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Clinical Coverage Policies

The Molina Clinical Policies accessible on this page are specific to Molina Healthcare of Ohio Medicaid members only and can be used as a tool to guide you in your medical decisions. Note: For Medicare, MyCare Ohio, and Marketplace Clinical Policies, please visit the Molina Clinical Policy page.

Please know that these Clinical Coverage Policies do not constitute plan authorization, nor is it an explanation of benefits. Prior authorization should be obtained prior to delivery of the service.

Tip: Using the Code LookUp Tool will provide further guidance on diagnosis or age considerations to help decide applicable criteria. Use the tool here.

Molina Clinical Policies (MCP)

All service requests not delegated to Evolent.

Buy and Bill Medications

Acthar Gel (repository corticotropin injection) C8373-A – Effective 1/10/24

Adakveo (crizanlizumab-tmca) C17920-A – Effective 11/10/24

Adcetris (brentuximab vedotin) UM ONC 1203 – Effective 9/1/24

Aduhelm (aducanumab-avwa) C21304-A – Effective 9/21/24

ADZYNMA (ADAMTS13, recombinant-krhn) C27325-A – Effective 11/3/24

Aldurazyme (laronidase) Policy No. C28302-A – Effective 11/3/24

Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A - Effective 11/3/24

Amondys 45 (casimersen) MNR C21154-A - Effective 9/21/24

Amvuttra (vutrisiran) C24213-A – Effective 11/3/24

Antiemetics C20780-A – Effective 5/1/24

Aphexda (motixafortide) C27171-A – Effective 4/12/24

Benlysta (belimumab) C2722-A – Effective 1/10/24

Beovu (brolucizumab) C17923-A – Effective 1/10/24

Botulinum Toxin C8755-A - Effective 4/12/24

Brineura (cerliponase alfa) C11526-A - Effective 11/16/24

Briumvi ublituximab-xiiy C25204-A - Effective 9/21/24

Cablivi (caplacizumab-yhdp) UM ONC 1353 – Effective 9/1/24

Calcitonin Gene-Related Peptide (CGRP) Antagonist C15443-C - Effective 11/20/23

Cimzia (certolizumab pegol) C10269-A - Effective 12/16/23

Cinqair (reslizumab) C9761-A – Effective 1/15/24

Cosela (trilaciclib) UM ONC 1424 – Effective 9/1/24

Cosentyx (secukinumab) C10410-A - Effective 5/1/24

Crysvita (burosumab-twza) Policy No. C14517-A – Effective 10/25/24

Cubicin (daptomycin) C10467-A - Effective 5/1/24

Cytogam (cytomegalovirus immune globulin) C9970-A – Effective 4/12/24

Dalvance (dalbavancin) C9351-A – Effective 4/12/24

Dextenza (dexamethasone intracanalicular insert) C24242-A – Effective 9/20/24

Dexycu (dexamethasone intraocular suspension) C16320-A – Effective 9/20/24

Durysta (bimatoprost implant) C19830-A – Effective 1/15/24

Elaprase (idursulfase) C2720-A – Effective 10/25/24

Elfabrio (pegunigalsidase alfa) Policy No. C25604-A – Effective 11/3/24

Enjaymo (sutimlimab) C22996-A - Effective 5/1/24

Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A – Effective 10/25/24

Evenity (romosozumab-aqqg) C17324-A – Effective 10/25/24

Evkeeza (evinacumab_dgnb) C21101-A – Effective 5/1/24

Exondys 51 (eteplirsen) MNR C18464-A - Effective 9/21/24

Eylea (aflibercept) C5674-A – Effective 1/10/24

Fabrazyme (agalsidase beta) C4865-A – Effective 10/25/24

Filgrastim C2437-A – Effective 10/25/24

Filsuvez (birch triterpenes gel) C27686-A - Effective 9/20/24

Furoscix (furosemide injection) C24669-A - Effective 4/22/24

Gamifant (emapalumab-lzsg) C15970-A – Effective 10/25/24

Givlaari (givosiran) C17924-A – Effective 10/25/24

Hepatitis B Immune Globulin C9971-A – Effective 4/12/24

Hereditary Angioedema Agents C21463-A – Effective 11/19/23

Hereditary Angioedema Agents C21463-A – Effective 11/29/24

Hyaluronic Acid Injections C14676-A - Effective 1/10/24

iDose TR (travoprost intracameral implant) C27707-A – Effective 9/20/24

Igalmi (dexmedetomidine) C23724-A – Effective 5/1/24

Ilaris (canakinumab) C2435-A - Effective 1/10/24

Ilumya (tildrakizumab) C15971-A - Effective 1/14/24

Iluvien (fluocinolone acetonide intravitreal implant) C11728-A - Effective 9/20/24

