Medicaid Managed Care Policies & Procedures Archive (2021)

"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 Comment Period Closed Status Document Links
2021-ABH-1169 Provider Appeals Policy 12/23/21 2/6/22 Approved Provider Appeals Policy
2021-ABH-1176 Act 421 Policy 12/22/21 2/5/22 Approved Act 421 Policy
2021-LDH-17 MCO Manual > Part 4: Services > Pharmacy > Brand Name and Generic Drugs (Proposed effective date = 3/13/2022) 12/22/21 2/5/22 Completed MCO Manual > Pharmacy Brand Name & Generic Drugs
2021-LDH-16 MCO Manual > Part 4: Services > Ambulatory Surgical Services > Outpatient Hospital Ambulatory Surgery (Proposed effective date = 3/13/2022) 12/22/21 2/5/22 Completed MCO Manual > Outpatient Hospital Ambulatory Surgery
2021-LDH-15 MCO Manual > Part 4: Services > Professional Services > Sinus Procedures (Proposed effective date = 3/6/2022) 12/14/21 1/28/22 Completed MCO Manual > Part 4: Services > Professional Services > Sinus Procedures (Proposed effective date = 3/6/2022)
2021-ABH-940 Policy for Applied Behavioral Health 12/3/21 1/17/22 Pending Policy for Applied Behavioral Health
2021-ABH-939 Peer Support Services 12/3/21 1/17/22 Pending Peer Support Services
2021-HBL-602 Psychiatric Support and Treatment 12/2/21 1/16/22 Pending Psychiatric Support and Treatment
2021-UHC-1167 Prostate Surgeries and Interventions 12/2/21 1/16/22 Pending Prostate Surgeries and Interventions
2021-ACLA-1177 Potential Upcoding of Surgical Services 12/22/21 2/5/22 Denied Potential Upcoding of Surgical Services
2021-LHCC-1168 Allergy Testing and Therapy 11/29/21 1/13/22 Pending Allergy Testing and Therapy
2021-UHC-1166 C & S Utilization Management of BH Benefits Addendum 11/23/21 1/7/22 Pending C & S Utilization Management of BH Benefits Addendum
2021-HBL-601 Hyperthermia for Cancer Therapy 11/22/21 1/6/22 Pending Hyperthermia for Cancer Therapy
2021-LDH-14 MCO Manual > Part 4: Services > Professional Services > Cardiovascular Services (Proposed effective date = 1/26/2022) 11/3/2021 12/18/2021 Completed MCO Manual > Part 4: Services > Professional Services > Cardiovascular Services
2021-LDH-13 MCO Manual > Part 4: Services > Professional Services > Cochlear Implant (Proposed effective date = 1/26/2022) MCO Manual > Part 4: Services > Professional Services > Cochlear Implant (Proposed effective date = 1/26/2022) 11/3/2021 12/18/2021 Completed MCO Manual > Part 4: Services > Professional Services > Cochlear Implant
2021-HBL-1165 Psychological testing and Neuropsychological Testing 11/2/21 12/17/21 Approved Psychological testing and Neuropsychological Testing
2021-HBL-1164 Serum Biomarker Tests for Risk of Preeclampsia 11/2/21 12/17/21 Approved Serum Biomarker Tests for Risk of Preeclampsia
2021-HBL-1163 TruGraf Blood Gene Exp Test for Trans Monit 11/2/21 12/17/21 Approved TruGraf Blood Gene Exp Test for Trans Monit
2021-HBL-1162 Substance Use Disorders-Residential Treatment 11/2/21 12/17/21 Approved Substance Use Disorders-Residential Treatment
2021-HBL-1154 Pre-certification of Requested Services 11/2/21 12/17/21 Approved Pre-certification of Requested Services
2021-ABH-938 Sterilization Policy 11/2/21 12/17/21 Approved Steilization Policy
2021-HBL-1031 Modifier 26 and TC: Professional and Technical Component 10/25/21 12/9/21 Approved Modifier 26 and TC: Professional and Technical Component
2021-HBL-1048 Intracardiac Electrophysiological Studies 10/25/21 12/9/21 Approved Intracardiac Electrophysiological Studies
2021-HBL-1149 Colonoscopy 10/25/21 12/9/21 Approved Colonoscopy
2021-HBL-1150 Cardiac Stress Testing with Electrocardiogram 10/25/21 12/9/21 Approved Cardiac Stress Testing with Electrocardiogram
2021-HBL-1151 Intracytoplasmic Sperm Injection 10/25/21 12/9/21 Approved Intracytoplasmic Sperm Injection
2021-HBL-1152 Functional Endoscopic Sinus Surgery 10/25/21 12/9/21 Approved Functional Endoscopic Sinus Surgery
2021-HBL-1153 Vagus Nervous Stimulator 10/25/21 12/9/21 Approved Vagus Nervous Stimulator
2021-HBL-1155 Home Parenteral Nutrition 10/25/21 12/9/21 Approved Home Parenteral Nutrition
2021-HBL-1156 Eye Move Analysis Using Non-spatial Calib for the Diag of Concussion 10/25/21 12/9/21 Approved Eye Move Analysis Using Non-spatial Calib for the Diag of Concussion
2021-HBL-1157 Open Sacroiliac Joint Fusion 10/25/21 12/9/21 Approved Open Sacroiliac Joint Fusion
2021-HBL-1158 Site of Care: Advanced Radiologic Imaging 10/25/21 12/9/21 Approved Site of Care: Advanced Radiologic Imaging
2021-HBL-1159 Endobronchial Valve Devices 10/25/21 12/9/21 Approved Endobronchial Valve Devices
2021-HBL-1160 Microprocessor Controlled Knee-Ankle-Foot Orthosis 10/25/21 12/9/21 Approved Microprocessor Controlled Knee-Ankle-Foot Orthosis
2021-HBL-1161 Tonsillectomy with or without Adenoidectomy for Adults 10/25/21 12/9/21 Approved Tonsillectomy with or without Adenoidectomy for Adults
2021-HBL-1162 Substance Use Disorders-Residential Treatment 10/25/21 12/9/21 Approved Substance Use Disorders-Residential Treatment
2021-ABH-1135 Drug Biological Policy 10/12/21 11/27/21 Approved Drug Biological Policy
2021-ACLA-1148 Unlisted Studies 10/12/21 11/26/21 Approved Unlisted Studies
2021-ACLA-1147 Brain PET Scan 10/12/21 11/26/21 Approved Brain PET Scan
2021-HBL-1145 Neuromuscular Stimulation in the Treatment of Muscle Atrophy 10/12/21 11/26/21 Approved Neuromuscular Stimulation in the Treatment of Muscle Atrophy
2021-ACLA-893 Abdomen CT Angiography 10/12/21 11/26/21 Approved Abdomen CT Angiography
2021-ACLA-892 Abdomen CT 10/12/21 11/26/21 Approved Abdomen CT
