Managed Care Policies & Procedures - Archive (2023)

"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
2023-LHCC-329

Adverse Determinations

12/27/23 2/10/24 Approved Adverse Determinations
2023-UHC-510

Collagen Crosslinks and Biochemical Markers of Bone Turnover

12/21/23 2/4/24 Approved Collagen Crosslinks and Biochemical Markers of Bone Turnover
2023-UHC-781

Deep Brain Cortical Stimulation

12/21/23 2/4/24 Approved Deep Brain Cortical Stimulation
2023-UHC-782

Discogenic Pain Treatment

12/21/23 2/4/24 Approved Discogenic Pain Treatment
2023-UHC-948

Catheter Ablation for Atrial Fibrillation

12/21/23 2/4/24 Approved Catheter Ablation for Atrial Fibrillation
2023-HBL-1061

Venous Angio w or w/out Stent Placement or Venous Stent Alone

12/21/23 2/4/24 Approved Venous Angio w or w/out Stent Placement or Venous Stent Alone
2023-ACLA-1954

Cochlear Implants

12/21/23 2/4/24 Approved Cochlear Implants
2023-UHC-2275

ID and Strat of Mbrs for CM

12/21/23 2/4/24 Approved ID and Strat of Mbrs for CM
2023-HBL-2284

Septoplasty

12/21/23 2/4/24 Approved Septoplasty
2023-HUM-2286

Code Removal – VADs

12/21/23 2/4/24 Completed Code Removal – VADs
2023-HUM-2287

Code Removal – Transplant

12/21/23 2/4/24 Completed Code Removal – Transplant
2023-LHCC-2282

Provider Preventable Conditions

12/21/23 2/4/24 Approved Provider Preventable Conditions
2023-LHCC-1515

Temporary Limited Authorization Reviews

12/21/23 2/4/24 Completed Temporary Limited Authorization Reviews
2023-LDH-17

MCO Manual > Part 4: Services > In Lieu of Services > Physical Health Services > Outpatient Lactation Support (Proposed effective date = 1/1/2024)

12/8/23 1/22/24 Pending Outpatient Lactation Support
2023-UHC-201 Aphersis 12/7/23 1/21/24 Approved Aphersis
2023-UHC-205 Computed Tomographic Colonography 12/7/23 1/21/24 Approved Computed Tomographic Colonography
2023-UHC-218 Pharmacogenetic Testing 12/7/23 1/21/24 Approved Pharmacogenetic Testing
2023-UHC-223 Vagus and External Trigeminal Nerve Stimulation 12/7/23 1/21/24 Approved Vagus and External Trigeminal Nerve Stimulation
2023-UHC-224 Visual Information Processing Evaluation and Orthoptic and Vision Therapy 12/7/23 1/21/24 Approved Visual Information Processing Evaluation and Orthoptic and Vision Therapy
2023-UHC-248 Vertebral Tethering for Scoliosis 12/7/23 1/21/24 Approved Vertebral Tethering for Scoliosis
2023-UHC-310 Total Artificial Disc Replacement Spine – Revised 12/7/23 1/21/24 Approved Total Artificial Disc Replacement Spine – Revised
2023-UHC-478 Obstructive and Central Sleep Apnea Treatment 12/7/23 1/21/24 Approved Obstructive and Central Sleep Apnea Treatment
2023-UHC-486 Abnormal Uterine Bleeding and Uterine Fibroids 12/7/23 1/21/24 Approved Abnormal Uterine Bleeding and Uterine Fibroids
2023-UHC-791 Neurophysiologic Testing 12/7/23 1/21/24 Approved Neurophysiologic Testing
2023-UHC-1063 Temporomandibular Joint Disorder 12/7/23 1/21/24 Approved Temporomandibular Joint Disorder
2023-LHCC-1217 Ultrasound in Pregnancy 12/7/23 1/21/24 Approved Ultrasound in Pregnancy
2023-LHCC-1273 Orthognathic Surgery 12/7/23 1/21/24 Approved Orthognathic Surgery
2023-LHCC-1277 Panniculectomy 12/7/23 1/21/24 Approved Panniculectomy
2023-LHCC-1361 Pediatric Heart Transplant 12/7/23 1/21/24 Approved Pediatric Heart Transplant
2023-UHC-1461 Unicondylar Spacer Devices for Treatment of Pain or Disability 12/7/23 1/21/24 Approved Unicondylar Spacer Devices for Treatment of Pain or Disability
2023-LHCC-1710 Maternal Child Health Program Description 12/7/23 1/21/24 Completed Maternal Child Health Program Description
2023-LHCC-1741 AHCT for Sickle Cell Anemia and Thalassemia 12/7/23 1/21/24 Approved AHCT for Sickle Cell Anemia and Thalassemia
2023-LHCC-1742 Ferriscan R2 MRI 12/7/23 1/21/24 Approved Ferriscan R2 MRI
2023-LHCC-1744 Phototherapy for Neonatal Hyperbilirubinemia 12/7/23 1/21/24 Approved Phototherapy for Neonatal Hyperbilirubinemia
2023-LHCC-1745 Donor Lymphocyte Infusion 12/7/23 1/21/24 Approved Donor Lymphocyte Infusion
2023-UHC-1760 Radiation Therapy 12/7/23 1/21/24 Approved Radiation Therapy
2023-UHC-1762 Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery 12/7/23 1/21/24 Approved Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery
2023-LHCC-1834 Enteral Nutrition 12/7/23 1/21/24 Approved Enteral Nutrition
2023-LHCC-1842 Cosmetic and Reconstructive Procedures 12/7/23 1/21/24 Approved Cosmetic and Reconstructive Procedures
2023-ACLA-2276 Level 3.7 Adolescent CCP.4047 12/7/23 1/21/24 Approved Level 3.7 Adolescent CCP.4047
2023-LHCC-140 Timeliness of UM Decisions 11/20/23 1/4/24 Approved Timeliness of UM Decisions
2023-UHC-483 Genetic Testing for Hereditary Cancer 11/20/23 1/4/24 Approved Genetic Testing for Hereditary Cancer
2023-LHCC-502 Clinical Information and Documentation Policy 11/20/23 1/4/24 Approved Clinical Information and Documentation Policy
2023-LHCC-694 Record Keeping and Documentation Standards 11/20/23 1/4/24 Approved Record Keeping and Documentation Standards
2023-ABH-822 ABH Provider Manual 11/20/23 1/4/24 Approved ABH Provider Manual
2023-HBL-1060 Level of Care - Specialty Pharmaceuticals 11/20/23 1/4/24 Approved Level of Care - Specialty Pharmaceuticals
2023-HBL-1149 Colonoscopy 11/20/23 1/4/24 Approved Colonoscopy
2023-ACLA-1442 ACLA Prior Authorization Service List 11/20/23 1/4/24 Completed ACLA Prior Authorization Service List
2023-LHCC-1478 Visits on Same Day as Surgery 11/20/23 1/4/24 Approved Visits on Same Day as Surgery
2023-LHCC-1480 Pre-operative Visits 11/20/23 1/4/24 Approved Pre-operative Visits
2023-LHCC-1481 Outpatient Consultation 11/20/23 1/4/24 Approved Outpatient Consultation
2023-LHCC-1485 Unbundled Surgical Procedures 11/20/23 1/4/24 Approved Unbundled Surgical Procedures
2023-LHCC-1486 Post-operative Visits 11/20/23 1/4/24 Approved Post-operative Visits
2023-LHCC-1488 Unbundled Professional Services 11/20/23 1/4/24 Approved Unbundled Professional Services
2023-LHCC-1513 Continuity and Coordination of Services 11/20/23 1/4/24 Approved Continuity and Coordination of Services
2023-HBL-2258 Claims Sub-Professional 11/20/23 1/4/24 Approved Claims Sub-Professional
2023-HBL-2259 Gender Affirming Prior Authorization Changes 11/20/23 1/4/24 Completed Gender Affirming Prior Authorization Changes
2023-HBL-2270 Provider and Member Bill of Rights 11/20/23 1/4/24 Approved Provider and Member Bill of Rights
2023-HBL-2271 Provider Network and Management 11/20/23 1/4/24 Approved Provider Network and Management
2023-HUM-1826

