR.89
07/24/15
Synribo (omacetaxine mepesuccinate) (PDF) AR.PHAR.108
04/01/16
Tadalafil (PDF) AR.PHAR.198
07/01/16
Tarceva (PDF) AR.PHAR.74
07/24/15
Teduglutide (Gattex) (PDF) AR.PHAR.114
09/08/17
telbivudine (Tyzeka) (PDF) HIM.PA.95
03/01/16
Temozolomide (PDF) AR.PHAR.77
12/08/17
Teriflunomide (Aubagio) (PDF) AR.PHAR.262
12/08/17
Teriparatide (PDF) AR.PHAR.188
07/01/16
Thalidomide (PDF) AR.PHAR.78
10/30/16
Thyrogen (PDF) AR.PHAR.95
07/24/15
Tobramycin (PDF) AR.PHAR.211
09/08/17
Tocilizumab (Actemra) (PDF) AR.PHAR.263
11/07/17
Tofacitinib (XeljanzXeljanz XR) (PDF) AR.PHAR.267
11/07/17
Topical Immunomodulators (PDF) HIM.PA.56
03/01/16
Topical Testosterone (PDF) HIM.PA.87
03/01/16
Topotecan (PDF) AR.PHAR.64
10/30/16
Trabectedin (Yondelis) (PDF) AR.PHAR.204
09/08/17
Trametinib (Mekinist) (PDF) AR.PHAR.240
11/07/17
Treprostinil (PDF) AR.PHAR.199
07/01/16
Tykerb (lapatinib) (PDF) AR.PHAR.79
07/24/15
Ustekinumab (Stelara) (PDF) AR.PHAR.264
12/08/17
Valbenazine (Ingrezza) (PDF) AR.PHAR.340
11/07/17
Vedolizumab (Entyvio) (PDF) AR.PHAR.265
11/07/17
Verteporfin (PDF) AR.PHAR.187
07/01/16
Vismodegib (Erivedge) (PDF) AR.PHAR.273
12/08/17
Votrient (pazopanib) (PDF) AR.PHAR.81
07/24/15
Xenazine (tetrabenazine) (PDF) AR.PHAR.92
07/24/15
Xiaflex (PDF) AR.PHAR.82
07/24/15
Xtandi (enzalutamide) (PDF) AR.PHAR.106
03/01/16
Zelboraf (vemurafenib) (PDF) AR.PHAR.91
07/24/15
Zoledronic acid (PDF) AR.PHAR.59
07/01/16
Zolinza (PDF) AR.PHAR.83
07/24/15
Zytiga (abiraterone) (PDF) AR.PHAR.84
07/24/15

 

