Managed Care Policies & Procedures - Archive (2024)

"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
2024-UHC-222 Skin and Soft Tissue Substitutes 4/30/24 6/14/24 Approved Skin and Soft Tissue Substitutes
2024-HBL-1058 Whole Genome Sequ. Whole Exome Sequ. Gene Panels and Molecular Prof 4/30/24 6/14/24 Approved Whole Genome Sequ. Whole Exome Sequ. Gene Panels and Molecular Prof
2024-LHCC-1190 PCP Auto-Assignment PP 4/30/24 6/14/24 Approved PCP Auto-Assignment PP
2024-HBL-1222 Mandibular/Maxillary (Orthognathic) Surgery 4/30/24 6/14/24 Approved Mandibular/Maxillary (Orthognathic) Surgery
2024-HBL-1245 Myoelectric Upper Extremity Prosthetic Devices 4/30/24 6/14/24 Approved Myoelectric Upper Extremity Prosthetic Devices
2024-HBL-1257 Compression Devices for Lymphedema 4/30/24 6/14/24 Approved Compression Devices for Lymphedema
2024-HUM-1428 Preauthorization and Notification List 4/30/24 6/14/24 Completed Preauthorization and Notification List
2024-HUM-1826 Revenue Codes for Outpatient Services 4/30/24 6/14/24 Approved Revenue Codes for Outpatient Services
2024-ABH-1900 Physical Safety for Field Based Colleagues 4/30/24 6/14/24 Completed Physical Safety for Field Based Colleagues
2024-UHC-1928 Transanal Endoscopic Microsurgery 4/30/24 6/14/24 Approved Transanal Endoscopic Microsurgery
2024-LHCC-1938 Continuity & Coordination Between Medical and Behavioral Health Care 4/30/24 6/14/24 Completed Continuity & Coordination Between Medical and Behavioral Health Care
2024-UHC-2277 Risk Strat NCM 012 4/30/24 6/14/24 Approved Risk Strat NCM 012
2024-ABH-2366 AMA XXXX Supplement Oxygen and Oxygen Supplies 4/30/24 6/14/24 Approved AMA XXXX Supplement Oxygen and Oxygen Supplies
2024-LHCC-2372 Member Reassignment 4/30/24 6/14/24 Approved Member Reassignment
2024-LHCC-2373 Provider Facing Policy for Member Moves 4/30/24 6/14/24 Approved Provider Facing Policy for Member Moves
2024-ABH-2376 Concurrent Review Observation Care 4/30/24 6/14/24 Approved Concurrent Review Observation Care
2024-ABH-2377 Common Hospital Observation 4/30/24 6/14/24 Approved Common Hospital Observation
2024-ABH-2385 UB 04 Reminder 4/30/24 6/14/24 Approved UB 04 Reminder
2024-ABH-2387 Biological Safety for Field Based Colleagues 4/30/24 6/14/24 Completed Biological Safety for Field Based Colleagues
2024-HBL-2388 Sacral Nerve Stim and Percut or Implant Tib Nerve Stim Urin and Fecal Incont Urin Ret 4/30/24 6/14/24 Approved Sacral Nerve Stim and Percut or Implant Tib Nerve Stim Urin and Fecal Incont Urin Ret
2024-ACLA-268 Care and BH Providers 4/16/24 5/31/24 Approved Care and BH Providers
2024-LHCC-423 EPSDT 4/16/24 5/31/24 Approved EPSDT
2024-UHC-474 Rhinoplasty and Other Nasal Procedures 4/16/24 5/31/24 Approved Rhinoplasty and Other Nasal Procedures
2024-UHC-490 Cardiovascular Disease Risk Tests 4/16/24 5/31/24 Approved Cardiovascular Disease Risk Tests
2024-UHC-785 Hearing Aids and Devices including wearable, bone-anchored and semi-implantable 4/16/24 5/31/24 Approved Hearing Aids and Devices including wearable, bone-anchored and semi-implantable
2024-UHC-1170 Prostate Surgeries and Interventions 4/16/24 5/31/24 Approved Prostate Surgeries and Interventions
2024-ACLA-1183 Personal Care Services 4/16/24 5/31/24 Completed Personal Care Services
2024-LHCC-1275 Oxygen Use and Concentrators 4/16/24 5/31/24 Approved Oxygen Use and Concentrators
2024-UHC-1394 Transpupillary Thermotherapy 4/16/24 5/31/24 Approved Transpupillary Thermotherapy
2024-HUM-1668 Wheelchair, Wheelchair repairs, Standing Frame, and Patient Lifts Clinical Coverage Policy 4/16/24 5/31/24 Approved Wheelchair, Wheelchair repairs, Standing Frame, and Patient Lifts Clinical Coverage Policy
