Behavioral Health
DME
Genetic Testing
Medical
- Actigraphy
- Ambulatory and Video EEG Monitoring Outpatient Setting
- Aneuploidy
- Autologous Chondrocyte Implantation Knee
- Bioimpedence Analysis for Lymphedema Assessment
- Breast Implant Removal
- Bronchial Thermoplasty
- Category III CPT Codes
- Clinical Trials and Rare Disease Policy
- Cluneal Nerve Block for Low Back Pain
- Coolief Cooled Radiofrequency
- Corneal Collagen Cross-Linking
- Covid 19 Co Pays and Cost Share (Marketplace)
- Covid 19 Co Pays and Cost Share (Medicaid)
- Covid 19 Co Pays and Cost Share (Medicare)
- Deep Brain Stimulation for Epilepsy with the Activa® PC Neurostimulator
- Electric Tumor Treatment Fields for Glioblastoma
- Electrostimulation and Electromagnetic Therapy for Wound Care
- Enteral Nutrition
- Epidural Steroid Injections for Chronic Back and Neck Pain
- Evaluation of New Technology UM 10
- Experimental and Investigational Services
- Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers
- Facet Joint Diagnostic Injections for Chronic Back Pain
- Functional Electrical Stimulation for Spinal Cord Injury
- Gastric Electrical Stimulation
- Gastroesophageal Reflux Disease GERD Treatment
- Genicular Artery Embolization of Knee OA
- Gender Affirmation Treatment and Procedures_Medicaid
- Gender Affirmation Treatment and Procedures_Medicare
- Gender Affirmation Treatment and Procedures_Marketplace
- High Intensity Focused Ultrasound for Prostate Cancer
- Hyperbaric Oxygen Therapy
- IB-Stim Device for Abdominal Pain in Adolescents
- Implantable Neurostimulator for Central Sleep Apnea
- Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure
- Interspinous Decompression Devices for Spinal Stenosis
- Intradialytic Parenteral Nutrition and Intraperitoneal Parenteral Nutrition
- Ketogenic Diet Induction for Treatment of Intractable Seizures
- Measurement of Carotid Artery Intima Thickness
- Microwave Tumor Ablation
- Minimally Invasive Sacroiliac Joint Fusion
- Medically Necessary
- Mobile Cardiac Outpatient Telemetry
- Moleculight Wound Care Device
- Monarch External Trigeminal Nerve Stimulation_eTNS_System
- Myocardial Strain Imaging
- Occupational Therapy
- Optical Coherence Tomography of the Anterior Eye Segment
- Percutaneous Epidural Adhesiolysis
- Phototherapy and Laser Therapy for Dermatological Conditions
- Physical and Occupational Therapy
- Plantar Fasciitis Treatment
- Platelet Enriched Plasma
- Prescription Digital Therapeutics
- QEEG for ADHD with NEBA System
- Radioactive Microspheres for Liver Cancer
- Radioembolization for Primary and Metastatic Tumors of the Liver
- Radiofrequency Ablation for Chronic Back Pain
- Radiofrequency Ablation of Primary or Metastatic Liver Tumors
- Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
- Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain
- Recombinant Human Bone Morphogenetic Protein
- Remote Patient Monitoring
- Renal Autotransplantation
- Sacroiliac Injections and RFA for SIJ Pain
- Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation
- Speech Therapy
- Stem Cell Therapy for Orthopedic Applications
- Skin Substitutes for Chronic Wound Healing Outpatient
- Therapeutic Apheresis
- Vagal Nerve Stimulation for Epilepsy
- Virtual Bronchoscopy for Pulmonary Lesions
- Water Vapor Thermal Therapy for BPH
- Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
- Wireless Pulmonary Artery Pressure Monitoring_CardioMEMS_for Congestive Heart Failure
- Wound Care
- XEN Gel Stent for Glaucoma
Payment & Reimbursement
- California
- Florida
- Illinois
- Michigan
- South Carolina
- Utah
- Washington
- Wisconsin
For Payment and Reimbursement policies, click on the applicable State link below.
Links to additional States will be posted as they become available.
