Managed Care Policies & Procedures - Archive

"Policy or procedure" shall mean a requirement governing the administration of managed care organizations specific to billing guidelines, medical management and utilization review guidelines, case management guidelines, claims processing guidelines and edits, grievance and appeals procedures and process, other guidelines or manuals containing pertinent information related to operations and pre-processing claims, and core benefits and services.

Below are items previously posted for public comment:

Item Number Policy/Procedure Date Posted Public Comments Due By Status Document Links
2020-PHARM-78  Asthma COPD Bronchodilator Anticholinergics Inhalation  7/31/20  9/14/20  Complete  Asthma COPD Bronchodilator Anticholinergics Inhalation 
2020-PHARM-77  Cytokineand CAM Antagonists  7/31/20   9/14/20  Complete Cytokineand CAM Antagonists 
2020-PHARM-76  Dermatology Atopic Dermatitis Immunomodulators  7/31/20   9/14/20  Complete Dermatology Atopic Dermatitis Immunomodulators  
2020-PHARM-75  Diabetes Hypoglycemics Incretin Mimetics Enhancers  7/31/20   9/14/20  Complete Diabetes Hypoglycemics Incretin Mimetics Enhancers  
2020-PHARM-74  Esbriet  7/31/20   9/14/20  Complete Esbriet
2020-PHARM-73  Fetroja  7/31/20   9/14/20  Complete Fetroja 
2020-PHARM-72  Givlaari  7/31/20   9/14/20  Complete Givlaari 
2020-PHARM-71  Hepatitis C DAA  7/31/20   9/14/20  Complete Hepatitis C DAA 
2020-PHARM-70  Infectious Disorders Hepatitis C Agents Direct Acting Antiviral Agents  7/31/20   9/14/20  Complete Infectious Disorders Hepatitis C Agents Direct Acting Antiviral Agents 
2020-PHARM-69 Koselugo   7/31/20   9/14/20  Complete Koselugo 
2020-PHARM-68 Ofev  7/31/20   9/14/20  Complete Ofev 
2020-PHARM-67 Oxbryta  7/31/20   9/14/20  Complete Oxbryta 
2020-PHARM-66 POS DUR October 2020  7/31/20   9/14/20  Complete POS DUR October 2020  
2020-PHARM-65 Sedative Hypnotics  7/31/20   9/14/20  Complete Sedative Hypnotics  
2020-PHARM-64 Tikosyn  7/31/20   9/14/20  Complete Tikosyn 
2020-PHARM-63 VMAT2 Inhibitors 7/31/20   9/14/20  Complete VMAT2 Inhibitors 
2020-PHARM-62 Xenleta  7/31/20   9/14/20  Complete Xenleta 
2020-HBL-366

Out-of-Area, Out-of-Network Care

7/24/20  9/7/20  Approved  Out-of-Area, Out-of-Network Care

2020-HBL-542.1

2020-HBL-542.2

Anesthesia Services for Interventional Pain Management Procedures and Clinical Guidelines 7/24/20  9/7/20  Completed Anesthesia Services for Interventional Pain Management Procedures Clinical Guidelines
2020-UHC-564

Benlysta

7/24/20  9/7/20  Approved Benlysta
2020-UHC-565

Crysvita

7/24/20  9/7/20  Approved Crysvita
2020-UHC-567

Maximum Dosage

7/24/20  9/7/20  Approved Maximum Dosage
2020-UHC-568 Ocrevus 7/24/20  9/7/20  Approved Ocrevus
2020-UHC-569 Off Label Unproven  7/24/20  9/7/20  Approved Off Label Unproven
2020-UHC-572 Reblozyl  7/24/20  9/7/20  Approved Reblozyl
2020-UHC-574 Testosterone Replacement  7/24/20  9/7/20  Approved Testosterone Replacement
2020-LHCC-610 Authorization Error Correction Process  7/24/20  9/7/20  Completed  Authorization Error Correction Process
2020-LHCC-636 Authorization for Second Clinical Opinions  7/24/20  9/7/20  Completed  Authorization for Second Clinical Opinions 
2020-LHCC-682 Active Procedures in Physical Medicine  7/24/20  9/7/20  Approved Active Procedures in Physical Medicine
2020-LHCC-683 Chiro Infant Care Policy  7/24/20  9/7/20  Approved Chiro Infant Care Policy
2020-LHCC-684 Chiro Infant Care Policy  7/24/20  9/7/20  Approved Chiro Infant Care Policy
2020-LHCC-685 Experimental, Unproven, or Investigational Services  7/24/20  9/7/20  Approved Experimental, Unproven, or Investigational Services
2020-HBL-318

Clinical Information for Utilization Review

7/16/20 8/30/20 Approved Clinical Information for Utilization Review
2020-HBL-328 Pre-Certification of Requested Services 7/16/20 8/30/20 Approved Pre-Certification of Requested Services
2020-UHC-535