Allwell Policies

Policy Title Policy Number Effective Date
Acupuncture (PDF) CP.MP.92 1/1/2018
Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) CP.MP.108 02/28/18
Ambulatory Surgery Center Optimization (PDF) CP.MP.158  02/16/18
Applied Behavioral Analysis for Autism (PDF) CP.MP.104 01/31/18
Articular Cartilage Defect Repairs (PDF) CP.MP.26 04/30/18
Assisted Reproductive Technology (PDF) CP.MP.55 03/31/18
Balloon sinus ostial dilation (PDF) CP.MP.119 1/1/2018
Bariatric Surgery (PDF) CP.MP.37 06/30/18
Biofeedback (PDF) CP.MP.168 05/31/18
Bone-anchored hearing aid (PDF) CP.MP.93 1/1/2018
Carrier Screening in Pregnancy (PDF) CP.MP.83 05/31/18
Cell-free Fetal DNA Testing (PDF) CP.MP.84 04/30/18
Clinical Trials (PDF) CP.MP.94 1/1/2018
Cochlear Implant Replacements (PDF) CP.MP.14 07/31/18
Cosmetic and Reconstructive Surgery (PDF) CP.MP.31 03/31/18
Dental Anesthesia (PDF) CP.MP.61 04/30/18
Digital breast tomosynthesis (PDF) CP.MP.90 1/1/2018
Disc Decompression Procedures (PDF) CP.MP.114 05/31/18
Discography (PDF) CP.MP.115 06/30/18
DNA analysis of stool to screen for colorectal cancer (PDF) CP.MP.125 07/31/18
Donor lymphocyte infusion (PDF) CP.MP.101 1/1/2018
Durable Medical Equipment (DME) (PDF) CP.MP.107 07/31/18
Electric Tumor Treating Fields (PDF) CP.MP.145 03/31/18
Essure Removal (PDF) CP.MP.131 1/1/2018
Experimental Technologies (PDF) CP.MP.36 06/30/18
Fecal incontinence treatments (PDF) CP.MP.137 1/1/2018
Ferriscan R2-MRI (PDF) CP.MP.53 1/1/2018
Fertility preservation (PDF) CP.MP.130 1/1/2018
Fetal surgery in utero for prenatally diagnosed malformations (PDF) CP.MP.129 1/1/2018
Functional MRI (PDF) CP.MP.43 1/1/2018
Gastric electrical stimulation (PDF) CP.MP.40 1/1/2018
Gender reassignment surgery (PDF) CP.MP.95 1/1/2018
Genetic Testing (PDF) CP.MP.89 04/30/18
Heart-Lung Transplant (PDF) CP.MP.132 06/30/18
Home Birth (PDF) CP.MP.136 1/1/2018
Home phototherapy for neonatal hyperbilirubinemia (PDF) CP.MP.150 1/1/2018
Hospice Services (PDF) CP.MP.54 04/30/18
Hyperbaric Oxygen Therapy (PDF) CP.MP.27 02/28/18
Hyperemesis gravidarum treatment (PDF) CP.MP.34 03/30/18
Hyperhidrosis treatments (PDF) CP.MP.62 02/28/18
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 04/30/18
Inhaled nitric oxide (PDF) CP.MP.87 1/1/2018
Injections for Pain Management (PDF) CP.MP.118 07/31/18
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 02/28/18
Intestinal and multivisceral transplant (PDF) CP.MP.58 06/30/18
Long Term Care Placement Criteria (PDF) CP.MP.71 04/30/18
Lung Transplantation (PDF) CP.MP.57 1/1/2018
Lysis of Epidural Lesions (PDF) CP.MP.116 05/31/18
Medical Necessity Criteria (PDF) CP.MP.68 06/30/18
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) CP.MP.161 05/31/18
Multiple Sleep Latency Testing (PDF) CP.MP.24 04/30/18
Neonatal abstinence syndrome guidelines (PDF) CP.MP.86 1/1/2018
Neonatal sepsis management (PDF) CP.MP.85 07/31/18
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 05/31/18
NICU discharge guidelines (PDF) CP.MP.81 1/1/2018
Non-myeloablative allogeneic stem cell transplants (PDF) CP.MP.141 02/28/18
Obstetrical Home Health Care Programs (PDF) CP.MP.91 01/31/18
Optic nerve decompression surgery (PDF) CP.MP.128 1/1/2018
Outpatient testing for drugs of abuse (PDF) CP.MP.50 07/31/18
Pancreas transplant (PDF) CP.MP.102 01/31/18
Panniculectomy (PDF) CP.MP.109 03/31/18
Pediatric heart transplant (PDF) CP.MP.138 01/31/18
Pediatric Liver Transplant (PDF) CP.MP.120 04/30/18
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 05/31/18
Posterior tibial nerve stimulation for voiding dysfunction CP.MP.133 01/01/18
Radial Head Implant (PDF) CP.MP.148 05/31/18
Reduction mammoplasty and gynecomastia surgery (PDF) CP.MP.51 07/31/18
Sacroiliac joint fusion (PDF) CP.MP.126 06/30/18
Sclerotherapy for Vericose Veins (PDF) CP.MP.146 04/30/18
Sickle cell disease observation (PDF) CP.MP.88 07/31/18
Spinal Cord Stimulation (PDF) CP.MP.117 05/31/18
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 01/31/18
Tandem Transplant (PDF) CP.MP.162 07/31/18
Therapy Services (PT/OT/ST) (PDF) CP.MP.49 06/22/18
Thyroid hormones and insulin testing in pediatrics (PDF) CP.MP.154 01/01/18
Total artificial heart (PDF) CP.MP.127 01/01/18
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 04/30/18
Transcatheter closure of patent foramen ovale (PDF) CP.MP.151 01/01/18
Ultrasound in Pregnancy (PDF) CP.MP.38 06/30/18
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 03/31/18
Urodynamic testing (PDF) CP.MP.98 01/01/18
Vagus Nerve Stimulation (PDF) CP.MP.12 01/01/18
Ventricular Assist Devices (PDF) CP.MP.46 02/28/18
Ventriculectomy and cardiomyoplasty (PDF) CP.MP.56 02/28/18
Wheelchair seating (PDF) CP.MP.99 01/01/18
Wireless Motility Capsule (PDF) CP.MP.143 03/31/18
Zika Virus Testing (PDF) CP.MP.111 05/31/18
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 1/1/2018