2021-ACLA-891 Abdomen MRI, MRCP 10/12/21 11/26/21 Approved Abdomen MRI, MRCP
2021-ACLA-890 Abdomen/Pelvis CT Combo 10/12/21 11/26/21 Approved Abdomen/Pelvis CT Combo
2021-ACLA-889 Abdomen MRA (Angiography) 10/12/21 11/26/21 Approved Abdomen MRA (Angiography)
2021-ACLA-888 Abdomen/Pelvis CT Combo 10/12/21 11/26/21 Approved Abdomen/Pelvis CT Combo
2021-ACLA-887 Abdominal Arteries CT Angiography 10/12/21 11/26/21 Approved Abdominal Arteries CT Angiography
2021-ACLA-886 Bone Marrow MRI 10/12/21 11/26/21 Approved Bone Marrow MRI
2021-ACLA-885 Brain (Head) CTA 10/12/21 11/26/21 Approved Brain (Head) CTA
2021-ACLA-884 Brain (Head) MRA/MRV 10/12/21 11/26/21 Approved Brain (Head) MRA/MRV
2021-ACLA-883 Brain (Head) CT 10/12/21 11/26/21 Approved Brain (Head) CT
2021-ACLA-882 Brain (Head) MRI, Brain (Head) MRI with IAC (Internal Auditory Canal) 10/12/21 11/26/21 Approved Brain (Head) MRI, Brain (Head) MRI with IAC (Internal Auditory Canal)
2021-ACLA-881 Cervical Spine CT 10/12/21 11/26/21 Approved Cervical Spine CT
2021-ACLA-880 Cervical Spine MRI 10/12/21 11/26/21 Approved Cervical Spine MRI
2021-ACLA-879 Brain (Head) MRS 10/12/21 11/26/21 Approved Brain (Head) MRS
2021-ACLA-878 Chest (Thorax) MRI 10/12/21 11/26/21 Approved Chest (Thorax) MRI
2021-ACLA-877 Chest MRA 10/12/21 11/26/21 Approved Chest MRA
2021-ACLA-876 Chest CTA 10/12/21 11/26/21 Approved Chest CTA
2021-ACLA-875 Chest (Thorax) CT 10/12/21 11/26/21 Approved Chest (Thorax) CT
2021-ACLA-874 CT Virtual Colonoscopy 10/12/21 11/26/21 Approved CT Virtual Colonoscopy
2021-ACLA-873 CT Bone Density Study 10/12/21 11/26/21 Approved CT Bone Density Study
2021-ACLA-872 CT Coronary Angiography (CCTA) 10/12/21 11/26/21 Approved CT Coronary Angiography (CCTA)
2021-ACLA-871 Sinus Face Orbit MRI 10/12/21 11/26/21 Approved Sinus Face Orbit MRI
2021-ACLA-870 Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal MRI 10/12/21 11/26/21 Approved Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal MRI
2021-ACLA-869 Sinus & Maxillofacial CT 10/12/21 11/26/21 Approved Sinus & Maxillofacial CT
2021-ACLA-868 Spinal Canal MRA 10/12/21 11/26/21 Approved Spinal Canal MRA
2021-ACLA-867 Temporomandibular Joint (TMJ) MRI 10/12/21 11/26/21 Approved Temporomandibular Joint (TMJ) MRI
2021-ACLA-866 Thoracic Spine CT 10/12/21 11/26/21 Approved Thoracic Spine CT
2021-ACLA-865 Upper Extremity CTA/CTV 10/12/21 11/26/21 Approved Upper Extremity CTA/CTV
2021-ACLA-864 Lower Extremity CTA/CTV 10/12/21 11/26/21 Approved Lower Extremity CTA/CTV
2021-ACLA-863  Thoracic Spine MRI  10/12/21 11/26/21 Approved Thoracic Spine MRI 
2021-ACLA-862 Upper Extremity CTA/CTV 10/12/21 11/26/21 Approved Upper Extremity CTA/CTV
2021-ACLA-861 Breast MRI 10/12/21 11/26/21 Approved Breast MRI
2021-ACLA-859 Upper Extremity MRI 10/12/21 11/26/21 Approved Upper Extremity MRI
2021-ACLA-858 Upper Extremity MRA/MRV 10/12/21 11/26/21 Approved Upper Extremity MRA/MRV
2021-ACLA-857 CT Heart, CT Heart Congenital 10/12/21 11/26/21 Approved CT Heart, CT Heart Congenital
2021-ACLA-856 Functional Brain MRI 10/12/21 11/26/21 Approved Functional Brain MRI
2021-ACLA-855 Heart (cardiac) PET 10/12/21 11/26/21 Approved Heart (cardiac) PET
2021-ACLA-854 EBCT 10/12/21 11/26/21 Approved EBCT
2021-ACLA-853 Heart MRI 10/12/21 11/26/21 Approved Heart MRI
2021-ACLA-852 Heart (Cardiac) PET withy CT for Attenuation 10/12/21 11/26/21 Approved Heart (Cardiac) PET withy CT for Attenuation
2021-ACLA-851 Low Dose CT for Lung Cancer Screening 10/12/21 11/26/21 Approved Low Dose CT for Lung Cancer Screening
2021-ACLA-850 Lower Extremity CT 10/12/21 11/26/21 Approved Lower Extremity CT
2021-ACLA-849 Lower Extremity MRA/MRV 10/12/21 11/26/21 Approved Lower Extremity MRA/MRV
2021-ACLA-848 Lower Extremity MRI   10/12/21 11/26/21 Approved Lower Extremity MRI  
2021-ACLA-847 Lumbar Spine MRI 10/12/21 11/26/21 Approved Lumbar Spine MRI
2021-ACLA-846 Lumbar Spine CT 10/12/21 11/26/21 Approved Lumbar Spine CT
2021-ACLA-845 MPI Myocardial Perfusion Imaging 10/12/21 11/26/21 Approved MPI Myocardial Perfusion Imaging
2021-ACLA-844 Low Field MRI 10/12/21 11/26/21 Approved Low Field MRI
2021-ACLA-843 Neck CT 10/12/21 11/26/21 Approved Neck CT
2021-ACLA-842 MUGA Multiple Gated Acquisition Scan 10/12/21 11/26/21 Approved MUGA Multiple Gated Acquisition Scan
2021-ACLA-841 Neck CTA 10/12/21 11/26/21 Approved Neck CTA
2021-ACLA-840 Neck MRA/MRV 10/12/21 11/26/21 Approved Neck MRA/MRV
2021-ACLA-839 Pelvis CT 10/12/21 11/26/21 Approved Pelvis CT
2021-ACLA-838 Pelvis CT Angiography 10/12/21 11/26/21 Approved Pelvis CT Angiography
2021-ACLA-837 Pelvis MRA 10/12/21 11/26/21 Approved Pelvis MRA
2021-ACLA-836 Pelvis MRI 10/12/21 11/26/21 Approved Pelvis MRI
2021-ABH-1129 Home Health Home Infusion 10/11/21 11/25/21 Approved Home Health Home Infusion
2021-LDH-12 MCO Manual > Part 4: Services > Medical Transportation > Ambulance (Proposed effective date = 12/27/2021) 10/7/21 11/21/21 Completed MCO Manual > Part 4: Services > Medical Transportation > Ambulance (Proposed effective date = 12/27/2021)
2021-HBL-1092 Cryoneurolysis for Treatment of Peripheral Nerve Pain 10/1/21 11/15/21 Approved Cryoneurolysis for Treatment of Peripheral Nerve Pain
2021-HBL-1116 Pre-Certification of Requested Services 10/1/21  11/15/21 Approved Pre-Certification of Requested Services
2021-ABH-1131 Revenue Code-HCPCS Code Links 10/1/21  11/15/21 Approved Revenue Code-HCPCS Code Links
2021-HBL-1146 Oral, Pharyn and Maxillo Surg Tx for Obstructive Sleep Apnea or Snoring 10/1/21  11/15/21 Approved Oral, Pharyn and Maxillo Surg Tx for Obstructive Sleep Apnea or Snoring