2024-LHCC-1913 Pharmacy Claims Processing 4/16/24 5/31/24 Approved Pharmacy Claims Processing
2024-LHCC-2321 Pharmacy Program 4/16/24 5/31/24 Completed Pharmacy Program
2024-ABH-2362 AMA XXXX Home Health and Extended Home Health 4/16/24 5/31/24 Approved AMA XXXX Home Health and Extended Home Health
2024-ABH-2363 AMA XXXX Hospice 4/16/24 5/31/24 Approved AMA XXXX Hospice
2024-ABH-2370 Dynamo Web Portals Data Security Breach Notification Amend 4/16/24 5/31/24 Completed Dynamo Web Portals Data Security Breach Notification Amend
2024-HUM-2371 Lactation Support Policy 4/16/24 5/31/24 Approved Lactation Support Policy
2024-UHC-2374 LA New Housecalls 4/16/24 5/31/24 Approved LA New Housecalls
2024-LDH-7 MCO Manual > Part 4: Services > Pharmacy > Preferred Drug List 4/11/24 5/26/24 Pending Preferred Drug List
2024-LDH-6 MCO Manual > Part 4: Services > MCO Covered Services > Behavioral Health Services 4/11/24 5/26/24 Pending Behavioral Health Covered Services
2024-LDH-5 MCO Manual > Part 8: Encounters 4/11/24 5/26/24 Pending Split-Billing for Encounters
2024-LDH-4 MCO Manual > Part 13: Quality > Performance Improvement Projects 4/11/24 5/26/24 Pending Quality Performance Improvement Projects
2024-LDH-3 MCO Manual > Part 13: Quality > Performance Improvement Projects > Quality Monitoring Reviews for Behavioral Health Providers 4/11/24 5/26/24 Pending Quality Monitoring Reviews for Behavioral Health Providers
2024-LDH-2 MCO Manual > Part 4: Services > Pharmacy 4/11/24 5/26/24 Pending Pharmacy
2024-LDH-1 MCO Manual > Part 9: Provider Network > Primary Care >Enrollee Reassignment Policy 4/11/24 5/26/24 Pending Enrollee Reassignment Policy
2024-ACLA-2318 Peer Support Services 4/2/24 5/17/24 Approved Peer Support Services
2024-HBL-2344 Leadless Pacemaker 4/2/24 5/17/24 Approved Leadless Pacemaker
2024-ABH-2360 AMA XXXX Enteral Nutrition and Infusion Pump 4/2/24 5/17/24 Approved AMA XXXX Enteral Nutrition and Infusion Pump
2024-ABH-2364 AMA XXXX Hospital Bed Mattress and Lift 4/2/24 5/17/24 Approved AMA XXXX Hospital Bed Mattress and Lift
2024-HBL-811 Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies 4/2/24 5/17/24 Approved Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies
2024-UHC-949 Chemotherapy-Observation or Inpatient Hospitalization 4/2/24 5/17/24 Approved Chemotherapy-Observation or Inpatient Hospitalization
2024-ABH-953 Multi-Systemic Therapy (MST) 4/2/24 5/17/24 Approved Multi-Systemic Therapy (MST)
2024-ABH-954 Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) 4/2/24 5/17/24 Approved Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR)
2024-ABH-955 Crisis Intervention (CI) Services 4/2/24 5/17/24 Approved Crisis Intervention (CI) Services
2024-LHCC-1214 Total Parenteral Nutrition and Intradialytic Parental Nutrition 4/2/24 5/17/24 Approved Total Parenteral Nutrition and Intradialytic Parental Nutrition
2024-LHCC-1218 Ventricular Assist Devices 4/2/24 5/17/24 Approved Ventricular Assist Devices
2024-LHCC-1353 Articular Cartilage Defect Repairs 4/2/24 5/17/24 Approved Articular Cartilage Defect Repairs
2024-LHCC-1355 Functional MRI 4/2/24 5/17/24 Approved Functional MRI
2024-LHCC-1358 Pancreas Transplantation 4/2/24 5/17/24 Approved Pancreas Transplantation
2024-LHCC-1360 Heart-Lung Transplant 4/2/24 5/17/24 Approved Heart-Lung Transplant
2024-LHCC-1362 Nonmyeloablative allogeneric SCT 4/2/24 5/17/24 Approved Nonmyeloablative allogeneric SCT
2024-LHCC-1363 Tandem Transplant 4/2/24 5/17/24 Approved Tandem Transplant
2024-LHCC-1410 Neurofeedback for Behavioral Health Disorders 4/2/24 5/17/24 Approved Neurofeedback for Behavioral Health Disorders
2024-ABH-1528 Substance Use Disorder Treatment - Intensive Outpatient and Residential LOC 4/2/24 5/17/24 Approved Substance Use Disorder Treatment - Intensive Outpatient and Residential LOC