Revenue Codes for Outpatient Services

12/21/23 2/4/24 Denied Revenue Codes for Outpatient Services
2023-LHCC-1111 Thyroid Insulin Test in Ped 11/9/23 12/24/23 Approved Thyroid Insulin Test in Ped
2023-LHCC-1112 Digital EEG Analysis 11/9/23 12/24/23 Approved Digital EEG Analysis
2023-LHCC-1113 Cardiac Biomarker Testing 11/9/23 12/24/23 Approved Cardiac Biomarker Testing
2023-LHCC-1115 Vitamin D Testing in Peds 11/9/23 12/24/23 Approved Vitamin D Testing in Peds
2023-LHCC-1168 Allergy Testing & Therapy 11/9/23 12/24/23 Approved Allergy Testing & Therapy
2023-HBL-1197 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction 11/9/23 12/24/23 Approved Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
2023-HBL-1249 Penile Prosthesis Implantation 11/9/23 12/24/23 Approved Penile Prosthesis Implantation
2023-LHCC-1278 Evoked Potential Testing 11/9/23 12/24/23 Approved Evoked Potential Testing
2023-LHCC-1279 Measure Serum 1.25 Vit D 11/9/23 12/24/23 Approved Measure Serum 1.25 Vit D
2023-LHCC-1280 EEG headache 11/9/23 12/24/23 Approved EEG headache
2023-LHCC-1359 Testing for Select Genitourinary Conditions 11/9/23 12/24/23 Approved Testing for Select Genitourinary Conditions
2023-LHCC-1386 Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins 11/9/23 12/24/23 Approved Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins
2023-LHCC-1417 Adult Crisis Stabilization 11/9/23 12/24/23 Approved Adult Crisis Stabilization
2023-HBL-1431 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver 11/9/23 12/24/23 Approved Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver
2023-LHCC-1702 Holter Monitor 11/9/23 12/24/23 Approved Holter Monitor
2023-LHCC-1704 Helicobacter Pylori Serology Testing 11/9/23 12/24/23 Approved Helicobacter Pylori Serology Testing
2023-LHCC-1706 Wireless Motility Capsule 11/9/23 12/24/23 Approved Wireless Motility Capsule
2023-UHC-1733 Coordination, Continuity and Transition of Behavioral Health Care 11/9/23 12/24/23 Approved Coordination, Continuity and Transition of Behavioral Health Care
2023-UHC-2250 Device and Skin Substitute Policy 11/9/23 12/24/23 Approved Device and Skin Substitute Policy
2023-HBL-2264 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting 11/9/23 12/24/23 Approved Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
2023-LHCC-2269

Concert Genetics Hereditary Cancer Susceptibility

11/9/23 12/24/23 Pending Concert Genetics Hereditary Cancer Susceptibility
2023-HBL-258

Health Care Management Denial

11/1/23 12/16/23 Approved Health Care Management Denial
2023-LHCC-336

Care Management Program Description

11/1/23 12/16/23 Approved Care Management Program Description
2023-UHC-579

Surgery of the Hip

11/1/23 12/16/23 Approved Surgery of the Hip
2023-UHC-789

Minimally Invasive Procedures for Gastric and Esophageal Diseases

11/1/23 12/16/23 Approved Minimally Invasive Procedures for Gastric and Esophageal Diseases
2023-UHC-827

Prolotherapy and Platelet Rich Plasma Therapies

11/1/23 12/16/23 Approved Prolotherapy and Platelet Rich Plasma Therapies
2023-LHCC-896

Physician Incentive Plan

11/1/23 12/16/23 Approved Physician Incentive Plan
2023-UHC-1589

Surgical Treatment of Lymphedema

11/1/23 12/16/23 Approved Surgical Treatment of Lymphedema
2023-UHC-1719

Louisiana BH Supplemental Clinical Care

11/1/23 12/16/23 Approved Louisiana BH Supplemental Clinical Care
2023-UHC-1785

Plagiocephaly and Craniosynostosis Treatment

11/1/23 12/16/23 Approved Plagiocephaly and Craniosynostosis Treatment
2023-UHC-2260