2021-HBL-1144 Vacuum Assisted Wound Therapy in the outpatient setting 9/24/21 11/8/21 Approved Vacuum Assisted Wound Therapy in the outpatient setting
2021-HBL-1143 Machie Learn der prob for rapid Kidney 9/24/21 11/8/21 Approved Machie Learn der prob for rapid Kidney
2021-HBL-1142 Perirectal Spacers for Use During Prostate Radiotherapy 9/24/21 11/8/21 Approved Perirectal Spacers for Use During Prostate Radiotherapy
2021-ABH-1126 Non-OB Ultrasound Redundant Policy 9/24/21 11/8/21 Approved Non-OB Ultrasound Redundant Policy
2021-HBL-543 Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome 9/22/21 11/6/21 Approved Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
2021-HBL-598 Janus Kinase 2 CALR and MPL GENE Mutation Assays 9/22/21 11/6/21 Approved Janus Kinase 2 CALR and MPL GENE Mutation Assays
2021-HBL-600 Tonsillectomy for Children with or without Adenoidectomy 9/22/21 11/6/21 Approved Tonsillectomy for Children with or without Adenoidectomy
2021-HBL-1140 Prostate Biopsy using MRI Fusion Techniques 9/22/21 11/6/21 Approved Prostate Biopsy using MRI Fusion Techniques
2021-HBL-1141 Paired DNA and Messenger RNA (mRNA) Genetic Test to Detect, Diag Mng Cancer 9/22/21 11/6/21 Approved Paired DNA and Messenger RNA (mRNA) Genetic Test to Detect, Diag Mng Cancer
2021-LDH-11 Part 4: Services > Professional Services > Skin Substitutes 9/22/21 11/6/21 Completed MCO Manual: Skin Substitutes
2021-LDH-10 Part 4: Services > Medical Transportation (NEMT) 9/14/21 10/29/21 Completed Medical Transportation: NEMT
2021-UHC-1123 Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds 8/17/21 9/30/21 Approved Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds
2021-UHC-1122 Percutaneous Vertebroplasty and Kyphoplasty 8/17/21 9/30/21 Approved Percutaneous Vertebroplasty and Kyphoplasty
2021-UHC-1121 Intrauterine Fetal Surgery 8/17/21 9/30/21 Approved Intrauterine Fetal Surgery
2021-UHC-1120 Percutaneous Patent Foramen Ovale (PFO) Closure 8/17/21 9/30/21 Approved Percutaneous Patent Foramen Ovale (PFO) Closure
2021-UHC-1119 Bronchial Thermoplasty 8/17/21 9/30/21 Approved Bronchial Thermoplasty
2021-LHCC-1118 Preventive Health and Clinical Practice Guidelines 8/17/21 9/30/21 Completed Preventive Health and Clinical Practice Guidelines
2021-UHC-378 Surgery of the Shoulder 8/17/21 9/30/21 Approved Surgery of the Shoulder
2021-LHCC-1117 Contract Effective Date 8/13/21 9/26/21 Completed Contract Effective Date
2021-LDH-9 Part 4: Services > Professional Services > Early and Periodic Screening, Diagnostic, and Treatment Preventive Services Program 8/11/21 9/25/21 Completed EPSDT Preventive Services Program
2021-LDH-8 Part 4: Services > Professional Services > Physician Administered Medication 8/6/21 9/20/21 Completed Physician Administered Medication
2021-LDH-7 Part 4: Services > Professional Services > Genetic Testing 7/27/2021 9/10/2021 Completed MCO Manual – Genetic Counseling
2021-ACLA-1106 Avesis Eye Authorizations 7/29/21 9/12/21 Approved Avesis Eye Authorizations
2021-ACLA-1104 Chest (Thorax) CT 7/26/21 9/9/21 Approved Chest (Thorax) CT
2021-ACLA-1105 Low Dose CT for Lung Cancer Screening 7/26/21 9/9/21 Approved Low Dose CT for Lung Cancer Screening
2021-HBL-1008 PDHC & PCS 7/22/21 9/5/21 Approved PDHC & PCS
2021-UHC-823 Provider Manual 7/20/21 9/2/21 Approved Provider Manual
2021-LHCC-993 Administrative Denials 7/2/21 8/16/21 Approved Administrative Denials
2021-HBL-1102 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft TissueGrafting 7/1/21 8/15/21 Approved Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft TissueGrafting
2021-HBL-1101 Cardiac Contractility Modulation Therapy 7/1/21 8/15/21 Approved Cardiac Contractility Modulation Therapy
2021-HBL-1100 Uterine Transplantation 7/1/21 8/15/21 Approved Uterine Transplantation
2021-HBL-1099 Focal Laser Ablation for the treatment of Prostate Cancer 7/1/21 8/15/21 Approved Focal Laser Ablation for the treatment of Prostate Cancer
2021-HBL-1098 Mechanical Circulatory Assist Device 7/1/21 8/15/21 Approved Mechanical Circulatory Assist Device
2021-HBL-1097 Implantable Peripheral Nerve Stimulation Devices 7/1/21 8/15/21 Approved Implantable Peripheral Nerve Stimulation Devices
2021-HBL-1096 Minimally Invasive treatment of the Posterior Nasal Nerve to treat Rhinitis 7/1/21 8/15/21 Approved Minimally Invasive treatment of the Posterior Nasal Nerve to treat Rhinitis
2021-HBL-1095 Implanted Artificial Iris Device 7/1/21 8/15/21 Approved Implanted Artificial Iris Device
2021-HBL-1094 Electrophysiolgy – Guided Non-invasive Stereotactic Cardiac Radioblation 7/1/21 8/15/21 Approved Electrophysiolgy – Guided Non-invasive Stereotactic Cardiac Radioblation
2021-HBL-1093 Microsurgical Procedures for the treatment of Lymphedema 7/1/21 8/15/21 Approved Microsurgical Procedures for the treatment of Lymphedema
2021-HBL-1092 Cryoneurolysis for treatment of Peripheral Nerve Pain 7/1/21 8/15/21 Approved Cryoneurolysis for treatment of Peripheral Nerve Pain
2021-HBL-804 Non-Hematopoietic Adult Stem Cell Therapy 7/1/21 8/15/21 Approved Non-Hematopoietic Adult Stem Cell Therapy
2021-HBL-1091 Transcatheter Heart Valve Procedures 6/28/21 8/12/21 Approved Transcatheter Heart Valve Procedures
2021-HBL-1090 Internal Rib Fixation 6/28/21 8/12/21 Approved Internal Rib Fixation
2021-HBL-1089 Implantation of Occippiral, Supraorbital or Trigeminal Nerve Stimulation Device 6/28/21 8/12/21 Approved Implantation of Occippiral, Supraorbital or Trigeminal Nerve Stimulation Device