2024-LHCC-1837 Obstetrical Home Care Programs 4/2/24 5/17/24 Approved Obstetrical Home Care Programs
2024-LHCC-1934 Experimental Technologies 4/2/24 5/17/24 Approved Experimental Technologies
2024-LHCC-1935 Gastric Electrical Stimulation 4/2/24 5/17/24 Approved Gastric Electrical Stimulation
2024-LHCC-2225 Lantidra (donislecel) Allogeneic Pancreatic Islet Cellular Therapy 4/2/24 5/17/24 Approved Lantidra (donislecel) Allogeneic Pancreatic Islet Cellular Therapy
2024-UHC-126 Supplemental Clinical Criteria 3/15/24 4/29/24 Approved Supplemental Clinical Criteria
2024-UHC-247 Negative Pressure Wound Therapy 3/15/24 4/29/24 Approved Negative Pressure Wound Therapy
2024-HBL-366 Out-of-Area, Out-of-Network Care 3/15/24 4/29/24 Approved Out-of-Area, Out-of-Network Care
2024-LHCC-636 Authorization for Second Clinical Opinions PP 3/15/24 4/29/24 Approved Authorization for Second Clinical Opinions PP
2024-UHC-1371 Athletic Pubalgia Surgery 3/15/24 4/29/24 Approved Athletic Pubalgia Surgery
2024-ABH-1891 Member Appeals 3/15/24 4/29/24 Approved Member Appeals
2024-UHC-1931 Fecal Microbiota Transplantation 3/15/24 4/29/24 Approved Fecal Microbiota Transplantation
2024-ABH-2255 Decision Making Criteris Notification Amendment 3/15/24 4/29/24 Approved Decision Making Criteris Notification Amendment
2024-HUM-2267 HPS Finance OPS Post Adj Procedure 3/15/24 4/29/24 Approved HPS Finance OPS Post Adj Procedure
2024-HUM-2273 Additions and Removals to PAL 3/15/24 4/29/24 Approved Additions and Removals to PAL
2024-HBL-2348 Pharmacogenomic Testing 3/15/24 4/29/24 Approved Pharmacogenomic Testing
2024-ABH-2349 AMA XXXX Bariatric Surgery 3/15/24 4/29/24 Approved AMA XXXX Bariatric Surgery
2024-ABH-2350 AMA XXXX BRCA Genetic Testing and Counseling 3/15/24 4/29/24 Approved AMA XXXX BRCA Genetic Testing and Counseling
2024-ABH-2351 AMA XXXX Continuous Positive Airway Pressure 3/15/24 4/29/24 Approved AMA XXXX Continuous Positive Airway Pressure
2024-LHCC-2352 ID Multisystem Lab Testing 3/15/24 4/29/24 Approved ID Multisystem Lab Testing
2024-LHCC-2353 Dermatologic Lab Testing 3/15/24 4/29/24 Approved Dermatologic Lab Testing
2024-LHCC-2354 ID Respiratory Lab Testing 3/15/24 4/29/24 Approved ID Respiratory Lab Testing
2024-LHCC-2355 ID Vector Borne and Tropical Disease Lab Testing 3/15/24 4/29/24 Approved ID Vector Borne and Tropical Disease Lab Testing
2024-LHCC-2356 Primary Care Preventative Lab Testing 3/15/24 4/29/24 Approved Primary Care Preventative Lab Testing
2024-LHCC-2357 ID Genitourinary Lab Testing 3/15/24 4/29/24 Approved ID Genitourinary Lab Testing
2024-ABH-2358 AMA XXXX CPT Vest-High Frequency Chest Wall Oscillation Device 3/15/24 4/29/24 Approved AMA XXXX CPT Vest-High Frequency Chest Wall Oscillation Device
2024-LHCC-2359 Gastroenterologic Lab Testing 3/15/24 4/29/24 Approved Gastroenterologic Lab Testing
2024-HBL-810 Bone Mineral Density Testing Measurement 3/7/24 4/21/24 Approved Bone Mineral Density Testing Measurement
2024-LHCC-1112 Digital EEG Analysis 3/7/24 4/21/24 Approved Digital EEG Analysis
2024-HBL-1198 Treatment of Keloids and Scar Revision 3/7/24 4/21/24 Approved Treatment of Keloids and Scar Revision
2024-LHCC-1212 Spinal Cord Stimulation 3/7/24 4/21/24 Approved Spinal Cord Stimulation
2024-LHCC-1224 Fetal Surgery in Utero 3/7/24 4/21/24 Approved Fetal Surgery in Utero
2024-LHCC-1378 Wheelchair Seating 3/7/24 4/21/24 Approved Wheelchair Seating
2024-UHC-1407 Utilization Management of Behavioral Health Benefits Addendum 3/7/24 4/21/24 Approved Utilization Management of Behavioral Health Benefits Addendum
2024-LHCC-1455 Optic Nerve Decompression Surgery 3/7/24 4/21/24 Approved Optic Nerve Decompression Surgery