Mobility Devices, Options and Accessories

11/1/23 12/16/23 Approved Mobility Devices, Options and Accessories
2023-UHC-443 Ambulance Services 11/9/23 12/24/23 Denied Ambulance Services
2023-LDH-16

MCO Manual > Part 4: Services > Professional Services > Tobacco Cessation Counseling Services

(Effective date = 6/20/2023)

 10/26/23 12/10/23  Pending  Tobacco Cessation Counseling Services
2023-ABH-1007

BH Provider Monitoring Strategy

10/24/23 12/8/23 Approved BH Provider Monitoring Strategy
2023-LHCC-1477

Duplicate Primary Code Billing

10/23/23 12/7/23 Approved Duplicate Primary Code Billing
2023-LHCC-1484

Status B Bundled Services

10/23/23 12/7/23 Approved Status B Bundled Services
2023-LHCC-1492

New Patient

10/23/23 12/7/23 Approved New Patient
2023-HBL-1717

Utilization Management

10/23/23 12/7/23 Completed Utilization Management
2023-UHC-1737

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures

10/23/23 12/7/23 Approved Computer-Assisted Surgical Navigation for Musculoskeletal Procedures
2023-LHCC-1752

Epidural Spine Injections

10/23/23 12/7/23 Approved Epidural Spine Injections
2023-LHCC-1880

Hip Arthroplasty

10/23/23 12/7/23 Approved Hip Arthroplasty
2023-LHCC-1881

Hip Arthroscopy

10/23/23 12/7/23 Approved Hip Arthroscopy
2023-LHCC-1960

Dually Diagnosed Continuous Improvement

10/23/23 12/7/23 Approved Dually Diagnosed Continuous Improvement
2023-HUM-2212

80305, 80306, 80307 Limit Reimbursement for Presumptive Drug Testing to 24 per Year

10/23/23 12/7/23 Approved 80305, 80306, 80307 Limit Reimbursement for Presumptive Drug Testing to 24 per Year
2023-UHC-2252

Hospital Services: Observation and Inpatient

10/23/23 12/7/23 Approved Hospital Services: Observation and Inpatient
2023-ABH-2253

Utilization Management Timeliness Standards and Decision Notification Amendment

10/23/23 12/7/23 Completed Utilization Management Timeliness Standards and Decision Notification Amendment
2023-ABH-2254

Benefit Exception Amendment

10/23/23 12/7/23 Completed Benefit Exception Amendment
2023-ABH-2255

Decision Making Criteria Notification Amendment

10/23/23 12/7/23 Completed Decision Making Criteria Notification Amendment
2023-HBL-2223

Provider Quality Monitoring Strategy

10/23/23 12/7/23 Approved Provider Quality Monitoring Strategy
2023-UHC-206

Electric Tumor Treatment Field Therapy

10/23/23 12/7/23 Approved Electric Tumor Treatment Field Therapy
2023-UHC-378

Surgery of the Shoulder

10/23/23 12/7/23 Approved Surgery of the Shoulder
2023-UHC-474

Rhinoplasty and Other Nasal Procedures

10/23/23 12/7/23 Approved Rhinoplasty and Other Nasal Procedures
2023-LHCC-682

Active Procedures in Physical Medicine

10/23/23 12/7/23 Approved Active Procedures in Physical Medicine
2023-LHCC-685

Experimental, Unproven, or Investigational Services

10/23/23 12/7/23 Approved Experimental, Unproven, or Investigational Services
2023-LHCC-732

Heart (cardiac) PET

10/23/23 12/7/23 Approved Heart (cardiac) PET
2023-LHCC-770

Fractional Flow Reserve CT

10/23/23 12/7/23 Approved Fractional Flow Reserve CT
2023-LHCC-776

Transeophageal (TEE) Echo

10/23/23 12/7/23 Approved Transeophageal (TEE) Echo
2023-UHC-780

Core Decompression Avascular Necrosis

10/23/23 12/7/23 Approved Core Decompression Avascular Necrosis
2023-UHC-787

Lithotripsy Salivary Stones

10/23/23 12/7/23 Approved Lithotripsy Salivary Stones
2023-UHC-793

Virtual Upper Gastrointestinal Endoscopy

10/23/23 12/7/23 Approved Virtual Upper Gastrointestinal Endoscopy
2023-UHC-826

Surgery of the Elbow

10/23/23 12/7/23 Approved Surgery of the Elbow
2023-UHC-1122

Percutaneous Vertebroplasty and Kyphoplasty

10/23/23 12/7/23 Approved Percutaneous Vertebroplasty and Kyphoplasty
2023-LHCC-1167

DME Clinical Policy

10/23/23 12/7/23 Approved DME Clinical Policy
2023-LHCC-1268

Bone-Anchored Hearing Aid

10/23/23 12/7/23 Approved Bone-Anchored Hearing Aid
2023-UHC-1404

Breast Imaging for Screening and Diagnosing Cancer

10/23/23 12/7/23 Approved Breast Imaging for Screening and Diagnosing Cancer
2023-UHC-1418

Autologous Cellular Therapy

10/23/23 12/7/23 Approved Autologous Cellular Therapy
2023-UHC-1424

Intraoperative Hyperthermic Intraperitoneal Chemotherapy

10/23/23 12/7/23 Approved Intraoperative Hyperthermic Intraperitoneal Chemotherapy
2023-UHC-1458

Hepatitis Screening

10/23/23 12/7/23 Approved Hepatitis Screening
2023-LHCC-1476

Status P Bundled Service

10/23/23 12/7/23 Approved Status P Bundled Service
2023-LDH-15

MCO Manual > Part 4: Services > Pharmacy > Behavioral Health Specific Pharmacy Policies and Procedures (Proposed effective date = 12/1/2023)

10/18/23  12/2/23  Completed Behavioral Health Specific Pharmacy Policies and Procedures
2023-ACLA-873