Immunoglobulin (SCIg, IVIg) MHI C21554-A – Effective 11/16/24

Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A – Effective 5/1/24

Intravenous Bisphosphonates C16790-A - Effective 11/20/23

Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) C15214-A - Effective 10/25/24

Iron Deficiency Anemia Agents C14569-A - Effective 10/25/24

Izervay (avacincaptad intravitreal) C26436-A – Effective 1/10/24

Kanuma (sebelipase alfa) C9974-A - Effective 10/25/24

Korsuva (difelikefalin) C23743-A – Effective 10/25/24

Krystexxa (pegloticase) C2729-A – Effective 4/12/24

Lamzede (velmanase alfa-tycv) Policy No. C25436-A – Effective 11/3/24

Lemtrada (alemtuzumab) C6919-A - Effective 9/21/24

Leqembi (lecanemab-irmb) C25201-A – Effective 9/21/24

Leqvio (inclisiran) C23141-A - Effective 5/1/24

Leukine (sargramostim) C2439-A - Effective 4/12/24

Leuprolide long acting (Lupron Depot, Eligard, Lupron Depot Ped, Fensolvi, Camcevi) C8756-A - Effective 4/12/24

Lumizyme (alglucosidase alfa) C8716_A - Effective 10/25/24

Mepsevii (vestronidase alfa-vjbk) C17942-A - Effective 10/25/24

Mozobil (plerixafor injection) C9017-A - Effective 4/12/24

Naglazyme (galsulfase) Policy No. C28288-A – Effective 11/3/24

NexoBrid (anacaulase-bcdb) C25200-A – Effective 9/21/24

Nexviazyme (alglucosidase alfa-ngpt) C21948-A – Effective 10/25/24

Nplate (romiplostim) C6662-A – Effective 10/25/24

Nucala (mepolizumab) C9704-A – Effective 1/10/24

Nulibry (fosdenopterin) C21306-A – Effective 10/25/24

Nulojix (belatacept) C9968-A – Effective 1/15/24

Nuzyra (omadacycline tosylate) C15914-A - Effective 5/1/24

Ocrevus (ocrelizumab) C11250-A – Effective 9/21/24

Octreotide Policy No. C8839-A – Effective 11/10/24

Off-Label Use of Drugs and Biologic Agents C4141-A – Effective 1/10/24

Omvoh (mirikizumab) C27293-A - Effective 4/12/24

Onpattro (patisiran)_Tegsedi_(inotersen) C17894-A - Effective 10/25/24

Orencia (abatacept) C10420-A - Effective 4/12/24

Oxlumo (lumasiran) C21126-A – Effective 10/25/24

Ozurdex (dexamethasone intravitreal implant) C9975-A – Effective 2/3/24

Parsabiv (etelcalcetide) C17883-A - Effective 10/25/24

Physician Administered Drugs C11251-A - Effective 1/7/24

Pombiliti (cipaglucosidase alfa) Policy No. C27242-A – Effective 10/25/24

Prevymis (letermovir) C15922-A - Effective 5/1/24

Prolia (denosumab) C8848-A – Effective 10/25/24

Qutenza (capsaicin) C2809-A – Effective 9/21/24

Radicava (edaravone) C11528-A – Effective 9/21/24

Ranibizumab and Biosimilars (Lucentis, Byooviz, Cimerli) C10417-A – Effective 12/16/23

Reblozyl (luspatercept-aamt) C18002-A – Effective 5/1/24

Rebyota (fecal microbiota, live-jslm) C25213-A - Effective 4/12/24

Retisert, Yutiq (fluocinolone acetonide) Intravitreal Implants C11728-A - Effective 9/20/24