2024-UHC-1733 Coordination, Continuity and Transition of Behavioral Health Care 3/7/24 4/21/24 Approved Coordination, Continuity and Transition of Behavioral Health Care
2024-LHCC-1843 Extended Home Health Services 3/7/24 4/21/24 Approved Extended Home Health Services
2024-LHCC-1845 PDHC Policy 3/7/24 4/21/24 Approved PDHC Policy
2024-UHC-1849 Upper Extremity Myoelectric Prosthetic Devices 3/7/24 4/21/24 Approved Upper Extremity Myoelectric Prosthetic Devices
2024-LHCC-1904 Homebuilder Services 3/7/24 4/21/24 Approved Homebuilder Services
2024-LHCC-1905 Stereotactic Body Radiation Therapy 3/7/24 4/21/24 Approved Stereotactic Body Radiation Therapy
2024-LHCC-1906 Facility-Based Sleep Studies for OSA 3/7/24 4/21/24 Approved Facility-Based Sleep Studies for OSA
2024-LHCC-1907 Hyperhidrousis Treatments 3/7/24 4/21/24 Approved Hyperhidrousis Treatments
2024-LHCC-1948 Implantable Loop recorder 3/7/24 4/21/24 Approved Implantable Loop recorder
2024-LHCC-2242 Concert Genetics Prenatal and Preconception Carrier Screening 3/7/24 4/21/24 Approved Concert Genetics Prenatal and Preconception Carrier Screening
2024-LHCC-2246 Concert Genetics Metabolic Endocrine Mitochondrial Dsrdr 3/7/24 4/21/24 Approved Concert Genetics Metabolic Endocrine Mitochondrial Dsrdr
2024-LHCC-2269 Concert Genetics Hereditary Cancer Susceptibility 3/7/24 4/21/24 Approved Concert Genetics Hereditary Cancer Susceptibility
2024-ABH-2336 Personal Care Services- Behavioral Health 3/7/24 4/21/24 Approved Personal Care Services- Behavioral Health
2024-HBL-2348 Pharmacogenomic Testing 3/7/24 4/21/24 Approved Pharmacogenomic Testing
2024-ABH-2335 Privacy and Confidentiality Amendment 3/1/24 4/15/24 Approved Privacy and Confidentiality Amendment
2024-ABH-2338 Peer to Peer Amendment 3/1/24 4/15/24 Approved Peer to Peer Amendment
2024-HBL-2341 PA CHANGES 3/1/24 4/15/24 Completed PA CHANGES
2024-HBL-2342 Gene Therapy for Duchenne Muscular Dystrophy 3/1/24 4/15/24 Approved Gene Therapy for Duchenne Muscular Dystrophy
2024-UHC-2343 Electrical Stimulation for Wounds 3/1/24 4/15/24 Approved Electrical Stimulation for Wounds
2024-HBL-2345 Parenteral Antibiotics for the Treatment of Lyme Disease 3/1/24 4/15/24 Approved Parenteral Antibiotics for the Treatment of Lyme Disease
2024-HBL-2346 Noninvasive Imaging Technologies for the Evaluation of Skin Lesions 3/1/24 4/15/24 Approved Noninvasive Imaging Technologies for the Evaluation of Skin Lesions
2024-HBL-2347 Cellfree DNA Testing (Liquid Biopsy) for the Management of Cancer 3/1/24 4/15/24 Approved Cellfree DNA Testing (Liquid Biopsy) for the Management of Cancer
2024-UHC-375 Pneumatic Compression Devices 3/1/24 4/15/24 Approved Pneumatic Compression Devices
2024-UHC-491 Electrical Stimulation And Electromagnetic Therapy For Wounds 3/1/24 4/15/24 Approved Electrical Stimulation And Electromagnetic Therapy For Wounds
2024-LHCC-1167 DME Clinical Policy 3/1/24 4/15/24 Approved DME Clinical Policy
2024-ABH-1173 Peer Support Services 3/1/24 4/15/24 Approved Peer Support Services
2024-HBL-1250 Radiation Oncology 3/1/24 4/15/24 Approved Radiation Oncology
2024-ACLA-1292 Durable Medical Equipment 3/1/24 4/15/24 Approved Durable Medical Equipment
2024-HBL-1343 Intermittent Abdominal Pressure Ventilation Devices 3/1/24 4/15/24 Approved Intermittent Abdominal Pressure Ventilation Devices
2024-UHC-1873 Lower Extremity Prosthetics 3/1/24 4/15/24 Approved Lower Extremity Prosthetics
2024-UHC-1932 Corneal Collagen Cross-Linking 3/1/24 4/15/24 Approved Corneal Collagen Cross-Linking
2024-ACLA-2133 Prior Authorization Services List 3/1/24 4/15/24 Approved Prior Authorization Services List