2021-HBL-1088 Vertebral Body Stapling 6/28/21 8/12/21 Approved Vertebral Body Stapling
2021-HBL-1087 Uterine Fibroid Ablation 6/28/21 8/12/21 Approved Uterine Fibroid Ablation
2021-HBL-1086 Vein Embolization 6/28/21 8/12/21 Approved Vein Embolization 
2021-HBL-1085 Transendoscopic Therapy 6/28/21 8/12/21 Approved Transendoscopic Therapy
2021-HBL-1084 Extracorporeal Shock Wave 6/28/21 8/12/21 Approved Extracorporeal Shock Wave
2021-HBL-803 Percutaneoud Vertebral Disc and Vertebral Endplate Procedures 6/28/21 8/12/21 Approved Percutaneoud Vertebral Disc and Vertebral Endplate Procedures
2021-HBL-591 Wireless Cardiac Resynchronization Therapy 6/28/21 8/12/21 Approved Wireless Cardiac Resynchronization Therapy
2021-HBL-1083 Treatment of Varicose Veins 6/25/21 8/9/21 Approved Treatment of Varicose Veins
2021-HBL-1082 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention 6/25/21 8/9/21 Approved Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
2021-HBL-1081 Non-Invasive HF and Arrhythmia and Monitoring System 6/25/21 8/9/21 Approved Non-Invasive HF and Arrhythmia and Monitoring System
2021-HBL-1080 Ingestion Event Monitors 6/25/21 8/9/21 Approved Ingestion Event Monitors
2021-HBL-1079 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation 6/25/21 8/9/21 Approved Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation
2021-HBL-1078 Electronic Home Visual Field Monitoring 6/25/21 8/9/21 Approved Electronic Home Visual Field Monitoring
2021-HBL-1077 Insulin Potentiation Therapy 6/25/21 8/9/21 Approved Insulin Potentiation Therapy
2021-HBL-1076 Chelation Therapy 6/25/21 8/9/21 Approved Chelation Therapy
2021-HBL-1075 Gene Therapy for Ocular Conditions Medical Policy 6/25/21 8/9/21 Approved Gene Therapy for Ocular Conditions Medical Policy
2021-HBL-1074 Optical Detection for Screen and Ident of Cervical Cancer 6/25/21 8/9/21 Approved Optical Detection for Screen and Ident of Cervical Cancer
2021-HBL-1073 Tech for the evaluation of Skin Lesions 6/25/21 8/9/21 Approved Tech for the evaluation of Skin Lesions
2021-HBL-1072 Pooled Antibiotic Sensitivity Testing 6/25/21 8/9/21 Approved Pooled Antibiotic Sensitivity Testing
2021-HBL-1071 Cell-free DNA Test to Aid in the Monitoring of Kidney Trans for Rejection 6/25/21 8/9/21 Approved Cell-free DNA Test to Aid in the Monitoring of Kidney Trans for Rejection
2021-HBL-1070 Serologic Testing for Biomarkers of IBS 6/25/21 8/9/21 Approved Serologic Testing for Biomarkers of IBS
2021-HBL-1069 Protein Biomarkers for the Screening Detection and Management of Prostate Cancer 6/25/21 8/9/21 Approved Protein Biomarkers for the Screening Detection and Management of Prostate Cancer
2021-HBL-1068 Selected Blood Serum and Cellular Allergy and Toxicity Tests Policy 6/25/21 8/9/21 Approved Selected Blood Serum and Cellular Allergy and Toxicity Tests Policy
2021-HBL-1067 Analysis of Proteomic Patterns 6/25/21 8/9/21 Approved Analysis of Proteomic Patterns
2021-HBL-1066 Gene Expression Profiling for Bladder Cancer Policy 6/25/21 8/9/21 Approved Gene Expression Profiling for Bladder Cancer Policy
2021-HBL-1065 Gene Expression Profiling for Risk Strat of IBD severity 6/25/21 8/9/21 Approved Gene Expression Profiling for Risk Strat of IBD severity
2021-HBL-802 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, Soft Tissue Grafting, and Regenerative Therapy 6/25/21 8/9/21 Approved Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, Soft Tissue Grafting, and Regenerative Therapy
2021-HBL-796 Surface Electromyography Devices for Seizure Monitoring 6/25/21 8/9/21 Approved Surface Electromyography Devices for Seizure Monitoring
2021-HBL-594 Genotype Testing for Genetic Polymorphisms to determine Drug-Metabolizer status 6/25/21 8/9/21 Approved Genotype Testing for Genetic Polymorphisms to determine Drug-Metabolizer status
2021-ACLA-997 Optometry Prior Authorization requirement revisions 6/24/21 8/8/21 Approved Optometry Prior Authorization requirement revisions fee schedule Optometry Prior Authorization requirement revisions memorandum
2021-ACLA-996 Ophthalmology Prior Authorization requirement revisions 6/24/21 8/8/21 Approved Ophthalmology Prior Authorization requirement revisions fee schedule Ophthalmology Prior Authorization requirement revisions memorandum
2021-ACLA-995 Ocularist Prior Authorization requirement revisions 6/24/21 8/8/21 Approved Ocularist Prior Authorization requirement revisions fee schedule Ocularist Prior Authorization requirement revisions memorandum
2021-UHC-1064 Utilization Management of Behavioral Health Benefits Addendum 6/23/21 8/7/21 Approved Utilization Management of Behavioral Health Benefits Addendum
2021-UHC-1063 Temporomandibular Joint Disorder 6/23/21 8/7/21 Approved Temporomandibular Joint Disorder
2021-HBL-1062 Metagenomic Sequencing for Infectious Disease in the outpatient setting 6/23/21 8/7/21 Approved Metagenomic Sequencing for Infectious Disease in the outpatient setting
2021-HBL-1061 Venous Angiop w or w/out Stent Placement or Venous Stent Alone 6/23/21 8/7/21 Approved Venous Angiop w or w/out Stent Placement or Venous Stent Alone
2021-HBL-1060 Level of Care - Specialty Pharmaceitcals 6/23/21 8/7/21 Approved Level of Care - Specialty Pharmaceitcals
2021-HBL-1059 HIFU for Oncologic Indications 6/23/21 8/7/21 Approved HIFU for Oncologic Indications
2021-HBL-1058 Whole Genome Sequ. Whole Exome Sequ. Gene Panels and Molecular Prof 6/23/21 8/7/21 Approved Whole Genome Sequ. Whole Exome Sequ. Gene Panels and Molecular Prof