Pharmacy
- Dextenza (dexamethasone intracanalicular ophthalmic insert)
- Dexycu (dexamethasone intraocular suspension)
- Durysta (bimatoprost implant)
- Hemgenix (etranacogene dezaparvovec-drlb)
- Iluvien (fluocinolone acetonide intravitreal implant)
- Lutathera (lutetium Lu 177 dotatate)
- Ozurdex (dexamethasone intravitreal implant)
- Pluvicto lutetium Lu 177 vipivotide tetraxetan
- Prialt (ziconotide intrathecal infusion)
- Provenge sipuleucel-T
- Retisert, Yutiq_Intravitreal Corticosteroid Implants
- Scenesse (afamelanotide) Implant
- Skysona (elivaldogene autotemcel)
- Spinraza_nusinersen
- Steroid-Eluting Sinus Stents and Implants_PROPEL SINUVA
- Susvimo_ranibizumab intravitreal_Injection Implant
- Topical and Intralesional Therapies
- Visudyne_verteporfin_for Ocular Photodynamic Therapy
- Abecma (idecabtagene vicleucel)
- Breyanzi (lisocabtagene maraleucel; liso-cel)
- Carvykti (ciltacabtagene autoleucel)
- Kymriah (tisagenlecleucel)
- Luxturna (voretigene neparvovec-rzyl)
- Tecartus_brexucabtagene autoleucel
- Yescarta_axicabtagene ciloleucel
- Zolgensma_onasemnogene abeparvovec
- Zynteglo_betibeglogene autotemcel
- For Marketplace, please refer to Marketplace Pharmacy Policies located here. Select your State at the top right of the page.
- For Medicaid policies, please review your State specific webpage via the MolinaHealthCare.com main page – select your State at the top of the page. For further questions, please contact Member Services.
- For Medicare policies, please review your State specific webpage via the MolinaHealthCare.com main page – select your State at the top of the page.
Medical
Gene Therapy
Radiology
- 3D Interpretation and Reporting of Imaging Studies
- Abdomen Pelvis CT
- Brain MRI
- Brain PET
- Breast MRI
- Chest MRI
- External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT
- Focused Microwave Thermotherapy for Breast Cancer
- Lower Extremity MRI
- Lumbar Spine CT
- Lumbar Spine MRI
- Magnetic Resonance Guided Focused Ultrasound MRgFUS for Essential Tremor
- Neutron and Proton Beam Radiation Therapy
- Shoulder MRI
- Thermography and BSGI Imaging for the Detection of Breast Lesions
- Transarterial Chemoembolization for Liver Tumors
- Whole Body MRI
Surgery
- Artificial Disc Replacement
- Balloon Sinus Ostial Dilation Balloon Sinuplasty
- Blepharoplasty
- Facet Joint Allograft
- Foot Surgery Guidelines
- Gastrointestinal Electrical Stimulation (GES) for Obesity
- Genicular RFA for Chronic Knee Pain
- Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea OSA
- Minimally Invasive Lumbar Decompression MILD for Spinal Stenosis
- Interspinous Process Fixation Devices for Spinal Fusion
- Intervertebral Stabilization Devices
- Pediatric Bariatric Surgery
- Percutaneous Ventricular Assist Devices
- Peroral Endoscopic Myotomy for Esophageal Achalasia
- Plantar Fasciitis Surgery
- Prostatic Urethral Lift or UroLift for Benign Prostatic Hyperplasia BPH
- Robotically Assisted Surgery
- Shoulder Arthroscopy Guidelines
- Skin Substitutes
- Transcatheter Aortic Valve Replacement
- Transcatheter Pulmonary Valve Replacement
- Transcatheter Tricuspid Valve Replacement
- Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury
Transplant
- Donor Lymphocyte Infusion
- Haploididentical Transplantation
- Heart Transplantation
- Heart Transplantation with a Total Artificial Heart
- Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia ALL
- Hematopoietic Stem Cell Transplantation for Acute Myelogenous Leukemia AML
- Hematopoietic Stem Cell Transplantation for Aplastic Anemia
- Hematopoietic Stem Cell Transplantation for Chronic Lymphoblastic Leukemia CLL
- Hematopoietic Stem Cell Transplantation for Chronic Myelogenous Leukemia CML
- Hematopoietic Stem Cell Transplantation for Ewing's Sarcoma
- Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
- Hematopoietic Stem Cell Transplantation for Hodgkins and Non Hodgkins Lymphoma
- Hematopoietic Stem Cell Transplantation for Immunodeficiency Disorders
- Hematopoietic Stem Cell Transplantation for Mucopolysaccharidoses MPS
- Hematopoietic Stem Cell Transplantation for Multiple Myeloma
- Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndromes
- Hematopoietic Stem Cell Transplantation for Neuroblastoma
- Hematopoietic Stem Cell Transplantation for Primary Myelofibrosis
- Hematopoietic Stem Cell Transplantation for Sickle Cell Anemia
- Hematopoietic Stem Cell Transplantation for Wilms Tumor
- Kidney Transplantation
- Liver Transplantation Adult and Pediatric
- Lung Transplantation
- Pancreas Transplant Procedures
- Pretransplant Evaluation
- Small Bowel Multivisceral Transplantation
Utilization Management