Revcovi (elapegademase) C16329-A - Effective 10/25/24

Rezzayo (rezafungin) C26183-A - Effective 4/12/24

Rituxan (rituximab) and Biosimilars C10423-A - Effective 1/10/24

Rolvedon, Neulasta, and Related Biosimilars C10419-A – Effective 10/25/24

Ryplazim (plasminogen, human) C22238-A – Effective 10/25/24

Rystiggo (rozanolixizumab) C26210-A – Effective 1/10/24

Saphnelo (anifrolumab) C21970-A – Effective 1/10/24

Sexual Dysfunction Criteria - Non-Coverage C16658-A - Effective 5/1/24

Signifor (pasireotide diaspartate) C15367-A - Effective 10/25/24

Simponi_Simponi Aria (golimumab) C10422-A - Effective 12/16/23

Sivextro (tedizolid) C9353-A – Effective 4/12/24

Skyrizi (risankizumab-rzaa) C17336-A - Effective 1/10/24

Soliris (eculizumab) Ultomiris (ravulizumab) C4867-A C4867-A – Effective 10/25/24

Spevigo (spesolimab-sbzo) C20780-A – Effective 9/20/24

Standard Oncology Criteria C16154-A - Effective 5/1/24

Stelara (usketinumab) C10424-A - Effective 1/10/24

Sunlenca (lenacapavir) C25206-A – Effective 4/12/24

Supprelin LA (histrelin acetate) Implant C20611-A – Effective 10/25/24

Susvimo (ranibizumab) Intravitreal Implant C24231-A – Effective 9/20/24

Syfovre (pegcetacoplan intravitreal) C25311-A - Effective 1/14/24

Tepezza (teprotumumab-trbw) C18462-A – Effective 1/10/24

Tezspire(tezepelumab) C23042-A – Effective 1/10/24

Triptodur (triptorelin pamoate) C14649-A - Effective 10/25/24

Trogarzo (ibalizumab-uiyk) C14522-A - Effective 5/1/24

Tysabri (natalizumab) C10276-A – Effective 9/21/24

Tzield (teplizumab-mzwv) C24729-A – Effective 9/21/24

Uplizna (inebilizumab-cdon) C20171-A – Effective 10/25/24

Vabysmo (faricimab) C22795-A – Effective 5/1/24

Veopoz (pozelimab-bbfg) C26434-A – Effective 10/25/24

Vibativ (telavancin) C14575-A - Effective 5/1/24

Vimizim (elosulfase alfa) C7068-A – Effective 10/25/24

Vyondys 53 (golodirsen) MNR C18466-A - Effective 9/21/24

Vyvgart (efgartigimod alfa) C23127-A – Effective 1/10/24

Xacduro (sulbactam and durlobactam) C26432-A – Effective 4/22/24

Xenpozyme (olipudase alfa-rpcp) Policy No. C24670-A – Effective 11/3/24

Xgeva (denosumab) C8849-A – Effective 4/12/24

Xipere (triamcinolone ocular inj) C22222-A – Effective 1/15/24

Zinplava (bexlotoxumab) C14821-A – Effective 9/20/24

Zoladex (goserelin acetate) C8757-A - Effective 10/25/24

Zulresso (brexanolone) C16319-A - Effective 8/22/24

Molina Clinical Policies

MCP 000 Evaluation of New Technology - Effective 9/20/24

MCP 006 Vagal Nerve Stimulation for Epilepsy - Effective 5/1/24

MCP 011 Lumbar Artificial Intervertebral Disc Replacement - Effective 4/22/24

MCP 030 Facet Joint Diagnostic Injections for Chronic Back Pain - Effective 7/13/24

MCP 032 Epidural Steroid Injections for Back and Neck Pain - Effective 11/3/24

MCP 033 Sacroiliac Injections and RFA for SIJ Pain - Effective 7/13/24

MCP 050 Hyperbaric Oxygen Therapy and Topical Oxygen Therapy - Effective 7/13/24

MCP 051 Genetic Testing - Effective 9/20/24

MCP 051 Genetic Testing - Effective 12/15/24

MCP 085 Radiofrequency Ablation for Chronic Back Pain - Effective 7/13/24

MCP 120 Transarterial Chemoembolization (TACE) and Transarterial Embolization (TAE) for Liver Tumors - Effective 7/13/24