Nat'l Drug Code (NDC) Requirement Policy

7/16/20 8/30/20 Approved Nat'l Drug Code (NDC) Requirement Policy
2020-ACLA-538 PCP Assignment 7/16/20 8/30/20 Approved PCP Assignment
2020-HBL-588 Retrospective Review 7/16/20 8/30/20 Approved Retrospective Review
2020-LHCC-609 Court Ordered Services Louisiana PP   7/16/20 8/30/20 Approved Court Ordered Services Louisiana PP  
2020-HBL-677 SPOT AIM Rehab Transition Bulletin 7/16/20 8/30/20 Approved SPOT AIM Rehab Transition Bulletin
2020-HB-PHARM-1

 

Louisiana Compound Coverage 7/21/20 9/4/20 Approved Louisiana Compound Coverage
2020-HBL-316 Associates Performing Utilization Review 7/9/20 8/23/20 Approved Associates Performing Utilization Review
2020-HBL-576 AIM Musculoskeletal Prog Clinical Appropriateness Guidelines 7/9/20 8/23/20 Approved AIM Musculoskeletal Prog Clinical Appropriateness Guidelines
2020-LHCC-329 Adverse Determinations 7/9/20 8/23/20 Approved Adverse Determinations
2020-LHCC-429 UM Program Description  7/9/20 8/23/20 Approved UM Program Description 
2020-LHCC-498 Mental Health Rehab MNC Policy 7/9/20 8/23/20 Approved Mental Health Rehab MNC Policy
2020-LHCC-532

Appropriate UM Professionals

7/9/20 8/23/20 Approved Appropriate UM Professionals
2020-LHCC-607 Inpatient Leveling of Care WP 7/9/20 8/23/20 Completed Inpatient Leveling of Care WP
2020-UHC-557 Transcranial Magnetic Stimulation 7/9/20 8/23/20 Approved Transcranial Magnetic Stimulation
2020-UHC-558

Knee Replacement Surgery (Arthroplasty), Total and Partial

7/9/20 8/23/20 Approved Knee Replacement Surgery (Arthroplasty), Total and Partial
2020-UHC-559 Implantable Beta-Emitting Microspheres 7/9/20 8/23/20 Approved Implantable Beta-Emitting Microspheres
2020-UHC-560 Home Hemodialysis 7/9/20 8/23/20 Approved Home Hemodialysis
2020-UHC-561 Cognitive Rehabilitation 7/9/20 8/23/20 Approved Cognitive Rehabilitation
2020-HBL-602.1 Medical drug Clinical Criteria updates 7/2/20 8/16/20 Approved Medical drug Clinical Criteria updates
2020-HBL-602.2 Faslodex Criteria 7/2/20 8/16/20 Approved Faslodex Criteria
2020-HBL-602.3 Gazyva Criteria 7/2/20 8/16/20 Approved Gazyva Criteria
2020-HBL-602.4 Immunoglobulins Criteria 7/2/20 8/16/20 Approved Immunoglobulins Criteria
2020-HBL-602.5 Intravitreal Corticosteroid Implants Criteria 7/2/20 8/16/20 Approved Intravitreal Corticosteroid Implants Criteria
2020-HBL-602.6 Keytruda Criteria 7/2/20 8/16/20 Approved Keytruda Criteria
2020-HBL-602.7 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications Criteria 7/2/20 8/16/20 Approved Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications Criteria
2020-LHCC-505 New Follow-Up After Hospitalization Policy 7/2/20 8/16/20 Approved New Follow-Up After Hospitalization Policy
2020-LHCC-611 Appeals Process 7/2/20 8/16/20 Completed Appeals Process
2020-UHC-563 Actemra Criteria 7/2/20 8/16/20 Approved Actemra Criteria
2020-UHC-570 Orencia Criteria 7/2/20 8/16/20 Approved Orencia Criteria
2020-LHCC-331   Provider Manual 6/25/20 8/10/20 Approved Provider Manual
2020-UHC-585  Chelation Therapy 6/25/20 8/10/20 Approved Chelation Therapy
2020-PHARM-61 Hepatitis C DAA 6/22/20 8/7/20 Approved Hepatitis C DAA
2020-ACLA-325 Provider Manual 6/18/20  8/3/20 Approved Provider Manual
2020-HBL-115 Multiple Bilateral Article and Policy 6/18/20  8/3/20 Approved Multiple Bilateral Article and Policy 1Multiple Bilateral Article and Policy 2
2020-HBL-120 Psychiatris Res Trmt Fac PRTF Gde, Med Gde and Withdrawal Gde 6/18/20  8/3/20 Approved Psychiatris Res Trmt Fac PRTF Gde Med Gde Withdrawal Gde
2020-HBL-250 Provider Manual 6/18/20  8/3/20 Denied Provider Manual
2020-UHC-324 Provider Manual 6/18/20  8/3/20 Approved Provider Manual
2020-UHC-513 Epidural Steroid and Facet Injections for Spinal Pain (for Louisiana Only) 6/18/20  8/3/20 Approved Epidural Steroid and Facet Injections for Spinal Pain (for Louisiana Only)
2020-UHC-516 Reimbursement Policy: Obstetrical Services Policy 6/18/20  8/3/20 Approved Reimbursement Policy: Obstetrical Services Policy
2020-UHC-518 Reimbursement Policy: Global Days Policy 6/18/20  8/3/20 Approved Reimbursement Policy: Global Days Policy
2020-UHC-519 Reimbursement Policy: Vaccines for Children 6/18/20  8/3/20 Approved Reimbursement Policy: Vaccines for Children
2020-UHC-529 AIM Advanced Imaging Clinical Appropr. Guidelines 6/18/20  8/3/20 Approved