CT Bone Density Study

10/18/23 12/2/23 Approved CT Bone Density Study
2023-ACLA-874

CT (Virtual) Colonoscopy

10/18/23 12/2/23 Approved CT (Virtual) Colonoscopy
2023-ACLA-875

Chest (Thorax) CT

10/18/23 12/2/23 Approved Chest (Thorax) CT
2023-ACLA-876

Chest CTA

10/18/23 12/2/23 Approved Chest CTA
2023-ACLA-877

Chest MRA

10/18/23 12/2/23 Approved Chest MRA
2023-ACLA-878

Chest (Thorax) MRI

10/18/23 12/2/23 Approved Chest (Thorax) MRI
2023-ACLA-879

Brain (Head) MRS

10/18/23 12/2/23 Approved Brain (Head) MRS
2023-ACLA-880

Cervical Spine MRI

10/18/23 12/2/23 Approved Cervical Spine MRI
2023-ACLA-881

Cervical Spine CT

10/18/23 12/2/23 Approved Cervical Spine CT
2023-ACLA-882

Brain (Head) MRI, Brain (Head) MRI with IAC (Internal Auditory Canal)

10/18/23 12/2/23 Approved Brain (Head) MRI, Brain (Head) MRI with IAC (Internal Auditory Canal)
2023-ACLA-884

Brain (Head) MRA/MRV

10/18/23 12/2/23 Approved Brain (Head) MRA/MRV
2023-ACLA-887

CTA Aortogram with Runoff

10/18/23 12/2/23 Approved CTA Aortogram with Runoff
2023-ACLA-1147

Brain PET Scan

10/18/23 12/2/23 Approved Brain PET Scan
2023-ACLA-1148

Unlisted Studies

10/18/23 12/2/23 Approved Unlisted Studies
2023-ACLA-1448

Pet Scans

10/18/23 12/2/23 Approved Pet Scans
2023-ACLA-2249

Tumor Imaging PET-Any Site (Unlisted PET)

10/18/23 12/2/23 Approved Tumor Imaging PET-Any Site (Unlisted PET)
2023-ACLA-852

Heart (Cardiac) PET with CT for Attenuation

10/17/23 12/1/23 Approved Heart (Cardiac) PET with CT for Attenuation
2023-ACLA-853

Heart MRI

10/17/23 12/1/23 Approved Heart MRI
2023-ACLA-854

Electron-Beam Tomography (EBCT) or Non-Contrast Coronary Computed Tomography (Non-contrast CCT)

10/17/23 12/1/23 Approved Electron-Beam Tomography (EBCT) or Non-Contrast Coronary Computed Tomography (Non-contrast CCT)
2023-ACLA-855

Heart (cardiac) PET

10/17/23 12/1/23 Approved Heart (cardiac) PET
2023-ACLA-856

Functional Brain MRI

10/17/23 12/1/23 Approved Functional Brain MRI
2023-ACLA-857

CT Heart, CT Heart Congenital (Not including coronary arteries)

10/17/23 12/1/23 Approved CT Heart, CT Heart Congenital (Not including coronary arteries)
2023-ACLA-858

Upper Extremity MRA/MRV

10/17/23 12/1/23 Approved Upper Extremity MRA/MRV
2023-ACLA-859

Upper Extremity MRI

10/17/23 12/1/23 Approved Upper Extremity MRI
2023-ACLA-861

Breast MRI

10/17/23 12/1/23 Approved Breast MRI
2023-ACLA-862

Upper Extremity CT

10/17/23 12/1/23 Approved Upper Extremity CT
2023-ACLA-863

Thoracic Spine MRI

10/17/23 12/1/23 Approved Thoracic Spine MRI
2023-ACLA-864

Lower Extremity CTA/CTV

10/17/23 12/1/23 Approved Lower Extremity CTA/CTV
2023-ACLA-865

Upper Extremity CTA/CTV

10/17/23 12/1/23 Approved Upper Extremity CTA/CTV
2023-ACLA-866

Thoracic Spine CT

10/17/23 12/1/23 Approved Thoracic Spine CT
2023-ACLA-867

Temporomandibular Joint (TMJ) MRI

10/17/23 12/1/23 Approved Temporomandibular Joint (TMJ) MRI
2023-ACLA-868

Spinal Canal MRA

10/17/23 12/1/23 Approved Spinal Canal MRA
2023-ACLA-869

Sinus & Maxillofacial CT Limited or Localized Follow Up Sinus CT

10/17/23 12/1/23 Approved Sinus & Maxillofacial CT Limited or Localized Follow Up Sinus CT
2023-ACLA-870

Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT

10/17/23 12/1/23 Approved Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT
2023-ACLA-871

Sinus Face Orbit MRI

10/17/23 12/1/23 Approved Sinus Face Orbit MRI
2023-ACLA-872

CT Coronary Angiography (CCTA)

10/17/23 12/1/23 Approved CT Coronary Angiography (CCTA)
2023-LHCC-687

Measurable Progressive Improvement

10/17/23 12/1/23 Approved Measurable Progressive Improvement
2023-LHCC-689

Outpatient Habilitative PT and OT Therapy

10/17/23 12/1/23 Approved Outpatient Habilitative PT and OT Therapy
2023-LHCC-690

Outpatient Habilitative and Rehabilitative Speech Therapy

10/17/23 12/1/23 Approved Outpatient Habilitative and Rehabilitative Speech Therapy
2023-LHCC-691