2021-HBL-1057 Bronchial Gene Exp Class for the Diagnostic Eval of Lung Cancer 6/23/21 8/7/21 Approved Bronchial Gene Exp Class for the Diagnostic Eval of Lung Cancer 
2021-HBL-1056 Elec Posit Devices for the treatment of Obstructive Sleep Apnea 6/23/21 8/7/21 Approved Elec Posit Devices for the treatment of Obstructive Sleep Apnea
2021-HBL-1055 Low Intensity Therapeutic Ultrasound for the treatment of pain 6/23/21 8/7/21 Approved Low Intensity Therapeutic Ultrasound for the treatment of pain
2021-HBL-1054 Cooling Devices and Combined Cooling-Heating Devices 6/23/21 8/7/21 Approved Cooling Devices and Combined Cooling-Heating Devices
2021-HBL-1053 Elect Stim as a Trtmnt for Pain and Other Cond-Surf and Percut Devices 6/23/21 8/7/21 Approved Elect Stim as a Trtmnt for Pain and Other Cond-Surf and Percut Devices
2021-HBL-1052 Panniculectomy and Abdominoplasty 6/23/21 8/7/21 Approved Panniculectomy and Abdominoplasty
2021-HBL-1051 Cardioverter Defibrillators 6/23/21 8/7/21 Approved Cardioverter Defibrillators
2021-HBL-1050 Minimally Invasive Ablative Procedures for Elipesy 6/23/21 8/7/21 Approved Minimally Invasive Ablative Procedures for Elipesy
2021-HBL-1049 Reduction Mammoplasty 6/23/21 8/7/21 Approved Reduction Mammoplasty
2021-HBL-1048 Intracardiac Electrophysiological Studies 6/23/21 8/7/21 Approved Intracardiac Electrophysiological Studies
2021-HBL-1047 Gender Reassignment Surgery 6/23/21 8/7/21 Approved Gender Reassignment Surgery
2021-HBL-1046 Stereotactic Radiofrequency Pallidotomy 6/23/21 8/7/21 Approved Stereotactic Radiofrequency Pallidotomy
2021-HBL-1045 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia 6/23/21 8/7/21 Approved Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia
2021-HBL-811 HBL-Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies 6/23/21 8/7/21 Approved HBL-Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
2021-HBL-800 Prothrombin Genetic Testing 6/23/21 8/7/21 Approved Prothrombin Genetic Testing
2021-HBL-798 Gene Expression Profiling of Melanomas 6/23/21 8/7/21 Approved Gene Expression Profiling of Melanomas
2021-HBL-589 Non-Covered and Cost Effective Alternative Services 6/23/21 8/7/21 Approved Non-Covered and Cost Effective Alternative Services
2021-HBL-599 Temporomandibular Disorders 6/17/21 7/31/21 Approved Temporomandibular Disorders
2021-HBL-807 Male Circumcision  6/17/21 7/31/21 Approved Male Circumcision
2021-HBL-983 Professional Anesthesia  6/17/21 7/31/21 Approved Professional Anesthesia
2021-HBL-1041 Cranial Remodeling Bands and Helmets  6/17/21 7/31/21 Approved Cranial Remodeling Bands and Helmets
2021-HBL-1042 Ablative Techniques as a treatment for Barrett’s Esophagus  6/17/21 7/31/21 Approved Ablative Techniques as a treatment for Barrett’s Esophagus
2021-HBL-1043 Alcohol Septal Ablation for treatment of Hypertrophic Cardiomyopathy  6/17/21 7/31/21 Approved Alcohol Septal Ablation for treatment of Hypertrophic Cardiomyopathy
2021-HBL-1044 Intraoperative Neurophysiological Monitoring  6/17/21 7/31/21 Approved Intraoperative Neurophysiological Monitoring
2021-LDH-6 Part 7: Provider Services > Enrollee Reassignment Policy 6/10/21 7/25/2021 Pending Part 7: Provider Services > Enrollee Reassignment Policy
2021-LHCC-912 Medical Management 6/10/21 7/25/21 Approved Medical Management - Attachment 1, Attachment 2, Attachment 3, Attachment 4, Attachment 5, Attachment 6, Attachment 7, Attachment 8, Attachment 9, Attachment 10
2021-HBL-1040 Genetic Testing for PTEN Hematoma Tumor Syndrome 6/14/21 7/28/21 Approved Genetic Testing for PTEN Hematoma Tumor Syndrome
2021-HBL-1039 BCR-ABLK Mutation Analysis 6/14/21 7/28/21 Approved BCR-ABLK Mutation Analysis
2021-HBL-1038 Enhanced External Counter pulsation in the outpatient setting 6/14/21 7/28/21 Approved Enhanced External Counter pulsation in the outpatient setting
2021-HBL-1037 Posterior Segment Optical Coherence Tomography 6/14/21 7/28/21 Approved Posterior Segment Optical Coherence Tomography
2021-HBL-1036 Home Health Utilization Management 6/14/21 7/28/21 Approved Home Health Utilization Management
2021-HBL-1035 Diaphragmatic/Phrenic Nerve stim and Diaph Pacing system 6/14/21 7/28/21 Approved Diaphragmatic/Phrenic Nerve stim and Diaph Pacing system
2021-HBL-1034 Anesthesia Services for Interventional Pain Management 6/14/21 7/28/21 Approved Anesthesia Services for Interventional Pain Management
2021-HBL-1033 Therapeutic Apheresis 6/14/21 7/28/21 Approved Therapeutic Apheresis
2021-HBL-1032 Transcath ablation of arrhyth foci in the pulm veins 6/14/21 7/28/21 Approved Transcath ablation of arrhyth foci in the pulm veins
2021-ACLA-1029 Endovascular treatment for intermittent claudication 6/14/21 7/28/21 Approved Endovascular treatment for intermittent claudication
2021-HBL-1028 Molecular (GIPP) Testing for Infectious Diarrhea in the outpatient setting 6/14/21 7/28/21 Approved Molecular (GIPP) Testing for Infectious Diarrhea in the outpatient setting
2021-HBL-1027 Red blood cell folic acid testing 6/14/21 7/28/21 Approved Red blood cell folic acid testing
2021-HBL-1026 Gene Expression Profiling for managing breast cancer treatment 6/14/21 7/28/21 Approved Gene Expression Profiling for managing breast cancer treatment
2021-HBL-1025 Detect and Quant of tumor DNA Usage next gen sequence in lymph cancers 6/14/21 7/28/21 Approved Detect and Quant of tumor DNA Usage next gen sequence in lymph cancers
2021-HBL-1024 Gene Mutat Test for solid tumor cancer susceptibility and management 6/14/21 7/28/21 Approved Gene Mutat Test for solid tumor cancer susceptibility and management