AIM Advanced Imaging Clinical Appropr. Guidelines 1

AIM Advanced Imaging Clinical Appropr. Guidelines 2

AIM Advanced Imaging Clinical Appropr. Guidelines 3

AIM Advanced Imaging Clinical Appropr. Guidelines 4

2020-UHC-531 AIM Advanced Imaging Clinical Appropr. Guidelines 6/18/20  8/3/20 Approved AIM Advanced Imaging Clinical Appropr. Guidelines
2020-UHC-534 Add On Codes Policy 6/18/20 8/3/20 Approved

Add On Codes Policy 1

Add On Codes Policy 2

2020-PHARM-60 Multiple Sclerosis Agents for August 2020 6/15/20 7/30/20 Pending Multiple Sclerosis Agents
2020-UHC-511 Manipulation Under Anesthesia 6/10/20 7/25/20 Approved Manipulation Under Anesthesia
2020-UHC-512 Glaucoma Surgical Treatment 6/10/20 7/25/20 Approved Glaucoma Surgical Treatment
2020-ABH-114 Limitations on Abortions 6/9/20 7/24/20 Approved Limitations on Abortions
2020-ABH-496 Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) Services 6/9/20 7/24/20 Approved Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) Services
2020-ACLA-368 Split Surgery Care 6/9/20 7/24/20 Approved Split Surgery Care
2020-ACLA-380 Assistant Surgery Care 6/9/20 7/24/20 Approved Assistant Surgery Care

2020-ACLA-381

Co-Surgery 6/9/20 7/24/20 Approved Co-Surgery

2020-ACLA-484

Prior Authorization Requirements 6/9/20 7/24/20 Completed Prior Authorization Requirements

2020-ACLA-495

Anesthesia Services for Gastrointestinal Endoscopy 6/9/20 7/24/20 Approved Anesthesia Services for Gastrointestinal Endoscopy

2020-ACLA-507

Site of Care Medical Pharmacy 6/9/20 7/24/20 Approved Site of Care Medical Pharmacy

2020-ACLA-508

Outpatient Surgical Procedures 6/9/20 7/24/20 Approved Outpatient Surgical Procedures
2020-HBL-257 Pediatric Day Health Care and Personal Care Services 6/9/20 7/24/20 Approved Pediatric Day Health Care and Personal Care Services
2020-HBL-319 Unlisted Unspecified Misc Codes Newsletter 6/9/20 7/24/20 Completed Unlisted Unspecified Misc Codes Newsletter
2020-HBL-327 Distinct Procedural 6/9/20 7/24/20 Completed Distinct Procedural
2020-HBL-359 Justice Involved Case Management 6/9/20 7/24/20 Approved Justice Involved Case Management
2020-HBL-360 Durable Medical Equipment 6/9/20 7/24/20 Approved Durable Medical Equipment
2020-HBL-415 Case Management Face to Face Intervention 6/9/20 7/24/20 Approved Case Management Face to Face Intervention
2020-HBL-416 Unlisted Unspecified Misc Codes Policy 6/9/20 7/24/20 Completed Unlisted Unspecified Misc Codes Policy
2020-HBL-485 Standing Referral 6/9/20 7/24/20 Completed Standing Referral
2020-HBL-515 Louisiana Provider Payment Suspension (Hold) 6/9/20 7/24/20 Completed Louisiana Provider Payment Suspension (Hold)
2020-LHCC-314 Infusion Therapy Site Of Care Optimization 6/9/20 7/24/20 Approved Infusion Therapy Site Of Care Optimization
2020-LHCC-315  Testing Select GU Conditions 6/9/20 7/24/20 Approved Testing Select GU Conditions
2020-LHCC-334 Disease Management Policies 6/9/20 7/24/20 Approved Disease Management Policies
2020-LHCC-335 Quality Program Description 6/9/20 7/24/20 Approved Quality Program Description
2020-LHCC-336 Care Management Program Description 6/9/20 7/24/20 Completed Care Management Program Description
2020-LHCC-338 Perinatal Substance Use Disorder Care Management Program 6/9/20 7/24/20 Approved Perinatal Substance Use Disorder Care Management Program
2020-LHCC-342 Medical Record Review 6/9/20 7/24/20 Completed Medical Record Review
2020-LHCC-419 Provider Termination 6/9/20 7/24/20 Completed Provider Termination
2020-LHCC-421 Provider Relations Demographic Provider Roster Affiliation Verification 6/9/20 7/24/20 Completed Provider Relations Demographic Provider Roster Affiliation Verification
2020-LHCC-422 Network Development and Management 6/9/20 7/24/20 Completed Network Development and Management