Passive Treatment

10/17/23 12/1/23 Approved Passive Treatment
2023-ACLA-836

Pelvis MRI

10/17/23 12/1/23 Approved Pelvis MRI
2023-ACLA-837

Pelvis MRA

10/17/23 12/1/23 Approved Pelvis MRA
2023-ACLA-838

Pelvis CT Angiography

10/17/23 12/1/23 Approved Pelvis CT Angiography
2023-ACLA-839

Pelvis CT

10/17/23 12/1/23 Approved Pelvis CT
2023-ACLA-840

Neck MRA/MRV

10/17/23 12/1/23 Approved Neck MRA/MRV
2023-ACLA-841

Neck CTA

10/17/23 12/1/23 Approved Neck CTA
2023-ACLA-842

MUGA (Multiple Gated Acquisition) Scan

10/17/23 12/1/23 Approved MUGA (Multiple Gated Acquisition) Scan
2023-ACLA-843

Neck CT

10/17/23 12/1/23 Approved Neck CT
2023-ACLA-844

Low Field MRI

10/17/23 12/1/23 Approved Low Field MRI
2023-ACLA-845

MPI - Myocardial Perfusion Imaging

10/17/23 12/1/23 Approved MPI - Myocardial Perfusion Imaging
2023-ACLA-846

Lumbar Spine CT

10/17/23 12/1/23 Approved Lumbar Spine CT
2023-ACLA-847

Lumbar Spine MRI

10/17/23 12/1/23 Approved Lumbar Spine MRI
2023-ACLA-848

Lower Extremity MRI (foot, ankle, knee, leg, or hip MRI)

10/17/23 12/1/23 Approved Lower Extremity MRI (foot, ankle, knee, leg, or hip MRI)
2023-ACLA-849

Lower Extremity MRA/MRV

10/17/23 12/1/23 Approved Lower Extremity MRA/MRV
2023-ACLA-850

Lower Extremity CT

10/17/23 12/1/23 Approved Lower Extremity CT
2023-ACLA-851

Low Dose CT for Lung Cancer Screening

10/17/23 12/1/23 Approved Low Dose CT for Lung Cancer Screening
2023-LHCC-769

Cardiac Resynchronization Therapy (CRT)

10/16/23 11/30/23 Approved Cardiac Resynchronization Therapy (CRT)
2023-LHCC-771

Heart Catheterization

10/16/23 11/30/23 Approved Heart Catheterization
2023-LHCC-775

Stress Echocardiography

10/16/23 11/30/23 Approved Stress Echocardiography
2023-LHCC-778

Transthoracic (TTE) Echo

10/16/23 11/30/23 Approved Transthoracic (TTE) Echo
2023-ACLA-883

Brain {Head} CT

10/16/23 11/30/23 Approved Brain {Head} CT
2023-ACLA-885

Brain (Head) CTA

10/16/23 11/30/23 Approved Brain (Head) CTA
2023-ACLA-886

Bone Marrow MRI

10/16/23 11/30/23 Approved Bone Marrow MRI
2023-ACLA-888

Abdomen/Pelvis CTA Combo

10/16/23 11/30/23 Approved Abdomen/Pelvis CTA Combo
2023-ACLA-889

Abdomen MRA (Angiography}

10/16/23 11/30/23 Approved Abdomen MRA (Angiography}
2023-ACLA-890

Abdomen/Pelvis CT Combo

10/16/23 11/30/23 Approved Abdomen/Pelvis CT Combo
2023-ACLA-891

Abdomen MRI, MRCP

10/16/23 11/30/23 Approved Abdomen MRI, MRCP
2023-ACLA-892

Abdomen CT

10/16/23 11/30/23 Approved Abdomen CT
2023-ACLA-893

Abdomen CT Angiography

10/16/23 11/30/23 Approved Abdomen CT Angiography
2023-LHCC-1429

Heart PET with CT Attenuation

10/16/23 11/30/23 Approved Heart PET with CT Attenuation
2023-LHCC-1711

Sympathetic Nerve Block

10/16/23 11/30/23 Approved Sympathetic Nerve Block
2023-LHCC-1750

Sacroiliac Joint Injections-NIA

10/16/23 11/30/23 Approved Sacroiliac Joint Injections-NIA
2023-LHCC-1751

Spinal Cord Stimulation-NIA

10/16/23 11/30/23 Approved Spinal Cord Stimulation-NIA
2023-LHCC-1756

Facet Joint Denervation

10/16/23 11/30/23 Approved Facet Joint Denervation
2023-LHCC-1764

Single Photon Emission Computed Tomography SPECT

10/16/23 11/30/23 Approved Single Photon Emission Computed Tomography SPECT
2023-HBL-2158

Human Chorionic Gonadotrophin Testing

10/16/23 11/30/23 Approved Human Chorionic Gonadotrophin Testing
2023-LHCC-745

Neck CT (soft tissue)

10/16/23 11/30/23 Approved Neck CT (soft tissue)
2023-LHCC-746

Neck CTA

10/16/23 11/30/23 Approved Neck CTA
2023-LHCC-747

Neck MRA/MRV

10/16/23 11/30/23 Approved Neck MRA/MRV
2023-LHCC-748

Oncology PET Scans

10/16/23 11/30/23 Approved Oncology PET Scans
2023-LHCC-749

Pelvis CT

10/16/23 11/30/23 Approved Pelvis CT
2023-LHCC-750

Pelvis CT Angiography

10/16/23 11/30/23 Approved Pelvis CT Angiography
2023-LHCC-751

Pelvis MRA

10/16/23 11/30/23 Approved Pelvis MRA
2023-LHCC-752

Pelvis MRI

10/16/23 11/30/23 Approved Pelvis MRI
2023-LHCC-753

Orbit, Face, Neck, Sinus MRI

10/16/23 11/30/23 Approved Orbit, Face, Neck, Sinus MRI
2023-LHCC-754

Sinus & Maxillofacial CT limited or localized f/u Sinus CT

10/16/23 11/30/23 Approved Sinus & Maxillofacial CT limited or localized f/u Sinus CT
2023-LHCC-755

Spinal Canal MRA

10/16/23 11/30/23 Approved Spinal Canal MRA
2023-LHCC-756

Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT

10/16/23 11/30/23 Approved Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT
2023-LHCC-757

Temporomandibular Joint (TMJ) MRI

10/16/23 11/30/23 Approved Temporomandibular Joint (TMJ) MRI
2023-LHCC-758

Thoracic Spine CT

10/16/23 11/30/23 Approved Thoracic Spine CT
2023-LHCC-759

Thoracic Spine MRI

10/16/23 11/30/23 Approved Thoracic Spine MRI
2023-LHCC-763

Unlisted Studies

10/16/23 11/30/23 Approved Unlisted Studies
2023-LHCC-764

Upper Extremity CT (Hand, Wrist, Long bone, or Shoulder CT)