2021-HBL-1023 Genetic Testing for Inherited Disease 6/14/21 7/28/21 Approved Genetic Testing for Inherited Disease
2021-HBL-1022 Genotype Test for Individual Genetic Polymorph to determine Drug-metab status 6/14/21 7/28/21 Approved Genotype Test for Individual Genetic Polymorph to determine Drug-metab status
2021-HBL-1015 Mobile Devise-Based Health Management applications 6/14/21 7/28/21 Approved Mobile Devise-Based Health Management applications
2021-LHCC-994 Ambularoty Insulin Pump 6/14/21 7/28/21 Approved Ambularoty Insulin Pump
2021-HBL-810 Bone Mineral Density Testing Measurement 6/14/21 7/28/21 Approved Bone Mineral Density Testing Measurement
2021-HBL-809 Inpatient Inter-facility Transfers 6/14/21 7/28/21 Approved Inpatient Inter-facility Transfers
2021-HBL-805 Nininvasive Home Ventilator Therapy for Respiratory Failure 6/14/21 7/28/21 Approved Nininvasive Home Ventilator Therapy for Respiratory Failure
2021-HBL-801 Single Photon Emission CTS for Non-cardiovascular Indications 6/14/21 7/28/21 Approved Single Photon Emission CTS for Non-cardiovascular Indications
2021-HBL-597 Electric Tumor Treatment Field 6/14/21 7/28/21 Approved Electric Tumor Treatment Field
2021-HBL-590 Gene Expression Profiling for Coronary Artery Disease 6/14/21 7/28/21 Approved Gene Expression Profiling for Coronary Artery Disease
2021-HBL-999 UM AROW 1327 PA Requirements 6/8/21 7/23/21 Approved UM AROW 1327 PA Requirements
2021-HBL-1004 UM AROW 1837 PA Requirements 6/8/21 7/23/21 Approved UM AROW 1837 PA Requirements
2021-HBL-1005 UM AROW 1576 PA Requirements 6/8/21 7/23/21 Approved UM AROW 1576 PA Requirements
2021-HBL-1014 Imaging of the Chest (AIM) 6/7/21 7/22/21 Approved Imaging of the Chest (AIM)
2021-HBL-1013 Imaging of the Head and Neck (AIM) 6/7/21 7/22/21 Approved Imaging of the Head and Neck (AIM)
2021-HBL-1012 Oncology Imaging (AIM) 6/7/21 7/22/21 Approved Oncology Imaging (AIM)
2021-HBL-1011 Radiation Oncology (AIM) 6/7/21 7/22/21 Approved Radiation Oncology (AIM)
2021-HBL-1010 Imaging of the Brain (AIM) 6/7/21 7/22/21 Approved Imaging of the Brain (AIM)
2021-HBL-1009 Advanced Imaging of the Heart (AIM) 6/7/21 7/22/21 Approved Advanced Imaging of the Heart (AIM)
2021-HBL-985 Small Joint Surgery Criteria (AIM) 6/7/21 7/22/21 Approved Small Joint Surgery Criteria (AIM)
2021-UHC-961 Elective Inpatient Services 6/7/21 7/22/21 Approved Elective Inpatient Services
2021-HBL-256 Member Complaints and Grievances 6/7/21 7/22/21 Approved Member Complaints and Grievances
2021-LHCC-338 Perinatal Substance Use Disorder Care Management Program 5/27/21 7/11/21 Approved Perinatal Substance Use Disorder Care Management Program
2021-LHCC-911 Network Adequacy 5/27/21 7/11/21 Approved Network Adequacy
2021-HBL-951 Durable Medical Equipment 5/27/21 7/11/21 Approved Durable Medical Equipment
2021-ABH-953 Multi-Systemic Therapy (MST) 5/27/21 7/11/21 Approved Multi-Systemic Therapy (MST)
2021-ABH-954 Community Psychiatric Support and Treatment and Psychosocial Rehabilitation 5/27/21 7/11/21 Approved Community Psychiatric Support and Treatment and Psychosocial Rehabilitation
2021-ABH-955 Cris Intervention Services 5/27/21 7/11/21 Approved Cris Intervention Services
2021-ABH-956 Concurrent Review-Observation Care 5/27/21 7/11/21 Approved Concurrent Review-Observation Care
2021-ABH-957 Assertive Community Treatment Services 5/27/21 7/11/21 Approved Assertive Community Treatment Services
2021-ACLA-984 Behavioral Health Provider Quality Monitoring Plan 5/27/21 7/11/21 Approved Behavioral Health Provider Quality Monitoring Plan
2021-ACLA-989 Ambulance Services 5/27/21 7/11/21 Approved Ambulance Services
2021-LDH-5 Part 4: Services > Professional Services > Obstetrics 5/20/21 7/4/21 Pending MCO Manual: Obstetrics -- Tobacco Cessation
2021-HBL-986 Diagnostic Coronary Angiography 5/20/21 7/3/21 Approved Diagnostic Coronary Angiography
2021-HBL-998 Laser Trabeculoplasty and Laser Peripheral Iridotomy 5/20/21 7/3/21 Approved Laser Trabeculoplasty and Laser Peripheral Iridotomy
2021-LHCC-990 Medical Necessity
Review		 5/20/21 7/3/21 Completed Medical Necessity
Review
2021-LHCC-991 Concurrent Review 5/20/21 7/3/21 Completed Concurrent Review
2021-LHCC-992 Post Discharge Member Outreach Calls 5/20/21 7/3/21 Completed Post Discharge Member Outreach Calls
2021-LHCC-140 Timeliness of UM Decisions 5/13/21 6/27/21 Approved Timeliness of UM Decisions Attachment 1 Attachment 2
2021-LHCC-982 Outpatient Applied Behavioral Analysis Medical Necessity 5/13/21 6/27/21 Approved Outpatient Applied Behavioral Analysis Medical Necessity
2021-HBL-952 Multiple and Bilateral Policy 5/13/21 6/27/21 Approved Multiple and Bilateral Policy
2021-HBL-947 Modifier 90 Reimbursement Policy 5/13/21 6/27/21 Approved Modifier 90 Reimbursement Policy
2021-LHCC-915 PASRR Level II Evaluations Work Plan 5/13/21 6/27/21 Approved PASRR Level II Evaluations Work Plan
2021-LHCC-913 PASRR Level II Evaluations 5/13/21 6/27/21 Approved PASRR Level II Evaluations
2021-LHCC-606 Grievance Process 5/13/21 6/27/21 Approved Grievance Process
2021-LHCC-504 Quality PIPs 5/13/21 6/27/21 Approved Quality PIPs
2021-LHCC-501 Access to Non-Emergency Transportation 5/13/21 6/27/21 Approved Access to Non-Emergency Transportation
2021-LHCC-966 Cultural and Linguistic Policy 4/26/21 6/9/21 Completed Cultural and Linguistic Policy
2021-LHCC-965 Member Provider Call Audit and Quality Criteria and Protocol 4/26/21 6/9/21 Completed Member Provider Call Audit and Quality Criteria and Protocol
2021-LHCC-964 Predictive Modeling Methodology 4/26/21 6/9/21 Approved Predictive Modeling Methodology