2020-LHCC-423

EPSDT 6/9/20 7/24/20 Approved EPSDT

2020-LHCC-424

PASRR 6/9/20 7/24/20 Approved PASRR
2020-LHCC-426 Adverse Incidents 6/9/20 7/24/20 Approved Adverse Incidents
2020-LHCC-430 Covered Benefits and Services 6/9/20 7/24/20 Approved Covered Benefits and Services
2020-LHCC-431 Monitoring Utilization 6/9/20 7/24/20 Approved Monitoring Utilization
2020-LHCC-432 Psychiatric Treatment Facility 6/9/20 7/24/20 Approved Psychiatric Treatment Facility
2020-LHCC-497 Emergency Services Policy 6/9/20 7/24/20 Completed Emergency Services Policy
2020-LHCC-499 Retrospective Review For Services Requiring Authorizations 6/9/20 7/24/20 Completed Retrospective Review For Services Requiring Authorizations
2020-LHCC-500 Policy, Procedure and Job Description Guidelines Policy 6/9/20 7/24/20 Completed Policy, Procedure and Job Description Guidelines Policy
2020-LHCC-501 Access to Non-Emergency Transportation policy 6/9/20 7/24/20 Approved Access to Non-Emergency Transportation policy
2020-LHCC-502 Clinical Information and Documentation Policy 6/9/20 7/24/20 Completed Clinical Information and Documentation Policy
2020-LHCC-503 Evaluation of the Accessibility of services 6/9/20 7/24/20 Completed Evaluation of the Accessibility of services
2020-LHCC-504 Quality PIPs policy 6/9/20 7/24/20 Approved Quality PIPs policy
2020-LHCC-525 Remote Field Staff Quarterly HIPPA and Equipment audit policy 6/9/20 7/24/20 Completed Remote Field Staff Quarterly HIPPA and Equipment audit policy
2020-LHCC-526 TruCare Standards for Documentation policy 6/9/20 7/24/20 Completed TruCare Standards for Documentation policy
2020-LHCC-527 Organizational Cultural Competency policy 6/9/20 7/24/20 Completed Organizational Cultural Competency policy
2020-LHCC-528 Public Records Request policy 6/9/20 7/24/20 Completed Public Records Request policy
2020-UHC-374 Electrical and Ultrasound Bone Growth Stimulators 6/9/20 7/24/20 Completed Electrical and Ultrasound Bone Growth Stimulators
2020-UHC-382 Benlysta (Belimumab) 6/9/20 7/24/20 Completed Benlysta (Belimumab)
2020-UHC-383 Oncology Medication Clinical Coverage 6/9/20 7/24/20 Completed Oncology Medication Clinical Coverage
2020-UHC-384 Intravenous Iron Replacement Therapy (Feraheme & Injectafer) 6/9/20 7/24/20 Completed Intravenous Iron Replacement Therapy (Feraheme & Injectafer)