2024-ABH-2256 Assertive Community Treatment (ACT) 3/1/24 4/15/24 Approved Assertive Community Treatment (ACT)
2024-HUM-2310 CPT Eval & Mngt Services 3/1/24 4/15/24 Approved CPT Eval & Mngt Services
2024-HUM-2316 Hospital-Based Care Coordination of Pregnant 3/1/24 4/15/24 Approved Hospital-Based Care Coordination of Pregnant
2024-ACLA-2317 Wheelchairs 3/1/24 4/15/24 Approved Wheelchairs
2024-UHC-2320 Member Enrollment & Disenrollment 3/1/24 4/15/24 Approved Member Enrollment & Disenrollment
2024-ABH-2330 Hours of Operation and After Hours Call Amend 3/1/24 4/15/24 Approved Hours of Operation and After Hours Call Amend
2024-ABH-2331 Clinical Personnel License Requirements 3/1/24 4/15/24 Approved Clinical Personnel License Requirements
2024-ABH-2332 Electronic and Remote Access of Medical Records Amend 3/1/24 4/15/24 Approved Electronic and Remote Access of Medical Records Amend
2024-ABH-2333 Potential Quality of Care Amendment 3/1/24 4/15/24 Approved Potential Quality of Care Amendment
2024-ABH-2334 Reviewing-Additional Information Following Initial Denial Amendment 3/1/24 4/15/24 Approved Reviewing-Additional Information Following Initial Denial Amendment
2024-HBL-2325 Chromosomal Microarray Analysis 2/21/24 4/6/24 Approved Chromosomal Microarray Analysis
2024-HBL-2326 Hereditary Cancer Testing 2/21/24 4/6/24 Approved Hereditary Cancer Testing
2024-HBL-2327 Endovas Revascul Mngmnt of Arterial Dis of Low Ext 2/21/24 4/6/24 Approved Endovas Revascul Mngmnt of Arterial Dis of Low Ext
2024-HBL-2328 Carrier Screening Prenatal Set and Preimplant Gen Testing 2/21/24 4/6/24 Approved Carrier Screening Prenatal Set and Preimplant Gen Testing
2024-HBL-2329 Somatic Tumor Testing 2/21/24 4/6/24 Approved Somatic Tumor Testing
2024-LHCC-419 Provider Termination 2/21/24 4/6/24 Approved Provider Termination
2024-UHC-443 Ambulance Services 2/21/24 4/6/24 Approved Ambulance Services
2024-HBL-1051 Implantable Cardioverter Defibrillator (ICD) 2/21/24 4/6/24 Approved Implantable Cardioverter Defibrillator (ICD)
2024HBL-1014 Imaging of the Chest AIM Guidelines 2/21/24 4/6/24 Approved Imaging of the Chest AIM Guidelines
2024-HBL-1199 Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps 2/21/24 4/6/24 Approved Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
2024-HBL-1239 Advanced Imaging of the Brain 2/21/24 4/6/24 Approved Advanced Imaging of the Brain
2024-HBL-1241 Advanced Imaging of the Head and Neck 2/21/24 4/6/24 Approved Advanced Imaging of the Head and Neck
2024-HBL-1243 Musculoskeletal Program- Interventional Pain Management 2/21/24 4/6/24 Approved Musculoskeletal Program- Interventional Pain Management
2024-HBL-1310 HBL-Cell-free Prenatal DNA Testing 2/21/24 4/6/24 Approved HBL-Cell-free Prenatal DNA Testing
2024-HBL-1327 Advanced Imaging-Oncologic Imaging 2/21/24 4/6/24 Approved Advanced Imaging-Oncologic Imaging
2024-HBL-1349 Outpatient Rehabilitative and Habilitative AIM 2/21/24 4/6/24 Approved Outpatient Rehabilitative and Habilitative AIM
2024-LHCC-2209 MTM Provider Manual 2/21/24 4/6/24 Approved MTM Provider Manual
2024-ACLA-2313 Microwave Thermotherapy Lung Kidney Tumors 2/21/24 4/6/24 Approved Microwave Thermotherapy Lung Kidney Tumors
2024-ACLA-2314 Prostatic Urethral Lift UroLift Benign Prostatic Hypertrophy 2/21/24 4/6/24 Approved Prostatic Urethral Lift UroLift Benign Prostatic Hypertrophy
2024-ACLA-2315 Chronic Pain Management 2/21/24 4/6/24 Approved Chronic Pain Management
2024-ACLA-2319 Opioid Treatment 2/21/24 4/6/24 Approved Opioid Treatment
2024-LHCC-107 Utilization Management Program Description 2/21/24 4/6/24 Completed Utilization Management Program Description
2024-HBL-2322 Whole Exome Sequencing and Whole Genome Sequencing 2/21/24 4/6/24 Approved Whole Exome Sequencing and Whole Genome Sequencing
