Program Specific Clinical Coverage Policies

Policies

Allergies

  • 1N-1, Allergy Testing
  • 1N-2, Allergy Immunotherapy

 

Ambulance

  • 15, Ambulance Services

 

Anesthesia

  • 1L-1, Anesthesia Services
  • 1L-2, Moderate (Conscious) Sedation, AKA Procedural Sedation and Analgesia(PSA)

 

Auditory Implants External Parts

  • 13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair
  • 13B, Soft Band and Implantable Bone Conduction Hearing Aid External Parts Replacement and Repair

 

Behavioral Health

  • 8A, Enhanced Mental Health and Substance Abuse Services
  • 8A-1, Assertive Community Treatment (ACT) Program
  • 8A-2, Facility-Based Crisis Service for Children and Adolescents
  • 8A-5, Diagnostic Assessment
  • 8A-6, Community Support Team (CST)
  • 8B, Inpatient Behavioral Health Services
  • 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers
  • 8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of21
  • 8D-2, Residential Treatment Services
  • 8E, Intermediate Care Facilities for Individuals with Intellectual Disabilities
  • 8F, Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD
  • 8G, Peer Support Services
  • 8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population
  • 8J, Children's Developmental Service Agencies (CDSAs)
  • 8L, Mental Health/Substance Abuse Targeted Case Management
  • 8N, NC Health Choice Intellectual and Developmental Disabilities Targeted Case Management
  • 8-O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders
  • 8-P, North Carolina Innovations

 

Burn Treatments & Skin Substitutes & Skin Substitutes

  • 1G-1, Burn Treatment
  • 1G-2, Skin Substitutes

 

Cardiac Procedures

  • 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs
  • 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound

 

Chiropractic Services

  • 1F, Chiropractic Services

 

Community Based Services

  • 3A, Home Health Services
  • 3B, PACE (Program of All-Inclusive Care for the Elderly)
  • 3D, Hospice Services
  • 3G-1, Private Duty Nursing for Beneficiaries Age 21 and Older
  • 3G-2, Private Duty Nursing for Beneficiaries Under 21 years of Age
  • 3H-1, Home Infusion Therapy
  • 3K-1, Community Alternatives Program for Children (CAP/C)
  • 3K-2, Community Alternatives Program for Disabled Adults (CAP/DA)
  • 3L, State Plan Personal Care Services (PCS)

 

Dental

  • 4A, Dental Services
  • 4B, Orthodontic Services

 

Dietary Evaluation and Counseling

  • 1-I, Dietary Evaluation and Counseling and Medical Lactation Services

 

Facility Services

  • 2A-1, Acute Inpatient Hospital Services
  • 2A-2, Long Term Care Hospital Services
  • 2A-3, Out-of-State Services
  • 2B-1, Nursing Facilities
  • 2B-2, Geropsychiatric Units in Nursing Facilities

 

Hearing Aid Services

  • 7, Hearing Aid Services

 

Laboratory Services

  • 1S-1, Genotyping and Phenotyping for HIV Drug Resistance Testing
  • 1S-2, HIV Tropism Assay
  • 1S-3, Laboratory Services
  • 1S-4, Genetic Testing
  • 1S-5, Genetic Testing for Susceptibility to Breast and Ovarian Cancer (BRCA)
  • 1S-7, Gene Expression Profiling for Breast Cancer
  • 1S-8, Drug Testing for Opioid Treatment and Controlled Substance  Monitoring

 

Maternal Support Services (Baby Love)

  • 1M-2, Childbirth Education
  • 1M-3, Health and Behavior Intervention
  • 1M-4, Home Visit for Newborn Care and Assessment
  • 1M-5, Home Visit for Postnatal Assessment and Follow-up Care
  • 1M-6, Maternal Care Skilled Nurse Home Visit

 

Medical Equipment

  • 5A-1, Physical Rehabilitation Equipment and Supplies
  • 5A-2, Respiratory Equipment and Supplies
  • 5A-3, Nursing Equipment and Supplies
  • 5B, Orthotics & Prosthetics

 

Obstetrics & Gynecology

  • 1E-1, Hysterectomy
  • 1E-2, Therapeutic and Non-therapeutic Abortions
  • 1E-3, Sterilization Procedures
  • 1E-4, Fetal Surveillance
  • 1E-5, Obstetrics
  • 1E-6, Pregnancy Medical Home
  • 1E-7, Family Planning Services

Ophthalmological Services

  • 1T-1, General Ophthalmological Services
  • 1T-2, Special Ophthalmological Services

 