2020-UHC-385

Ketalar (Ketamine) and Spravato (Esketamine) 6/9/20 7/24/20 Completed Ketalar (Ketamine) and Spravato (Esketamine)
2020-UHC-386 Luxturna (Voretigene Neparvovec-rzyl) 6/9/20 7/24/20 Completed Luxturna (Voretigene Neparvovec-rzyl)
2020-UHC-387 Review At Launch For New To Market Medications 6/9/20 7/24/20 Completed Review At Launch For New To Market Medications
2020-UHC-389 Somatostatin Analogs 6/9/20 7/24/20 Completed Somatostatin Analogs
2020-UHC-390 Vyondys 53 (Golodirsen) 6/9/20 7/24/20 Completed Vyondys 53 (Golodirsen)
2020-UHC-391 Zulresso (Brexanolone) 6/9/20 7/24/20 Completed Zulresso (Brexanolone)
2020-UHC-392 Alpha1-Proteinase Inhibitors 6/9/20 7/24/20 Completed Alpha1-Proteinase Inhibitors
2020-UHC-393 Botulinum Toxins A and B 6/9/20 7/24/20 Completed Botulinum Toxins A and B
2020-UHC-394 Denosumab (Prolia & Xgeva) 6/9/20 7/24/20 Completed Denosumab (Prolia & Xgeva)
2020-UHC-396 Exondys 51 (Eteplirsen) 6/9/20 7/24/20 Approved Exondys 51 (Eteplirsen)
2020-UHC-397 Ilaris (Canakinumab) 6/9/20 7/24/20 Completed Ilaris (Canakinumab)
2020-UHC-398 Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease 6/9/20 7/24/20 Completed Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease
2020-UHC-399 Buprenorphine (Probuphine & Sublocade) 6/9/20 7/24/20 Approved Buprenorphine (Probuphine & Sublocade)
2020-UHC-400 Compliment Inhibitors (SOLIRIS & ULTOMIRIS) 6/9/20 7/24/20 Completed Compliment Inhibitors (SOLIRIS & ULTOMIRIS)
2020-UHC-401 Crysvita (BUROSUMAB-TWZA) 6/9/20 7/24/20 Completed Crysvita (BUROSUMAB-TWZA)
2020-UHC-402 Denied Drug Codes - Pharmacy Benefit Drugs 6/9/20 7/24/20 Approved Denied Drug Codes - Pharmacy Benefit Drugs
2020-UHC-403 Enzyme Replacement Therapy 6/9/20 7/24/20 Completed Enzyme Replacement Therapy
2020-UHC-404 Erythropoiesis Stimulating Agents 6/9/20 7/24/20 Completed Erythropoiesis Stimulating Agents
2020-UHC-405 Gonadatropin Releasing Hormones 6/9/20 7/24/20 Approved Gonadatropin Releasing Hormones
2020-UHC-406 Immune Globulin (IVIG and SCIG) 6/9/20 7/24/20 Approved Immune Globulin (IVIG and SCIG)
2020-UHC-407 Krystexxa 6/9/20 7/24/20 Completed Krystexxa
2020-UHC-408 Maximum Dosage 6/9/20 7/24/20 Approved Maximum Dosage
2020-UHC-409 Opthalmologic VEGF Inhibitors 6/9/20 7/24/20 Approved Opthalmologic VEGF Inhibitors
2020-UHC-410 Sodium Hyaluronate 6/9/20 7/24/20 Approved Sodium Hyaluronate
2020-UHC-411 Tysabri 6/9/20 7/24/20 Approved Tysabri
2020-UHC-412 WBC-CSF 6/9/20 7/24/20 Approved WBC-CSF
2020-UHC-413 Addendum to BH Utilization Management 6/9/20 7/24/20 Approved Addendum to BH Utilization Management
2020-UHC-417 Prior Authorization Requirements 6/9/20 7/24/20 Completed Prior Authorization Requirements
2020-UHC-479 Cardiac Event Monitoring -Annual CPT/HCPCS Code Updates and MCG 6/9/20 7/24/20 Completed Cardiac Event Monitoring -Annual CPT/HCPCS Code Updates and MCG
2020-UHC-481 CPT/HCPCS Updates     Prosthetic Devices 6/9/20 7/24/20 Approved CPT/HCPCS Updates     Prosthetic Devices
2020-UHC-482 CPT / HCPCS Updates   Molecular Oncology Testing 6/9/20 7/24/20 Approved CPT / HCPCS Updates   Molecular Oncology Testing
2020-UHC-483 CPT/HCPCS Updates  Genetic Testing for Hereditary Cancer 6/9/20 7/24/20 Approved CPT/HCPCS Updates  Genetic Testing for Hereditary Cancer
2020-UHC-493 Surgical Treatment for Spine Pain 6/9/20 7/24/20 Completed Surgical Treatment for Spine Pain
2020-UHC-509 Breast Reconstruction Post Mastectomy 6/9/20 7/24/20 Approved Breast Reconstruction Post Mastectomy
2020-UHC-510 COLLAGEN CROSSLINKS AND BIOCHEMICAL MARKERS OF BONE TURNOVER 6/9/20 7/24/20 Approved COLLAGEN CROSSLINKS AND BIOCHEMICAL MARKERS OF BONE TURNOVER
2020-UHC-520 Panniculectomy Body Contouring Procedures 6/9/20 7/24/20 Approved Panniculectomy Body Contouring Procedures