2021-LHCC-919 Website Guidelines 4/26/21 6/9/21 Completed Website Guidelines
2021-LHCC-814 Crisis Intervention Policy 4/26/21 6/9/21 Approved Crisis Intervention Policy
2021-LHCC-605 Provider Visit Schedule PP 4/26/21 6/9/21 Completed Provider Visit Schedule PP
2021-LHCC-526 TruCare Standards for Documentation policy 4/26/21 6/9/21 Approved TruCare Standards for Documentation policy
2021-LHCC-499 Retrospective Review For Services Requiring Authorizations 4/26/21 6/9/21 Approved Retrospective Review For Services Requiring Authorizations
2021-LHCC-430 Covered Benefits and Services 4/26/21 6/9/21 Approved Covered Benefits and Services
2021-LHCC-934 Behavioral Health Provider Quality Program 4/20/21 6/3/21 Approved Behavioral Health Provider Quality Program
2021-UHC-960 Criteria for Medical Necessity & Prior Authorization – PDN/EHH 4/14/21 5/30/21 Approved Criteria for Medical Necessity & Prior Authorization – PDN/EHH
2021-UHC-959 Criteria for Medical Necessity & Prior Authorization – EPSDT – PCS 4/14/21 5/30/21 Approved Criteria for Medical Necessity & Prior Authorization – EPSDT – PCS
2021-UHC-958 Criteria for Medical Necessity & Prior Authorization – PDHC 4/14/21 5/30/21 Approved Criteria for Medical Necessity & Prior Authorization – PDHC
2021-HBL-946 Member Appeals Core Policy 4/14/21 5/30/21 Approved Member Appeals Core Policy
2021-LHCC-931 Appeals Process 4/14/21 5/30/21 Approved Appeals Process
2021-ABH-834 EPSDT reimbursement 4/14/21 5/30/21 Approved EPSDT reimbursement
2021-UHC-949 Chemotherapy – Observation or Inpatient Hospitalization 4/1/21 5/16/21 Approved Chemotherapy – Observation or Inpatient Hospitalization
2021-UHC-948 Catheter Ablation for Atrial Fibrilation 4/1/21 5/16/21 Approved Catheter Ablation for Atrial Fibrilation
2021-ABH-835 Vaccines for Children 3/31/21 5/15/21 Approved Vaccines for Children
2021-LHCC-927 Medical Record Review 3/18/21 5/2/21 Approved Medical Record Review
2021-LHCC-926 Provider Appointment Accessibility Standards 3/18/21 5/2/21 Approved Provider Appointment Accessibility Standards
2021-LHCC-925 Provider Complaints 3/18/21 5/2/21 Approved Provider Complaints
2021-LHCC-916 CM Assessment Process 3/18/21 5/2/21 Approved CM Assessment Process
2021-LHCC-830 Coordination of Benefits (COB/TPL) Act 421 3/18/21 5/2/21 Approved Coordination of Benefits (COB/TPL) Act 421
2021-LDH-4
LDH MCO Manual Part 11: Program Integrity
 3/17/21  5/1/21 Pending MCO Manual – Program Integrity
2021-LDH-3 LDH MCO Manual Part 4: Services > Professional Services > Obstetrics 3/17/21 5/1/21 Pending MCO Manual – Obstetrics
2021-ABH-937 Portable X-ray Policy 3/17/21 4/30/21 Approved Portable X-ray Policy
2021-LHCC-831 Act 421 Children’s Medicaid Option Policy 3/16/21 4/29/21 Approved Act 421 Children’s Medicaid Option Policy
2021-UHC-945 Act 421 LaHipp Notice 3/16/21 4/29/21 Approved Act 421 LaHipp Notice
2021-ABH-822 ABH Provider Manual 3/10/21 4/23/21 Approved ABH Provider Manual
2021-ACLA-944 Assertive Community Treatment 3/10/21 4/23/21 Approved Assertive Community Treatment
2021-ABH-942 Urine Drug Testing Policy 3/10/21 4/23/21 Approved Urine Drug Testing Policy
2021-ABH-939 Non-Invasive Prenatal Testing Policy 3/10/21 4/23/21 Approved Non-Invasive Prenatal Testing Policy
2021-ABH-935 Obestrical Ultrasound Policy 3/10/21 4/23/21 Approved Obestrical Ultrasound Policy
2021-ACLA-833 Act 421 Update 3/10/21 4/23/21 Approved Act 421 Update
2021-ACLA-893 Abdomen CT Angiography CG 3/4/21 4/17/21 Approved Abdomen CT Angiography CG
2021-ACLA-892 Abdomen CT CG 3/4/21 4/17/21 Approved Abdomen CT CG
2021-ACLA-891 Abdomen MRI, MRCP CG 3/4/21 4/17/21 Approved Abdomen MRI, MRCP CG
2021-ACLA-890 Abdomen/Pelvis CT Combo CG 3/4/21 4/17/21 Approved Abdomen/Pelvis CT Combo CG
2021-ACLA-889 Abdomen MRA (Angiography) CG 3/4/21 4/17/21 Approved Abdomen MRA (Angiography) CG
2021-ACLA-888 Abdomen/Pelvis CTA Combo CG 3/4/21 4/17/21 Approved Abdomen/Pelvis CTA Combo CG
2021-ACLA-887 Abdominal Arteries CT Angiography CG 3/4/21 4/17/21 Approved Abdominal Arteries CT Angiography CG
2021-ACLA-886 Bone Marrow MRI CG 3/4/21 4/17/21 Approved Bone Marrow MRI CG
2021-ACLA-885 Brain (Head) CTA CG 3/4/21 4/17/21 Approved Brain (Head) CTA CG
2021-ACLA-884 Brain (Head) MRA/MRV CG 3/4/21 4/17/21 Approved Brain (Head) MRA/MRV CG
2021-ACLA-883 Brain (Head) CT CG 3/4/21 4/17/21 Approved Brain (Head) CT CG
2021-ACLA-882 Brain (Head) MRI, Brain (Head) MRI with IAC (Internal Auditory Canal) CG 3/4/21 4/17/21 Approved Brain (Head) MRI, Brain (Head) MRI with IAC (Internal Auditory Canal) CG
2021-ACLA-881 Cervical Spine CT CG 3/3/21 4/16/21 Approved Cervical Spine CT CG
2021-ACLA-880 Cervical Spine MRI CG 3/3/21 4/16/21 Approved Cervical Spine MRI CG
2021-ACLA-879 Brain (Head) MRS CG 3/3/21 4/16/21 Approved Brain (Head) MRS CG
2021-ACLA-878 Chest (Thorax) MRI CG 3/3/21 4/16/21 Approved Chest (Thorax) MRI CG
2021-ACLA-877 Chest MRA CG 3/3/21 4/16/21 Approved Chest MRA CG
2021-ACLA-876 Chest CTA CG 3/3/21 4/16/21 Approved Chest CTA CG
2021-ACLA-875 Chest (Thorax) CT CG 3/3/21 4/16/21 Approved Chest (Thorax) CT CG
2021-ACLA-874 CT (Virtual) Colonoscopy CG 3/3/21 4/16/21 Approved CT (Virtual) Colonoscopy CG
2021-ACLA-873 CT Bone Density Study CG 3/3/21 4/16/21 Approved CT Bone Density Study CG
2021-ACLA-872 CT Coronary Angiography (CCTA) CG 3/3/21 4/16/21 Approved CT Coronary Angiography (CCTA) CG
2021-ACLA-871 Sinus Face Orbit MRI CG 3/3/21 4/16/21 Approved Sinus Face Orbit MRI CG