MCP 121 Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure – Effective 12/15/23

MCP 121 Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure – Effective 12/15/24

MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 12/16/23

MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 12/15/24

MCP 132 Percutaneous Ventricular Assist Devices - Effective 3/15/24

MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting - Effective 5/1/24

MCP 145 EPAP for Obstructive Sleep Apnea - Effective 3/6/24

MCP 145 EPAP for Obstructive Sleep Apnea - Effective 12/15/24

MCP 161 Robotically Assisted Surgery - Effective 7/13/24

MCP 180 QEEG for ADHD with NEBA System - Effective 11/3/24

MCP 181 Radioembolization for Primary and Metastatic Tumors of the Liver - Effective 11/3/24

MCP 183 Clinical Trials and Rare Disease Policy - Effective 9/20/24

MCP 184 Experimental and Investigational Services - Effective 9/20/24

MCP 204 Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair - Effective 7/13/24

MCP 205 Functional Electrical Stimulation for Spinal Cord Injury - Effective 9/20/24

MCP 206 Virtual Bronchoscopy for Pulmonary Lesions - Effective 9/20/24

MCP 207 Platelet-Riched Plasma (PRP) - Effective 7/13/24

MCP 216a Gender Affirmation Treatment and Procedures_Medicaid - Effective 5/29/24

MCP 218 Bone Graft Substitutes for Bone Fusion - Effective 7/13/24

MCP 222 Interspinous Decompression Devices for Spinal Stenosis - Effective 7/13/24

MCP 235 Measurement of Carotid Artery Intima Thickness – Effective 12/15/23

MCP 235 Measurement of Carotid Artery Intima Thickness – Effective 12/15/24

MCP 244 Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities – Effective 12/16/23

MCP 244 Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities – Effective 12/15/24

MCP 250 Prostatic Urethral Lift or UroLift for BPH - Effective 11/3/24

MCP 257 Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain (RACZ Procedure) - Effective 9/20/24

MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 9/20/24

MCP 292 Phototherapy and Laser Therapy for Dermatological Conditions - Effective 9/20/24

MCP 293 Spinraza_nusinersen - Effective 10/21/23

MCP 308 Visudyne_verteporfin_for Ocular Photodynamic Therapy - Effective 11/3/24

MCP 312 Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor - Effective 4/22/24

MCP 314 Genicular Radiofrequency Ablation RFA and Genicular Nerve Blocks for Chronic Knee Pain - Effective 5/1/24

MCP 315 Breast Implant Removal - Effective 7/13/24

MCP 318 Luxturna (voretigene neparvovec rzyl) - Effective 11/3/24

MCP 321 Category III CPT Codes - Effective 3/6/24

MCP 328 Corneal Collagen Cross Linking - Effective 11/3/24

MCP 329 Enclosed Bed Systems - Effective 1/7/24

MCP 332 Medically Necessary Services: Policy No. 332 - Effective 9/20/24

MCP 333 Steroid-Eluting Sinus Stents and Implants (PROPEL, SINUVA) - Effective 7/13/24

MCP 335 Deep Brain Stimulation DBS for Epilepsy - Effective 5/1/24

MCP 337 Gastroesophageal Reflux Disease GERD Treatment – Effective 12/15/23

MCP 337 Gastroesophageal Reflux Disease GERD Treatment – Effective 12/15/24

MCP 337 Gastroesophageal Reflux Disease GERD Treatment – Effective 11/3/24

MCP 338 Plantar Fasciitis Treatment - Effective 5/1/24

MCP 339 Interspinous Process Fixation Devices for Spinal Fusion - Effective 5/1/24

MCP 340 Implantable Neurostimulator for Central Sleep Apnea - Effective 5/1/24

MCP 341 Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation - Effective 5/1/24