2020-UHC-521 Gastrointestinal Motility Disorders Diagnosis and Treatment 6/9/20 7/24/20 Approved Gastrointestinal Motility Disorders Diagnosis and Treatment
2020-UHC-523 Intrauterine Fetal Surgery 6/9/20 7/24/20 Approved Intrauterine Fetal Surgery
2020-UHC-524 DME Repairs and Replacements 6/9/20 7/24/20 Approved DME Repairs and Replacements
2020-UHC-530 Reimbursement Policy: DRUG TESTING POLICY 6/9/20 7/24/20 Approved Reimbursement Policy: DRUG TESTING POLICY
2020-PHARM-59 Acne Agents 5/29/20 7/13/20 Approved Acne Agents 
2020-PHARM-58 Acne Criteria  5/29/20 7/13/20 Approved Acne Criteria 
2020-PHARM-57 Adakveo  5/29/20 7/13/20 Approved Adakveo 
2020-PHARM-56 CGRP Antagonists  5/29/20 7/13/20 Approved CGRP Antagonists 
2020-PHARM-55 Colony Stimulating Factors  5/29/20 7/13/20 Approved Colony Stimulating Factors  
2020-PHARM-54 Diabetes Hypoglycemics Incretin Mimetics Enhancers  5/29/20 7/13/20 Approved Diabetes Hypoglycemics Incretin Mimetics Enhancers 
2020-PHARM-53 Egrifta  5/29/20 7/13/20 Approved Egrifta 
2020-PHARM-52 Keveyis  5/29/20 7/13/20 Approved Keveyis  
2020-PHARM-51 Multiple Sclerosis Agents Immunomodulatory Agents  5/29/20 7/13/20 Approved Multiple Sclerosis Agents Immunomodulatory Agents 
2020-PHARM-50 Multiple Sclerosis Agents  5/29/20 7/13/20 Approved Multiple Sclerosis Agents  
2020-PHARM-49 Other Behavioral Health Under 6  5/29/20 7/13/20 Approved Other Behavioral Health Under 6  
2020-PHARM-48 Otrexup Rasuvo  5/29/20 7/13/20 Approved Otrexup Rasuvo 
2020-PHARM-47 Pain Management Antimigraine Agents CGRP Antagonists  5/29/20 7/13/20 Approved Pain Management Antimigraine Agents CGRP Antagonists  
2020-PHARM-46 Pain Management Antimigraine Agentss Triptans 5/27/20  5/29/20 7/13/20 Approved Pain Management Antimigraine Agentss Triptans 5/27/20 
2020-PHARM-45 Pain Management Antimigraine Agents Triptans 5/26/20  5/29/20 7/13/20 Approved Pain Management Antimigraine Agents Triptans 5/26/20  
2020-PHARM-44 POS Document for May DUR  5/29/20 7/13/20 Approved POS Document for May DUR 
2020-PHARM-43 Ranexa  5/29/20 7/13/20 Approved Ranexa 
2020-PHARM-42  Acne Criteria 5/15/20 6/29/20 Pending Acne Criteria 
2020-PHARM-41  ADD-ADHD Stimulants and Related Agents  5/15/20 6/29/20 Pending ADD-ADHD Stimulants and Related Agents 
2020-PHARM-40  ADHD  5/15/20 6/29/20 Pending ADHD  
2020-PHARM-39  Antipsychotic Agents  5/15/20 6/29/20 Pending Antipsychotic Agents 
2020-PHARM-38  Antipsychotics  5/15/20 6/29/20 Pending Antipsychotics  
2020-PHARM-37  CGRP Antagonists  5/15/20 6/29/20 Pending CGRP Antagonists  
2020-PHARM-36  Colony Stimulating Factors  5/15/20 6/29/20 Pending Colony Stimulating Factors 
2020-PHARM-35  Diabetes Hypoglycemics Insulins and Related Agents  5/15/20 6/29/20 Pending Diabetes Hypoglycemics Insulins and Related Agents 
2020-PHARM-34  Digestive Disorders Antiemetic Antivertigo Agents  5/15/20 6/29/20 Pending Digestive Disorders Antiemetic Antivertigo Agents 
2020-PHARM-33  Hemodialysis Phosphate Binders  5/15/20 6/29/20 Pending Hemodialysis Phosphate Binders 
2020-PHARM-32  Oncology Agents Oral Breast  5/15/20 6/29/20 Pending Oncology Agents Oral Breast  
2020-PHARM-31  Oncology Agents Oral Hematologic  5/15/20 6/29/20 Pending Oncology Agents Oral Hematologic  
2020-PHARM-30  Opiate Dependence Agents  5/15/20 6/29/20 Pending Opiate Dependence Agents 
2020-PHARM-29  Other Behavioral Health Under 6  5/15/20 6/29/20 Pending Other Behavioral Health Under 6  
2020-PHARM-28  Pain Management Antimigraine Agents CGRP Antagonists  5/15/20 6/29/20 Pending Pain Management Antimigraine Agents CGRP Antagonists  
2020-PHARM-27  Pain Management-Non Steroidal Antiinflammatory agents  5/15/20 6/29/20 Pending Pain Management-Non Steroidal Antiinflammatory agents  
2020-PHARM-26  Pulmonary Arterial Hypertension Agents  5/15/20 6/29/20 Pending Pulmonary Arterial Hypertension Agents 
2020-UHC-487