10/16/23 11/30/23 Approved Upper Extremity CT (Hand, Wrist, Long bone, or Shoulder CT)
2023-LHCC-765

Upper Extremity CT Angiography

10/16/23 11/30/23 Approved Upper Extremity CT Angiography
2023-LHCC-766

Upper Extremity MRA/MRV

10/16/23 11/30/23 Approved Upper Extremity MRA/MRV
2023-LHCC-767

Upper Extremity MRI (Hand, Wrist, Elbow, Long bone, or Shoulder MRI)

10/16/23 11/30/23 Approved Upper Extremity MRI (Hand, Wrist, Elbow, Long bone, or Shoulder MRI)
2023-LHCC-718

Chest (Thorax) MRI

10/16/23 11/30/23 Approved Chest (Thorax) MRI
2023-LHCC-719

Chest CTA

10/16/23 11/30/23 Approved Chest CTA
2023-LHCC-720

Chest MRA

10/16/23 11/30/23 Approved Chest MRA
2023-LHCC-721

CT (Virtual) Colonoscopy -1

10/16/23 11/30/23 Approved CT (Virtual) Colonoscopy -1
2023-LHCC-722

CT (Virtual) Colonoscopy -2

10/16/23 11/30/23 Approved CT (Virtual) Colonoscopy -2
2023-LHCC-723

CT Bone Density Study

10/16/23 11/30/23 Approved CT Bone Density Study
2023-LHCC-726

Coronary Artery Calcium Scoring by: EBCT or Non-Contrast CCT

10/16/23 11/30/23 Approved Coronary Artery Calcium Scoring by: EBCT or Non-Contrast CCT
2023-LHCC-727

Fetal MRI

10/16/23 11/30/23 Approved Fetal MRI
2023-LHCC-728

Functional Brain MRI

10/16/23 11/30/23 Approved Functional Brain MRI
2023-LHCC-729

CT Heart CT heart Congenital

10/16/23 11/30/23 Approved CT Heart CT heart Congenital
2023-LHCC-730

Heart MRI

10/16/23 11/30/23 Approved Heart MRI
2023-LHCC-735

Low Dose CT for Lung Cancer Screening

10/16/23 11/30/23 Approved Low Dose CT for Lung Cancer Screening
2023-LHCC-736

Lower Extremity CT (foot, ankle, leg or hip CT)

10/16/23 11/30/23 Approved Lower Extremity CT (foot, ankle, leg or hip CT)
2023-LHCC-737

Lower Extremity CT Angiography

10/16/23 11/30/23 Approved Lower Extremity CT Angiography
2023-LHCC-738

Lower Extremity MRA/MRV

10/16/23 11/30/23 Approved Lower Extremity MRA/MRV
2023-LHCC-739

Lower Extremity MRI (foot, ankle, knee, leg, or hip MRI)

10/16/23 11/30/23 Approved Lower Extremity MRI (foot, ankle, knee, leg, or hip MRI)
2023-LHCC-740

Lumbar Spine CT

10/16/23 11/30/23 Approved Lumbar Spine CT
2023-LHCC-741

Lumbar Spine MRI

10/16/23 11/30/23 Approved Lumbar Spine MRI
2023-LHCC-742

Myocardial Perfusion Imaging (Nuclear Cardiac Imaging Study)

10/16/23 11/30/23 Approved Myocardial Perfusion Imaging (Nuclear Cardiac Imaging Study)
2023-LHCC-744

MUGA (Multiple Gated Acquisition) Scan

10/16/23 11/30/23 Approved MUGA (Multiple Gated Acquisition) Scan
2023-LHCC-695

Abdomen CT

10/13/23 11/27/23 Approved Abdomen CT
2023-LHCC-696

Abdomen CT Angiography

10/13/23 11/27/23 Approved Abdomen CT Angiography
2023-LHCC-697

Abdomen MRA (Angiography)

10/13/23 11/27/23 Approved Abdomen MRA (Angiography)
2023-LHCC-698

Abdomen MRI

10/13/23 11/27/23 Approved Abdomen MRI
2023-LHCC-699

Abdomen/Pelvis CT Combo

10/13/23 11/27/23 Approved Abdomen/Pelvis CT Combo
2023-LHCC-700

Abdomen/Pelvis CTA

10/13/23 11/27/23 Approved Abdomen/Pelvis CTA
2023-LHCC-701

CTA Aortogram with Runoff

10/13/23 11/27/23 Approved CTA Aortogram with Runoff
2023-LHCC-703

Bone Marrow MRI

10/13/23 11/27/23 Approved Bone Marrow MRI
2023-LHCC-704

Brain (Head) CT

10/13/23 11/27/23 Approved Brain (Head) CT
2023-LHCC-705

Brain (Head) CTA

10/13/23 11/27/23 Approved Brain (Head) CTA
2023-LHCC-706

Brain (Head) MRA/MRV

10/13/23 11/27/23 Approved Brain (Head) MRA/MRV
2023-LHCC-707

Brain (Head) MRI/Brain (Head) MRI w Internal Auditory Canal

10/13/23 11/27/23 Approved Brain (Head) MRI/Brain (Head) MRI w Internal Auditory Canal
2023-LHCC-708

Brain (Head) MRS

10/13/23 11/27/23 Approved Brain (Head) MRS
2023-LHCC-709

Brain PET Scan

10/13/23 11/27/23 Approved Brain PET Scan
2023-LHCC-711

Breast MRI

10/13/23 11/27/23 Approved Breast MRI
2023-LHCC-712

CT Coronary Angiography (CCTA)

10/13/23 11/27/23 Approved CT Coronary Angiography (CCTA)
2023-LHCC-713

Cerebral Perfusion CT

10/13/23 11/27/23 Approved Cerebral Perfusion CT
2023-LHCC-715

Cervical Spine CT

10/13/23 11/27/23 Approved Cervical Spine CT
2023-LHCC-716

Cervical Spine MRI

10/13/23 11/27/23 Approved Cervical Spine MRI
2023-LHCC-717

Chest (Thorax) CT

10/13/23 11/27/23 Approved Chest (Thorax) CT
2023-LHCC-1753

Implantable Infusion Pump Insertion

10/11/23 11/25/23 Approved Implantable Infusion Pump Insertion
2023-LHCC-1754

Epidural Spine Injection Trial Intrathecal Hybrid

10/11/23 11/25/23 Approved Epidural Spine Injection Trial Intrathecal Hybrid
2023-LHCC-1755