2024-HBL-2323 Polygenic Risk Scores in Genetic Testing 2/21/24 4/6/24 Approved Polygenic Risk Scores in Genetic Testing
2024-HBL-2324 Genetic Testing for Inherited Conditions 2/21/24 4/6/24 Approved Genetic Testing for Inherited Conditions
2024-LHCC-814 Crisis Intervention Policy 2/7/24 3/23/24 Approved Crisis Intervention Policy
2024-LHCC-1270 Urinary Incontinence Devices and Treatments 2/7/24 3/23/24 Approved Urinary Incontinence Devices and Treatments
2024-LHCC-1271 Implantable Hypoglossal Nerve Stimulation for OSA 2/7/24 3/23/24 Approved Implantable Hypoglossal Nerve Stimulation for OSA
2024-LHCC-1272 PCR Respiratory Viral Panel Testing 2/7/24 3/23/24 Approved PCR Respiratory Viral Panel Testing
2024-UHC- 1350 Gender Dysphoria Treatment 2/7/24 3/23/24 Approved Gender Dysphoria Treatment
2024-LHCC-1819 Burn Surgery 2/7/24 3/23/24 Approved Burn Surgery
2024-LHCC-1820 Transcatheter Closure of Patent Foramen Ovale 2/7/24 3/23/24 Approved Transcatheter Closure of Patent Foramen Ovale
2024-LHCC-1821 Selective Dorsal Rhizotomy for Spasticity in CP 2/7/24 3/23/24 Approved Selective Dorsal Rhizotomy for Spasticity in CP
2024-LHCC-1822 Opioid Use Disorder (OUD) treatment in Opiod Treatment Programs 2/7/24 3/23/24 Approved Opioid Use Disorder (OUD) treatment in Opiod Treatment Programs
2024-LHCC-1823 Mechanical Stretch devices 2/7/24 3/23/24 Approved Mechanical Stretch devices
2024-LHCC-1824 Electric Tumor Treatment Fields 2/7/24 3/23/24 Approved Electric Tumor Treatment Fields
2024-LHCC-1825 Proton and Neutron Beam Therapies 2/7/24 3/23/24 Approved Proton and Neutron Beam Therapies
2024-LHCC-1837 Obstetrical Home Care Programs 2/7/24 3/23/24 Approved Obstetrical Home Care Programs
2024-LHCC-1844 Transplant Service Documentation Requirements 2/7/24 3/23/24 Approved Transplant Service Documentation Requirements
2024-ACLA-1954 Cochlear Implants 2/7/24 3/23/24 Approved Cochlear Implants
2024-ACLA-2201 Therapeutic Group Homes 2/7/24 3/23/24 Approved Therapeutic Group Homes
2024-UHC-2251 Private Duty Nursing (PDN) and Extended Home Health (EhH) 2/7/24 3/23/24 Approved Private Duty Nursing (PDN) and Extended Home Health (EhH)
2024-HUM-2289 VAB Policy 2/7/24 3/23/24 Approved VAB Policy
2024-UHC-2311 Injectables for Reconstructive Procedures 2/7/24 3/23/24 Approved Injectables for Reconstructive Procedures
2024-ACLA-2312 Plastic Reconstructive Surgery 2/7/24 3/23/24 Approved Plastic Reconstructive Surgery
2024-UHC-311 Transcatheter Heart Valve Procedures 1/29/24 3/14/24 Approved Transcatheter Heart Valve Procedures
2024-HBL-819 HBL Provider Manual 1/29/24 3/14/24 Approved HBL Provider Manual
2024-UHC-828 Minimally Invasive Spine Surgery Procedures 1/29/24 3/14/24 Approved Minimally Invasive Spine Surgery Procedures
2024-LHCC-966 Cultural and Linguistic Policy 1/29/24 3/14/24 Approved Cultural and Linguistic Policy
2024-UHC-1847 Spinal Fusion and Decompression 1/29/24 3/14/24 Approved Spinal Fusion and Decompression
2024-UHC-1851 Whole Exome and Whole Genome Sequencing 1/29/24 3/14/24 Approved Whole Exome and Whole Genome Sequencing
2024-HUM-2272 Negative PAL Change Notification 1/29/24 3/14/24 Approved Negative PAL Change Notification
2024-HBL-2274 Unspcfd Diag Code Site and Lat Art 1/29/24 3/14/24 Approved Unspcfd Diag Code Site and Lat Art
2024-UHC-2279 Special Health Care Needs Membership 1/29/24 3/14/24 Approved Special Health Care Needs Membership
2024-UHC-2280 Management of Care Transition NCM 1/29/24 3/14/24 Approved Management of Care Transition NCM
2024-HUM-2307 Non MCO Covered Codes 1/29/24 3/14/24 Approved Non MCO Covered Codes
2024-HBL-2308 Transanal Irrigation 1/29/24 3/14/24 Approved Transanal Irrigation