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

MCO retiring policy on 7/1/20

6/9/20 7/24/20 Withdrawn Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes
2020-HBL-553 PA Cont COVID19 Crisis Intervention 6/9/20 7/24/20 Withdrawn PA Cont COVID19 Crisis Intervention

2020-PHARM-25

Hepatitis C DAA 5/4/20 6/18/20 Approved Hepatitis C DAA
2020-PHARM-24 Infectious Disorders - Hepatitis C Agents 5/4/20 6/18/20 Approved Infectious Disorders - Hepatitis C Agents
2020-PHARM-23 Colony Stimulating Factors 5/4/20 6/18/20 Approved Colony Stimulating Factors
2020-PHARM-22 Vaccines for Adults 4/17/20 6/1/20 Approved Vaccines for Adults
2020-HPA-2 Tobacco Cessation for Pregnant Women 4/16/20 5/31/20 Approved HPA Tobacco Cessation for Pregnant Women
2020-PHARM-21 Colony Stimulating Factors 4/2/2020 5/17/20 Approved Colony Stimulating Factors
2020-BPE-1 Batch Pharmacy Encounter – Basis of Cost Determination 4/2/20 5/17/20 Approved Batch Pharmacy Encounter System Companion Guide
2020-PHARM-20 POS DUR May 2020 Posting  3/13/20 4/27/20 Approved POS DUR May 2020 Posting
2020-PHARM-19 POS Document for January 2020 May Implementation  3/13/20 4/27/20 Approved POS Document for January 2020 May Implementation 
2020-PHARM-18 Oral Glucocorticoids  3/13/20 4/27/20 Approved Oral Glucocorticoids 
2020-PHARM-17 Miscellaneous Agents with POS Req  3/13/20  4/27/20 Approved Miscellaneous Agents with POS Req  
2020-PHARM-16 Other Behavioral Health Under 6  3/13/20 4/27/20 Approved Other Behavioral Health Under 6
2020-PHARM-15 Kalydeco  3/13/20 4/27/20 Approved Kalydeco
2020-PHARM-14 Symdeko  3/13/20 4/27/20 Approved Symdeko
2020-PHARM-13 Orkambi  3/13/20 4/27/20 Approved Orkambi
2020-PHARM-12 Exondys  3/13/20 4/27/20 Approved Exondys
2020-PHARM-11 Cytokine and CAM Antagonists  3/13/20 4/27/20 Approved Cytokine and CAM Antagonists 
2020-PHARM-10 Hepatitis C DAA  3/13/20 4/27/20 Approved Hepatitis C DAA
2020-PHARM-9 Mytesi  3/13/20 4/27/20 Approved Mytesi
2020-PHARM-8 Samsca  3/13/20 4/27/20 Approved Samsca
2020-PHARM-7 Jynarque  3/13/20 4/27/20 Approved Jynarque 
2020-PHARM-6 Penicillamine  3/13/20 4/27/20 Approved Penicillamine
2020-PHARM-5 Buphenyl Carbaglu Ravicti 3/13/20   4/27/20 Approved Buphenyl Carbaglu Ravicti
2020-PHARM-4 Vyondys 3/13/20 4/27/20 Approved Vyondys
2020-PHARM-3 Trikafta 3/13/20 4/27/20 Approved Trikafta
2020-PHARM-2 Zulresso 3/13/20 4/27/20 Approved Zulresso
2020-UHC-126 Behavior Health Supportive Criteria 3/13/20 4/27/20 Approved Behavior Health Supportive Criteria
2020-SCG-2 Addition of new codes to Evidence Based Practice Codes:  EB06 and EB07 3/6/20 4/20/20 Complete MCO SCG v 57
2020-HBL-357 Non-Par Opioid Policy 3/6/20 4/20/20 Approved Non-Par Opioid Policy
2020 HBL-333 Medical Transportation 3/4/20 4/18/20 Approved Medical Transportation
2020-HPA-1 Revised Hysterectomy Acknowledgement Form 3/3/20 4/17/20 Approved HPA Hysterectomy Acknowledgement Form
2020-IB-1 Revised Hysterectomy Acknowledgement Form 3/3/20 4/17/20 Approved IB Hysterectomy Acknowledgement Form
2020-HBL-121 POA HCAC Article and Policy 2/26/20 4/11/20 Approved POA HCAC Article and Policy
2020-HBL-321 Behavioral Health Adverse Incidents Monitoring and Reporting 2/26/20 4/11/20 Approved Behavioral Health Adverse Incidents Monitoring and Reporting
2020-HBL-332 Prior Authorization Liaison (PAL) Policy 2/26/20 4/11/20 Approved Prior Authorization Liaison (PAL) Policy
2020-HBL-358 Behavioral Health – Nursing Facility Services 2/26//20 4/11/20 Approved Behavioral Health – Nursing Facility Services
2020-LHCC-339 Network Adequacy 2/17/20 4/2/20 Approved Network Adequacy
2020-UHC-369 ADAKVEO (CRIZANLIZUMAB-TMCA) 2/13/2020 3/29/20 Approved ADAKVEO (CRIZANLIZUMAB-TMCA)
2020-UHC-370 GIVLAARI (GIVOSIRAN) 2/13/2020 3/29/20 Approved GIVLAARI (GIVOSIRAN)
2020-UHC-371 REBLOZYL (LUSPATERCEPT-AAMT) 2/13/2020 3/29/20 Approved REBLOZYL (LUSPATERCEPT-AAMT)
2020-UHC-372 INTRAVENOUS IRON REPLACEMENT THERAPY (FERAHEME & INJECTAFER) 2/13/2020 3/29/20 Approved INTRAVENOUS IRON REPLACEMENT THERAPY (FERAHEME & INJECTAFER)
2020-ACLA-230 Avesis Utilization SOP 2/13/2020 3/29/20 Approved Avesis Utilization SOP
2020-UHC-312 Intensity-Modulated Radiation Therapy 2/6/2020 3/21/20 Approved Intensity-Modulated Radiation Therapy
2020-HBL-365 Coordinated System of Care (CSoC) Waiver 2/6/2020 3/21/20 Approved Coordinated System of Care (CSoC) Waiver
2020-HBL-363 Drug Screen Testing 2/5/2020 3/20/20 Approved Drug Screen Testing
2020-HBL-364 Drug Screen Testing Article 2/5/2020 3/20/20 Approved Drug Screen Testing Article
2020-UHC-252 Intraoperative Neuromonitoring Policy 2/5/2020 3/20/20 Approved Intraoperative Neuromonitoring Policy
2020-ABA-4 Aplied Behavior Analysis Fee Schedule Coding Update 1/31/20 3/15/20 Complete Applied Behavior Analysis Fee Schedule Coding Update
2020-UHC-310 Total Artificial Disc Replacement Spine 1/28/20 3/12/20 Approved Total Artificial Disc Replacement Spine
2020-UHC-311 Transcatheter Heart Valve Procedures 1/28/20 3/12/20 Approved Transcatheter Heart Valve Procedures
2020-UHC-313 Bariatric Surgery Policy 1/28/20 3/12/20 Approved Bariatric Surgery Policy
2020-ABH-233 Opioid Use Disorder 1/24/20 3/9/20 Approved Opioid Use Disorder
2020-HBL-320 Emergency and Post Stabilization Services 1/24/20 3/9/20 Approved Emergency and Post Stabilization Services
2020-LHCC-237 Opioid Use Disorder Treatment in Opioid Treatment Programs 1/24/20 3/9/20 Approved Opioid Use Disorder Treatment in Opioid Treatment Programs
2020-ACLA-236 Opioid Use Disorder Treatment in Opioid Treatment Programs 1/23/20 3/8/20 Approved Covered Benefits and Services
Standard and Urgent Prior Authorization
2020-HBL-235 Reimbursement in Opioid Treatment Programs 1/23/20 3/8/20 Approved Reimbursement in Opioid Treatment Programs
2020-LHCC-249