2021-ACLA-870 Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT CG 3/3/21 4/16/21 Approved Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT CG
2021-ACLA-869 Sinus & Maxillofacial CT Limited or Localized Follow Up Sinus CT CG 3/3/21 4/16/21 Approved Sinus & Maxillofacial CT Limited or Localized Follow Up Sinus CT CG
2021-ACLA-868 Spinal Canal MRA CG 3/3/21 4/16/21 Approved Spinal Canal MRA CG
2021-ACLA-867 Temporomandibular Joint (TMJ) MRI CG 3/3/21 4/16/21 Approved Temporomandibular Joint (TMJ) MRI CG
2021-ACLA-866 Thoracic Spine CT CG 3/3/21 4/16/21 Approved Thoracic Spine CT CG
2021-ACLA-865 Upper Extremity CTA/CTV CG 3/3/21 4/16/21 Approved Upper Extremity CTA/CTV CG
2021-ACLA-864 Lower Extremity CTA/CTV CG 3/3/21 4/16/21 Approved Lower Extremity CTA/CTV CG
2021-ACLA-863 Thoracic Spine MRI CG 3/3/21 4/16/21 Approved Thoracic Spine MRI CG
2021-ACLA-862 Upper Extremity CT CG 3/3/21 4/16/21 Approved Upper Extremity CT CG
2021-ACLA-861 Breast MRI CG 3/3/21 4/16/21 Approved Breast MRI CG
2021-ACLA-860 Ambulatory Surgery Center Procedures CG 3/3/21 4/16/21 Approved Ambulatory Surgery Center Procedures CG
2021-ACLA-859 Upper Extremity MRI CG 3/3/21 4/16/21 Approved Upper Extremity MRI CG
2021-ACLA-858 Upper Extremity MRA/MRV CG 3/3/21 4/16/21 Approved Upper Extremity MRA/MRV CG
2021-ACLA-857 CT Heart, CT Heart Congenital (Not including coronary arteries) CG 3/3/21 4/16/21 Approved CT Heart, CT Heart Congenital (Not including coronary arteries) CG
2021-ACLA-856 Functional Brain MRI 3/2/21  4/15/21 Approved Functional Brain MRI
2021-ACLA-855 Heart (cardiac) PET 3/2/21 4/15/21 Approved Heart (cardiac) PET
2021-ACLA-854 Electron-Beam Tomography CG 3/2/21 4/15/21 Approved Electron-Beam Tomography CG
2021-ACLA-853 Heart MRI CG 3/2/21 4/15/21 Approved Heart MRI CG
2021-ACLA-852 Heart (cardiac) PET with CT for Attenuation CG 3/2/21 4/15/21 Approved Heart (cardiac) PET with CT for Attenuation CG
2021-ACLA-851 Low Dose CT for Lung Cancer Screening CG 3/2/21 4/15/21 Approved Low Dose CT for Lung Cancer Screening CG
2021-ACLA-850 Lower Extremity CT CG 3/2/21 4/15/21 Approved Lower Extremity CT CG
2021-ACLA-849 Lower Extremity MRA/MRV CG 3/2/21 4/15/21 Approved Lower Extremity MRA/MRV CG
2021-ACLA-848 Lower Extremity MRI (foot, ankle, knee, leg, or hip MRI) CG 3/2/21 4/15/21 Approved Lower Extremity MRI (foot, ankle, knee, leg, or hip MRI) CG
2021-ACLA-847 Lumbar Spine MRI CG 3/2/21 4/15/21 Approved Lumbar Spine MRI CG
2021-ACLA-846 Lumbar Spine CT CG 3/2/21 4/15/21 Approved Lumbar Spine CT CG
2021-ACLA-845 Myocardial Perfusion Imaging CG 3/2/21 4/15/21 Approved Myocardial Perfusion Imaging CG
2021-ACLA-843 Neck CT CG 3/2/21 4/15/21 Approved Neck CT CG
2021-ACLA-842 Multiple Gated Acquisition Scan CG 3/2/21 4/15/21 Approved Multiple Gated Acquisition Scan CG
2021-ACLA-841 Neck CTA CG 3/2/21 4/15/21 Approved Neck CTA CG
2021-ACLA-840 Neck MRA/MRV CG 3/2/21 4/15/21 Approved Neck MRA/MRV CG
2021-ACLA-839 Pelvis CT CG 3/2/21 4/15/21 Approved Pelvis CT CG
2021-ACLA-838 Pelvis CT Angiography CG 3/2/21 4/15/21 Approved Pelvis CT Angiography CG
2021-ACLA-837 Pelvis MRA CG 3/2/21 4/15/21 Approved Pelvis MRA CG
2021-ACLA-836 Pelvis MRI CG 3/2/21 4/15/21 Approved Pelvis MRI CG
2020-UHC-788 Mechanical Stretching Devices 3/1/21 4/14/21 Approved Mechanical Stretching Devices
2020-UHC-785 Hearing Aids Devices 3/1/21 4/14/21 Approved Hearing Aids Devices
2020-LHCC-681 Claims Payment Reporting and Auditing 3/1/21 4/14/21 Approved Claims Payment Reporting and Auditing
2020-LHCC-680 Provider Reimbursement 3/1/21 4/14/21 Approved Provider Reimbursement
2020-LHCC-635 COB TPL TB 3/1/21 4/14/21 Approved COB TPL TB
2020-HBL-586 Global Surgical Package Reimbursement 3/1/21 4/14/21 Approved Global Surgical Package Reimbursement
2020-HBL-472 Women’s Health and Family Planning 3/1/21 4/14/21 Approved Women’s Health and Family Planning
2021-LDH-2 LDH MCO Manual Part 9: Third Party Liability 2/24/21 4/10/21 Pending LDH MCO Manual Part 9: Third Party Liability
2021-LDH-1 LDH MCO Manual Part 4: Services > Professional Services > "Incident to" Services 2/24/21 4/10/21 Pending LDH MCO Manual Part 4: Services > Professional Services > "Incident to" Services
2021-TPL-1 Cost avoidance and pay and chase policy changes for third party liability relative to prenatal, labor and delivery, and postpartum care, for child support enforcement cases, and for preventative pediatric services 2/12/21 3/29/2021 Pending HPA 21-XX Pay and Chase Updates for BBA Compliance

IB 21-XX Pay and Chase Updates for BBA Compliance

Diagnosis Codes Related to Prenatal Services [referenced in above HPA and IB]

Wait and See Provider Notice [referenced in above IB]

HPA 16-17 Pay and Chase, revised Primary Preventive Pediatric Care Diagnosis Codes [referenced in HPA 16-17 revision]
2021-UHC-825 Cardiac Event Monitoring 2/5/21 3/21/21 Approved Cardiac Event Monitoring
2021-UHC-826 Elbow Replacement Surgery (Arthroplasty) 2/5/21 3/21/21 Approved Elbow Replacement Surgery (Arthroplasty)
2021-UHC-827 Protherapy Musculoskeletal Indications 2/5/21 3/21/21 Approved Protherapy Musculoskeletal Indications
2021-UHC-828 Surgical Treatment for Spine Pain 2/5/21 3/21/21 Approved Surgical Treatment for Spine Pain
2020-HBL-589   Non-covered and Cost Effective Alternative Services 3/1/21 4/14/21 MCO Withdrawn Non-covered and Cost Effective Alternative Services
2020-HBL-250 Revised Provider Manual 3/1/21 4/14/21 MCO Withdrawn Revised Provider Manual

RELATED INFO

Surgeon General Ralph L. Abraham, M.D.

Secretary Bruce D. Greenstein

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