Paravertebral Facet Joint injections or blocks

10/11/23 11/25/23 Approved Paravertebral Facet Joint injections or blocks
2023-LHCC-1889

Shoulder Arthroscopy

10/11/23 11/25/23 Approved Shoulder Arthroscopy
2023-LHCC-2231

Concert Genetics Gastroenterologic Disorders non-cancerous

10/11/23 11/25/23 Approved Concert Genetics Gastroenterologic Disorders non-cancerous
2023-LHCC-2232

Concert Genetics General Approach to Genetic Testing

10/11/23 11/25/23 Approved Concert Genetics General Approach to Genetic Testing
2023-LHCC-2233

Concert Genetics Hearing Loss

10/11/23 11/25/23 Approved Concert Genetics Hearing Loss
2023-LHCC-2234

Concert Genetics Lung Disorders

10/11/23 11/25/23 Approved Concert Genetics Lung Disorders
2023-LHCC-2235

Concert Genetics Kidney Disorders

10/11/23 11/25/23 Approved Concert Genetics Kidney Disorders
2023-LHCC-2236

Concert Genetics Immune Autoimmune and Rheumatoid Disorders

10/11/23 11/25/23 Approved Concert Genetics Immune Autoimmune and Rheumatoid Disorders
2023-LHCC-2237

Concert Genetics Hematologic Conditions non-cancerous

10/11/23 11/25/23 Approved Concert Genetics Hematologic Conditions non-cancerous
2023-LHCC-2238

Concert Genetics Skeletal Dysplasia Rare Bone Disorders

10/11/23 11/25/23 Approved Concert Genetics Skeletal Dysplasia Rare Bone Disorders
2023-LHCC-2239

Concert Genetics Oncology Cytogenetic Testing

10/11/23 11/25/23 Approved Concert Genetics Oncology Cytogenetic Testing
2023-LHCC-2240

Concert Genetics Preimplantation Genetic Testing

10/11/23 11/25/23 Approved Concert Genetics Preimplantation Genetic Testing
2023-LHCC-2241

Concert Genetics Oncology Cancer Screening

10/11/23 11/25/23 Approved Concert Genetics Oncology Cancer Screening
2023-LHCC-2242

Concert Genetics Prenatal and Preconception Carrier Screening

10/11/23 11/25/23 Approved Concert Genetics Prenatal and Preconception Carrier Screening
2023-LHCC-2243

Concert Genetics Non-invasive Prenatal Screening

10/11/23 11/25/23 Approved Concert Genetics Non-invasive Prenatal Screening
2023-LHCC-2244

Concert Genetics Prenatal Diagnosis Pregnancy Loss

10/11/23 11/25/23 Approved Concert Genetics Prenatal Diagnosis Pregnancy Loss
2023-LHCC-2245

Concert Genetics Multi-system Inherited Disorders

10/11/23 11/25/23 Approved Concert Genetics Multi-system Inherited Disorders
2023-LHCC-2246

Concert Genetics Metabolic Endocrine Mitochondrial Disorder

10/11/23 11/25/23 Approved Concert Genetics Metabolic Endocrine Mitochondrial Disorder
2023-LHCC-1703

Pediatric Kidney Transplant

10/11/23 11/25/23 Approved Pediatric Kidney Transplant
2023-LHCC-1745

Donor Lymphocyte Infusion

10/11/23 11/25/23 Approved Donor Lymphocyte Infusion
2023-LHCC-1838

Intensity-Modulated Radiotherapy

10/11/23 11/25/23 Approved Intensity-Modulated Radiotherapy
2023-LHCC-1882

Knee Arthroplasty

10/11/23 11/25/23 Approved Knee Arthroplasty
2023-LHCC-1883

Lumbar Artificial Disc Replacement

10/11/23 11/25/23 Approved Lumbar Artificial Disc Replacement
2023-LHCC-1884

Lumbar Spine Surgery

10/11/23 11/25/23 Approved Lumbar Spine Surgery
2023-LHCC-1885

Knee Arthroscopy

10/11/23 11/25/23 Approved Knee Arthroscopy
2023-LHCC-1886

Sacroiliac Joint Infusion

10/11/23 11/25/23 Approved Sacroiliac Joint Infusion
2023-LHCC-1887

Shoulder Arthroplasty

10/11/23 11/25/23 Approved Shoulder Arthroplasty
2023-LHCC-1906

Facility-Based Sleep Studies for OSA

10/11/23 11/25/23 Approved Facility-Based Sleep Studies for OSA
2023-HUM-2199

Air Ambulance policy

10/11/23 11/25/23 Approved Air Ambulance policy
2023-ACLA-2221

Provider Quality Monitoring Strategy

10/11/23 11/25/23 Approved Provider Quality Monitoring Strategy
2023-UHC-2222

Provider Quality Monitoring Strategy

10/11/23 11/25/23 Approved Provider Quality Monitoring Strategy
2023-HUM-2224

Provider Quality Monitoring Strategy

10/11/23 11/25/23 Approved Provider Quality Monitoring Strategy
2023-LHCC-2225

Lantidra (donislecel) Allogeneic Pancreatic Islet Cellular Therapy

10/11/23 11/25/23 Approved Lantidra (donislecel) Allogeneic Pancreatic Islet Cellular Therapy
2023-LHCC-2226

Concert Genetics Aortopathies and Connective Tissue Disorders

10/11/23 11/25/23 Approved Concert Genetics Aortopathies and Connective Tissue Disorders
2023-LHCC-2227