Ambulatory Insulin Pump

1/23/20 3/8/20 Approved Ambulatory Insulin Pump
2020-UHC-234 Opioid Use Disorder Treatment in Opioid Treatment Programs 1/23/20 3/8/20 Approved Opioid Use Disorder Treatment in Opioid Treatment Programs
2020-PHARM-1 Pharmacy Lock-In Program 1/17/20 3/2/20 Approved Pharmacy Lock-In Program
2020-HBL-244 Assertive Community Treatment Billing 1/16/20 3/1/20 Approved Assertive Community Treatment Billing
2020-UHC-248 Vertebral Tethering for Scoliosis 1/14/20 2/28/20 Approved Vertebral Tethering for Scoliosis
2019-PHARM-15 Spinraza Single PDL 1/14/20 2/28/20 Approved Spinraza Single PDL
2020-HBL-121 POA HCAC Article 1/15/20 2/29/20 Withdrawn POA HCAC Article
2020-SCG-1 Change Disposition of Edit 202 from “E” to “D” 1/7/20 2/21/20 Pending MCO System Companion Guide, pg. 125
2019-LHCC-53 Homebuilders Services 1/7/20 2/21/20 Approved Homebuilders Services
2020-HBL-258 Health Care Management Denial 1/7/20 2/21/20 Approved Health Care Management Denial

 

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