2024-LHCC-2236 Concert Genetics Immune Autoimmune and Rheumatoid Disorders 1/11/24 2/25/24 Approved Concert Genetics Immune Autoimmune and Rheumatoid Disorders
2024-LHCC-2237 Concert Genetics Hematologic Conditions non-cancerous 1/11/24 2/25/24 Approved Concert Genetics Hematologic Conditions non-cancerous
2024-LHCC-2238 Concert Genetics Skeletal Dysplasia Rare Bone Disorders 1/11/24 2/25/24 Approved Concert Genetics Skeletal Dysplasia Rare Bone Disorders
2024-LHCC-2239 Concert Genetics Oncology Cytogenetic Testing 1/11/24 2/25/24 Approved Concert Genetics Oncology Cytogenetic Testing
2024-LHCC-2240 Concert Genetics Preimplantation Genetic Testing 1/11/24 2/25/24 Approved Concert Genetics Preimplantation Genetic Testing
2024-LHCC-2241 Concert Genetics Oncology Cancer Screening 1/11/24 2/25/24 Approved Concert Genetics Oncology Cancer Screening
2024-LHCC-2243 Concert Genetics Non-invasive Prenatal Screening 1/11/24 2/25/24 Approved Concert Genetics Non-invasive Prenatal Screening
2024-LHCC-2244 Concert Genetics Prenatal Diagnosis Pregnancy Loss 1/11/24 2/25/24 Approved Concert Genetics Prenatal Diagnosis Pregnancy Loss
2024-LHCC-2245 Concert Genetics Multi-system Inherited Disorders 1/11/24 2/25/24 Approved Concert Genetics Multi-system Inherited Disorders
2024-HBL-2274 Unspcfd Diag Code Site and Lat Art 1/11/24 2/25/24 Approved Unspcfd Diag Code Site and Lat Art
2024-UHC-2301 Molecular Oncology Companion Diagnostic Testing 1/11/24 2/25/24 Approved Molecular Oncology Companion Diagnostic Testing
2024-LHCC-2302 Concert Genetics Oncology Algorithmic Testing 1/11/24 2/25/24 Approved Concert Genetics Oncology Algorithmic Testing
2024-LHCC-2303 Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies 1/11/24 2/25/24 Approved Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies
2024-LHCC-2304 Concert Genetic Pharmacogenetics 1/11/24 2/25/24 Approved Concert Genetic Pharmacogenetics
2024-LHCC-2305 Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) 1/11/24 2/25/24 Approved Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)
2024-UHC-2306 Airway Clearance Devices 1/11/24 2/25/24 Completed Airway Clearance Devices
2024-UHC-312 Intensity Modulated Radiation Therapy – Revised 1/11/24 2/25/24 Approved Intensity Modulated Radiation Therapy – Revised
2024-UHC-377 Implanted Electrical Stimulator for Spinal Cord 1/11/24 2/25/24 Approved Implanted Electrical Stimulator for Spinal Cord
2024-UHC-511 Manipulation Under Anesthesia 1/11/24 2/25/24 Approved Manipulation Under Anesthesia
2024-UHC-524 Durable Medical Equipment, Orthotics, Medical Supplies and Repairs/Replacements 1/11/24 2/25/24 Approved Durable Medical Equipment, Orthotics, Medical Supplies and Repairs/Replacements
2024-UHC-580 Embolization Ovarian Iliac Pelvic Congestion Syndrome 1/11/24 2/25/24 Approved Embolization Ovarian Iliac Pelvic Congestion Syndrome
2024-UHC-786 Light and Laser Therapy 1/11/24 2/25/24 Approved Light and Laser Therapy
2024-LHCC-829 Interrater Reliability - Act 421 1/11/24 2/25/24 Completed Interrater Reliability - Act 421
2024-LHCC-982 Outpatient Applied Behavior Analysis Medical Necessity 1/11/24 2/25/24 Approved Outpatient Applied Behavior Analysis Medical Necessity
2024-LHCC-1747 PCS-EPSDT Policy 1/11/24 2/25/24 Approved PCS-EPSDT Policy
2024-UHC-1839 Genetic Testing Hereditary Cancer Susceptibility 1/11/24 2/25/24 Approved Genetic Testing Hereditary Cancer Susceptibility
2024-LHCC-2226 Concert Genetics Aortopathies and Connective Tissue Disorders 1/11/24 2/25/24 Approved Concert Genetics Aortopathies and Connective Tissue Disorders
2024-LHCC-2227 Concert Genetics Cardiac Disorders 1/11/24 2/25/24 Approved Concert Genetics Cardiac Disorders