Concert Genetics Cardiac Disorders

10/11/23 11/25/23 Approved Concert Genetics Cardiac Disorders
2023-LHCC-2228

Concert Genetics Eye Disorders

10/11/23 11/25/23 Approved Concert Genetics Eye Disorders
2023-LHCC-2229

Concert Genetics Dermatologic Conditions

10/11/23 11/25/23 Approved Concert Genetics Dermatologic Conditions
2023-LHCC-2230

Concert Genetics Epilepsy Neurodegenerative and Neuromuscular Conditions

10/11/23 11/25/23 Approved Concert Genetics Epilepsy Neurodegenerative and Neuromuscular Conditions
2023-UHC-486

Abnormal Uterine Bleeding and Uterine Fibroids

10/11/23 11/25/23 Approved Abnormal Uterine Bleeding and Uterine Fibroids
2023-UHC-562

Balloon Sinus Ostial Dilation

10/11/23 11/25/23 Approved Balloon Sinus Ostial Dilation
2023-UHC-788

Mechanical Stretching Devices

10/11/23 11/25/23 Approved Mechanical Stretching Devices
2023-UHC-790

Nerve Graft to restore Erectile Function during Radical Prostatectomy

10/11/23 11/25/23 Approved Nerve Graft to restore Erectile Function during Radical Prostatectomy
2023-LHCC-934

Behavioral Health Provider Quality Program

10/11/23 11/25/23 Approved Behavioral Health Provider Quality Program
2023-LHCC-1109

Diaphragmatic/Phrenic Nerve Stimulation

10/11/23 11/25/23 Approved Diaphragmatic/Phrenic Nerve Stimulation
2023-LHCC-1228

Sacroiliac Joint Interventions for Pain Management

10/11/23 11/25/23 Approved Sacroiliac Joint Interventions for Pain Management
2023-LHCC-1265

Vagus Nerve Stimulation

10/11/23 11/25/23 Approved Vagus Nerve Stimulation
2023-LHCC-1269

Gender Affirming Procedures

10/11/23 11/25/23 Approved Gender Affirming Procedures
2023-LHCC-1274

Osteogenic Stimulation

10/11/23 11/25/23 Approved Osteogenic Stimulation
2023-LHCC-1356

Lung Transplantation

10/11/23 11/25/23 Approved Lung Transplantation
2023-LHCC-1358

Pancreas Transplantation

10/11/23 11/25/23 Approved Pancreas Transplantation
2023-LHCC-1411

Medical Necessity Criteria

10/11/23 11/25/23 Approved Medical Necessity Criteria
2023-UHC-1423

Total Artificial Heart and Ventricular Assist Devices

10/11/23 11/25/23 Approved Total Artificial Heart and Ventricular Assist Devices
2023-UHC-1425

Neuropsychological Testing under the Medical Benefit

10/11/23 11/25/23 Approved Neuropsychological Testing under the Medical Benefit
2023-HUM-1428

Preauthorization and Notification List

10/11/23 11/25/23 Completed Preauthorization and Notification List
2023-LHCC-1524

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

10/11/23 11/25/23 Approved Posterior Tibial Nerve Stimulation for Voiding Dysfunction
2023-LHCC-1525

Intradiscal Steroid Injections for Pain Management

10/11/23 11/25/23 Approved Intradiscal Steroid Injections for Pain Management
2023-LHCC-1526

Trigger Point Injections

10/11/23 11/25/23 Approved Trigger Point Injections
2023-LHCC-1527

Nerve Blocks and Neurolysis for Pain Management

10/11/23 11/25/23 Approved Nerve Blocks and Neurolysis for Pain Management
2023-HBL-2263 Claims Interest Policy 11/9/23 12/24/23 Under LDH Review Claims Interest Policy
2023-HBL-98

Claim Submission: Required Information for Facilities

9/19/23 11/3/23 Approved Claim Submission: Required Information for Facilities
2023-UHC-215

Spinal Fusion and Bone Healing Enhancement Products

9/19/23 11/3/23 Approved Spinal Fusion and Bone Healing Enhancement Products
2023-LHCC-1416

Transportation Policy

9/19/23 11/3/23 Approved Transportation Policy
2023-HUM-1606

Louisiana UM Program Description

9/19/23 11/3/23 Completed Louisiana UM Program Description
2023-HBL-2220

Provider Digital Correspondence Initiative

9/19/23 11/3/23 Pending Provider Digital Correspondence Initiative
2023-LHCC-329

Adverse Determinations

9/18/23 11/2/23 Completed Adverse Determinations
2023-LHCC-532

Appropriate UM Professionals

9/18/23 11/2/23 Completed Appropriate UM Professionals
2023-LHCC-991

Concurrent Review

9/18/23 11/2/23 Completed Concurrent Review
2023-UHC-1761

Home Health

9/18/23 11/2/23 Approved Home Health
2023-HBL-1778

Outpatient Glycated Hemoglobin and Protein Testing

9/18/23 11/2/23 Approved Outpatient Glycated Hemoglobin and Protein Testing
2023-HBL-1783

Mechanical Embolectomy for Treatment of Stroke

9/18/23 11/2/23 Approved Mechanical Embolectomy for Treatment of Stroke
2023-HUM-2210

J7300 - prevention of pregnancy

9/18/23 11/2/23 Approved J7300 - prevention of pregnancy
2023-HUM-2211

G0480 & G0481 Limit Definitive Drug Testing to 12 Per Year

9/18/23 11/2/23 Approved G0480 & G0481 Limit Definitive Drug Testing to 12 Per Year
2023-HBL-2215

Gamma Glutamyl Transferase Testing

9/18/23 11/2/23 Approved Gamma Glutamyl Transferase Testing
2023-HBL-2216

Outpatient Laboratory-based Blood Glucose Testing

9/18/23 11/2/23 Approved Outpatient Laboratory-based Blood Glucose Testing
2023-HBL-2217

Cryopreservation of Oocytes or Ovarian Tissue

9/18/23 11/2/23 Approved Cryopreservation of Oocytes or Ovarian Tissue
2023-HBL-2218

Dynamic Low-Load Prolonged-Duration Stretch Devices

9/18/23 11/2/23 Approved Dynamic Low-Load Prolonged-Duration Stretch Devices

Managed Care Policies & Procedures Archive Continued