MCP 343 Intervertebral Stabilization Devices – Effective 12/15/23

MCP 343 Intervertebral Stabilization Devices – Effective 12/15/24

MCP 344 Ketogenic Diet for Treatment of Intractable Seizures - Effective 5/1/24

MCP 347 Autologous Chondrocyte Implantation for Knee – Effective 12/16/23

MCP 347 Autologous Chondrocyte Implantation for Knee – Effective 12/15/24

MCP 350 MyoPro Orthosis - Effective 5/1/24

MCP 351 Minimally Invasive Lumbar Decompression MILD for Spinal Stenosis - Effective 3/6/24

MCP 352 Dynamic Exoskeletal Orthoses for Lower Extremity Injuries - Effective 3/6/24

MCP 352 Dynamic Exoskeletal Orthoses for Lower Extremity Injuries - Effective 12/15/24

MCP 353 Electric Tumor Treatment Fields for Glioblastoma - Effective 5/1/24

MCP 357 Skin Substitutes - Effective 11/3/24

MCP 361 Renal Autotransplantation - Effective 7/13/24

MCP 363 Hypoglossal Nerve Stimulation for the Treatment of OSA - Effective 9/20/24

MCP 366 Cluneal Nerve Block for LBP - Effective 11/3/24

MCP 367 Scenesse (afamelanotide) Implant - Effective 7/13/24

MCP 368 Transcatheter Tricuspid Valve Repair and Replacement for Tricuspid Valve Disease - Effective 11/3/24

MCP 372 Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain – Effective 1/10/24

MCP 372 Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain – Effective 12/15/24

MCP 377 Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers - Effective 11/3/24

MCP 378 Tecartus (brexucabtagene autoleucel) - Effective 9/20/24

MCP 381 Focused Microwave Thermotherapy for Breast Cancer - Effective 11/3/24

MCP 383 IB-Stim Device for Abdominal Pain in Adolescents - Effective 3/6/24

MCP 384 Water Vapor Thermal Therapy for BPH - Effective 3/6/24

MCP 384 Water Vapor Thermal Therapy for BPH - Effective 12/15/24

MCP 385 Peroral Endoscopic Myotomy for Esophageal Achalasia - Effective 7/13/24

MCP 386 Coolief Cooled Radiofrequency - Effective 3/6/24

MCP 389 XEN Gel Stent for Glaucoma - Effective 3/6/24

MCP 389 XEN Gel Stent for Glaucoma - Effective 12/15/24

MCP 395 Kymriah (tisagenlecleucel) - Effective 9/20/24

MCP 396 Yescarta (axicabtagene ciloleucel) - Effective 9/20/24

MCP 397 Moleculight Wound Care Device - Effective 7/13/24

MCP 399 Electrostimulation and Electromagnetic Therapy for Wound Care - Effective 11/3/24

MCP 400 Breyanzi (lisocabtagene maraleucel) - Effective 11/3/24

MCP 402 Plantar Fasciitis Surgery - Effective 7/13/24

MCP 403 Abecma (idecabtagene vicleucel) - Effective 9/20/24

MCP 407 Wound Vac (NPWT) - Effective 5/1/24

MCP 408 Balloon Sinus Ostial Dilation Balloon Sinuplasty - Effective 3/6/24

MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis - Effective 5/1/24

MCP 412 Prescription Digital Therapeutics - Effective 7/13/24

MCP 413 Carvykti (ciltacabtagene autoleucel) - Effective 9/20/24

MCP 414 Gastric Electrical Stimulation - Effective 12/15/23

MCP 414 Gastric Electrical Stimulation - Effective 12/15/24

MCP 421 Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Parenteral Nutrition (IPN) – Effective 12/15/23

MCP 421 Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Parenteral Nutrition (IPN) – Effective 12/15/24

MCP 422 Neuromuscular Electrical Training for the Treatment of OSA or Snoring (eXciteOSA) – Effective 3/6/24

MCP 422 Neuromuscular Electrical Training for the Treatment of OSA or Snoring (eXciteOSA) – Effective 12/15/24