Add on Code Billed Without Primary Code (PDF)

CC.PP.030

1/1/2018
ADHD Assessment and Treatment (PDF) CP.MP.124 1/1/2018
Allergy Testing (PDF) CP.MP.100 1/1/2018
Ambulatory EEG (PDF) CP.MP.96 1/1/2018
Assistant Surgeon (PDF) CC.PP.029 1/1/2018
Bevacizumab (PDF) CP.PHAR.93 1/1/2018
Bilateral Procedures (PDF) CC.PP.037 1/1/2018
Bronchial Thermoplasty (PDF) CP.MP.110 1/1/2018
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 1/1/2018
Cerumen Removal (PDF) CC.PP.008 1/1/2018
Clean Claims (PDF) CC.PP.021 1/1/2018
CLIA Number (PDF) CC.PP.022 1/1/2018
Coding Overview (PDF) CC.PP.011 1/1/2018
Cosmetic Procedures (PDF) CC.PP.024 1/1/2018
Diagnosis of Vaginitis (PDF) CP.MP.97 1/1/2018
Digital Analysis of EEGs (PDF) CP.MP.105 1/1/2018
Distinct Procedural Modifiers (PDF) CC.PP.020 1/1/2018
Duplicate Primary Code Billing (PDF) CC.PP.044 1/1/2018
E&M Medical Decision-Making (PDF) CC.PP.051 1/1/2018
EEG in Evaluation of Headache (PDF) CP.MP.155 1/1/2018
EM Bundling Edits (PDF) CC.PP.010 1/1/2018
Endometrial Ablation (EA) (PDF) CP.MP.106 1/1/2018
EpiFix Wound Treatment (PDF) CP.MP.140 1/1/2018
Evoked Potentials (PDF) CP.MP.134 1/1/2018
Fecal Calprotectin Assay (PDF) CP.MP.135 1/1/2018
FeNo Testing (PDF) CP.MP.103 1/1/2018
Global Maternity Billing (PDF) CC.PP.016 1/1/2018
H Pylori Testing (PDF) CP.MP.153 1/1/2018
Holter Monitors (PDF) CP.MP.113 1/1/2018
Homocysteine Testing (PDF) CP.MP.121 1/1/2018
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 1/1/2018
Inpatient Consultation (PDF) CC.PP.038 1/1/2018
Inpatient Only Procedures (PDF) CC.PP.018 1/1/2018
IV Hydration (PDF) CC.PP.012 1/1/2018
Laser Skin Treatment (PDF) CP.MP.123 1/1/2018
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 1/1/2018
Maximum Units (PDF) CC.PP.007 1/1/2018
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 1/1/2018
Mechanical Stretch Devices (PDF) CP.MP.144 1/1/2018
Moderate Conscious Sedation (PDF) CC.PP.015 1/1/2018
Modifier -25 clinical validation (PDF) CC.PP.013 1/1/2018
Modifier -59 clinical validation (PDF) CC.PP.014 1/1/2018
Modifier DOS Validation (PDF) CC.PP.034 1/1/2018
Modifier to Procedure Code Validation (PDF) CC.PP.028 1/1/2018
Multiple CPT Code Replacement (PDF) CC.PP.033 1/1/2018
NCCI Unbundling (PDF) CC.PP.031 1/1/2018
Never Paid Events (PDF) CC.PP.017 1/1/2018
New Patient (PDF) CC.PP.036 1/1/2018
Outpatient Consultation (PDF) CC.PP.039 1/1/2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 1/1/2018
Pre-Operative Visits (PDF) CC.PP.041 1/1/2018
Professional Component (PDF) CC.PP.027 1/1/2018
PROM Testing (PDF) CP.MP.149 1/1/2018
Proton and Neutron Beam Therapy (PDF) CP.MP.70 1/1/2018
Pulse Oximetry (PDF) CC.PP.025 1/1/2018
Rituximab (PDF) CP.PHAR.260 5/21/2018
Robotic Surgery (PDF) CC.PP.050 5/21/2018
Same Day Visits (PDF) CC.PP.040 5/21/2018
Unbundled Professional Services (PDF) CC.PP.043 1/1/2018
Vitamin D Testing in Children (PDF) CP.MP.157 1/1/2018
Wheelchair Accessories (PDF) CC.PP.502 1/1/2018