2024-LHCC-2228 Concert Genetics Eye Disorders 1/11/24 2/25/24 Approved Concert Genetics Eye Disorders
2024-LHCC-2229 Concert Genetics Dermatologic Conditions 1/11/24 2/25/24 Approved Concert Genetics Dermatologic Conditions
2024-LHCC-2230 Concert Genetics Epilepsy Neurodegenerative and Neuromuscular Conditions 1/11/24 2/25/24 Approved Concert Genetics Epilepsy Neurodegenerative and Neuromuscular Conditions
2024-LHCC-2231 Concert Genetics Gastroenterologic Disorders non-cancerous 1/11/24 2/25/24 Approved Concert Genetics Gastroenterologic Disorders non-cancerous
2024-LHCC-2232 Concert Genetics General Approach to Genetic Testing 1/11/24 2/25/24 Approved Concert Genetics General Approach to Genetic Testing
2024-LHCC-2233 Concert Genetics Hearing Loss 1/11/24 2/25/24 Approved Concert Genetics Hearing Loss
2024-LHCC-2234 Concert Genetics Lung Disorders 1/11/24 2/25/24 Approved Concert Genetics Lung Disorders
2024-LHCC-2235 Concert Genetics Kidney Disorders 1/11/24 2/25/24 Approved Concert Genetics Kidney Disorders
2023-UHC-2278 Early Periodic Screening Diagnostic and Treatment EPSDT 1/5/24 2/19/24 Approved Early Periodic Screening Diagnostic and Treatment EPSDT
2023-HBL-2288 Prior Auth Requirement Changes 1/5/24 2/19/24 Completed Prior Auth Requirement Changes
2024-UHC-2293 Electroretinography 1/5/24 2/19/24 Approved Electroretinography
2024-UHC-2294 Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions 1/5/24 2/19/24 Approved Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions
2024-HUM-2299 OON OOS Policy 1/5/24 2/19/24 Approved OON OOS Policy
2024-HUM-2300 Rapid Whole Genome Sequencing 1/5/24 2/19/24 Approved Rapid Whole Genome Sequencing
2024-UHC-482 Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions 1/5/24 2/19/24 Approved Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions
2023-UHC-207 Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 1/5/24 2/19/24 Approved Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
2023-UHC-217 Omnibus Codes 1/5/24 2/19/24 Approved Omnibus Codes
2023-UHC-222 Skin and Soft Tissue Substitutes 1/5/24 2/19/24 Approved Skin and Soft Tissue Substitutes
2023-UHC-557 Transcranial Magnetic Stimulation 1/5/24 2/19/24 Approved Transcranial Magnetic Stimulation
2023-UHC-961 Elective Inpatient Services 1/5/24 2/19/24 Approved Elective Inpatient Services
2023-UHC-1120 Percutaneous Patent Foramen Ovale (PFO) Closure 1/5/24 2/19/24 Approved Percutaneous Patent Foramen Ovale (PFO) Closure
2023-UHC-1178 Liposuction for Lipodema 1/5/24 2/19/24 Approved Liposuction for Lipodema
2023-HUM-1606 Louisiana UM Program Description 1/5/24 2/19/24 Completed Louisiana UM Program Description
2024-HUM-1651 Gender Affirmation Surgery Clinical Coverage Policy 1/5/24 2/19/24 Approved Gender Affirmation Surgery Clinical Coverage Policy
2024-HUM-1657 Hospital Bed Clinical Coverage Policy 1/5/24 2/19/24 Approved Hospital Bed Clinical Coverage Policy
2023-UHC-1815 Sacral Nerve Stimulation for Urinary and Fecal Indications 1/5/24 2/19/24 Approved Sacral Nerve Stimulation for Urinary and Fecal Indications
2023-UHC-1817 Proton Beam Radiation Therapy 1/5/24 2/19/24 Approved Proton Beam Radiation Therapy
2023-UHC-1830 Hysterectomy 1/5/24 2/19/24 Approved Hysterectomy
2023-UHC-1846 Interspinous Fusion and Decompression Devices 1/5/24 2/19/24 Approved Interspinous Fusion and Decompression Devices
2024-HUM-1922 UM Home Health Clinical Coverage Policy 1/5/24 2/19/24 Approved UM Home Health Clinical Coverage Policy
2023-HBL-2262 Genetic Tests: Once per Lifetime 1/5/24 2/19/24 Approved Genetic Tests: Once per Lifetime
2023-LHCC-2268 Genetic and Molecular Testing 1/5/24 2/19/24 Approved Genetic and Molecular Testing

Managed Care Policies & Procedures Archive Continued