MCP 425 Hydrogel Spacer for Prostate Radiotherapy (SpaceOAR) - Effective 5/1/24

MCP 426 Stem Cell Therapy for Orthopedic Applications - Effective 3/6/24

MCP 426 Stem Cell Therapy for Orthopedic Applications - Effective 12/15/24

MCP 427 Microwave Ablation of Lung and Liver Tumors - Effective 3/6/24

MCP 430 Responsive Neurostimulation for Medically Intractable Focal Epilepsy (NeuroPace®) - Effective 9/11/23

MCP 430 Responsive Neurostimulation (RNS) for Epilepsy - Effective 7/13/24

MCP 432 Developmental Testing - Effective 9/20/24

MCP 435 OMISIRGE (omidubicel onlv) - Effective 9/20/24

MCP 439 Vyjuvek (beremagene geperpavec) - Effective 9/20/24

MCP 440 Pancreatic Islet Cell Transplantation (Autologous) – Effective 11/3/24

MCP 441 Pancreatic Islet Cell Allotransplantation Lantidra (donislecel-jujn) - Effective 11/3/24

MCP 442 MISHA Knee Implant System - Effective 11/3/24

MCP 443 Fractional Laser Treatment of Traumatic and Burn Scars – Effective 12/16/23

MCP 443 Fractional Laser Treatment of Traumatic and Burn Scars – Effective 12/15/24

MCP 444 Implantable Peripheral Nerve and Nerve Field Stimulators for Chronic Pain – Effective 5/1/24

MCP 446 Wheelchair Mounted Robotic Arm Devices – Effective 7/5/24

MCP 450 Amtagvi - Effective 9/20/24

MCP 452 Intraosseous Basivertebral Nerve Ablation - Effective 7/13/24

MCP 458 Beqvez (fidanacogene elaparvovec-dzkt) - Effective 9/20/24

MCP 458 Beqvez (fidanacogene elaparvovec-dzkt) - Effective 12/22/24

MCP 460 Tecelra (afamitresgene autoleucel) - Effective 11/3/24

MCP 662 Whole Body MRI and/or CT - Effective 11/3/24

MCP 667 Xenoview_Xenon MRI - Effective 9/20/24

MCP 700 Foot Surgery-Bunionectomy - Effective 7/13/24

MCP 701 Foot Surgery-Hallux Rigidus - Effective 7/13/24

MCP 702 Foot Surgery-Lesser Toe Deformities-Hammer Mallet and Claw Toe - Effective 7/13/24

UM ONC 1209 Criteria for Evidence Based Cancer Therapies – Effective 9/1/24

UM ONC 1245 Xofigo (radium Ra 223 dichloride) – Effective 9/1/24

UM ONC_1332 Lutathera (lutetium Lu 177 dotatate) – Effective 9/1/24

UM ONC 1342 Azedra (iobenguane I-131) – Effective 9/1/24

UM ONC 1463 Pluvicto (lutetium Lu 177 vipivotide tetraxetan) – Effective 9/1/24

UM XRT 2009 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT – Effective 9/1/24

UM XRT 2010 Neutron and Proton Beam Policy – Effective 9/1/24

Evolent

Evolent performs Utilization Management services on behalf of Molina Healthcare for certain cardiology services for members ages 18 and older.

Cardiology (CT, PET, MRA, MRI and high-tech radiology ages 18+)

SKYGEN Policies

SKYGEN performs dental service reviews on behalf of Molina Healthcare.

SKYGEN Policies

UM-2-4000-D Utilization Review Criteria - Effective 10/3/24

UM-2-4000-1 Diagnostic Services - Effective 5/24/24

UM-2-4000-2 Preventive Services - Effective 5/24/24

UM-2-4000-3 Restorative Services - Effective 5/24/24

UM-2-4000-4 Periodontic Services - Effective 5/24/24

UM-2-4000-5 Prosthodontic Services - Effective 5/24/24

UM-2-4000-6 Oral Surgery Services - Effective 5/24/24

UM-2-4000-7 Orthodontic Services - Effective 5/24/24

UM-2-4000-8 Anesthesia Services - Effective 5/24/24

UM-2-4000-9 Other Services - Effective 5/24/24

UM-2-4000-10 Endodontic Services - Effective 5/24/24

Archived Medicaid Clinical Coverage Policies can be found here.