Pharmacy Services

  • 9, Outpatient Pharmacy Program
  • 9A, Over-The-Counter Products
  • 9B, Hemophilia Specialty Pharmacy Program
  • 9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17
  • 9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older
  • Agents for Duchenne Muscular Dystrophy
  • Antifungal Agents - Vusion
  • Antinarcolepsy/Antihyperkinesis Agents
  • Cialis
  • Crinone
  • Cystic Fibrosis
  • Emend
  • Emflaza
  • Entresto
  • Epidiolex Initial PA Criteria
  • Epinephrine Auto-Injections
  • Evrysdi
  • Gattex
  • Gocovri and Osmolex ER
  • Growth Hormones
  • Hematinics (Procrit, Epogen, Aranesp, Mircera, Retacrit)
  • Hepatitis C medications
  • Hetlioz
  • Immunomodulators
  • Juxtapid
  • Lupus Medications
  • Migraine Therapy - Calcitonin Gene-Related Inhibitors
  • Monoclonal Antibodies
  • Movement Disorders
  • Neuromuscular Blocking Agents (Botox, Myobloc, Dysport, Xeomin)
  • Opioid Analgesics
  • Opioid Dependence Therapy Agents
  • PCSK9 Inhibitors
  • Mu-Opioid Receptor Antagonists, Peripherally-Acting (Relistor)
  • Sedative Hypnotics
  • Synagis
  • Therapeutic Continuous Glucose Monitoring Systems (CGM) and Related Supplies
  • Topical Antihistamines
  • Topical Anti-Inflammatories
  • Topical Local Anesthetics
  • Triptans
  • Zolgensma

 

Physician Administered Drug Program

  • 1B, Physician's Drug Program

 

Physician Clinical Coverage Policies

  • 1A-2, Preventive Medicine Annual Health Assessment
  • 1A-3, Noninvasive Pulse Oximetry
  • 1A-4, Cochlear and Auditory Brainstem Implants
  • 1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment
  • 1A-6, Invasive Electrical Bone Growth Stimulation
  • 1A-7, Neonatal and Pediatric Critical and Intensive Care Services
  • 1A-8, Hyperbaric Oxygenation Therapy
  • 1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)
  • 1A-11, Extracorporeal Shock Wave Lithotripsy
  • 1A-12, Breast Surgeries
  • 1A-13, Ocular Photodynamic Therapy
  • 1A-14, Surgery for Ambiguous Genitalia
  • 1A-15, Surgery for Clinically Severe or Morbid Obesity
  • 1A-16, Surgery of the Lingual Frenulum
  • 1A-17, Stereotactic Pallidotomy
  • 1A-19, Transcranial Doppler Studies
  • 1A-20, Sleep Studies and Polysomnography Services
  • 1A-21, Endovascular Repair of Aortic Aneurysm
  • 1A-22, Medically Necessary Circumcision
  • 1A-23, Physician Fluoride Varnish Services
  • 1A-24, Diabetes Outpatient Self-Management Education
  • 1A-25, Spinal Cord Stimulation
  • 1A-26, Deep Brain Stimulation
  • 1A-27, Electrodiagnostic Studies
  • 1A-28, Visual Evoked Potential (VEP)
  • 1A-30 Spinal Surgeries
  • 1A-31, Wireless Capsule Endoscopy
  • 1A-32, Tympanometry and Acoustic Reflex Testing
  • 1A-33, Vagus Nerve Stimulation for the Treatment of Seizures
  • 1A-34, Dialysis Services
  • 1A-36, Implantable Bone Conduction Hearing Aids (BAHA)
  • 1A-38, Special Services: After Hours
  • 1A-39, Routine Costs in Clinical Trial Services for Life Threatening Conditions
  • 1A-40, Fecal Microbiota Transplantation
  • 1A-41- Office Based Opioid Treatment: Use of Buprenorphine and Buprenorphine-Naloxone
  • 1A-42, Balloon Ostial Dilation

 

Podiatry

  • 1C-1, Podiatry Services
  • 1C-2, Medically Necessary Routine Foot Care

 

Radiology

  • 1K-1, Breast Imaging Procedures
  • 1K-2, Bone Mass Measurement
  • 1K-6, Radiation Oncology
  • 1K-7, Prior Approval for Imaging Services

 

Reconstructive Surgery

  • 1-O-1, Reconstructive and Cosmetic Surgery
  • 1-O-2, Craniofacial Surgery
  • 1-O-3, Keloid Excision and Scar Revision
  • 1-O-5, Rhinoplasty and/or Septorhinoplasty

 

Rural Health Clinics, FQHC and Health Departments. (RHC, FQHC, Health Depts)

  • 1D-1, Refugee Health Assessments Provided in Health Departments
  • 1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments
  • 1D-3, Tuberculosis Control and Treatment Provided in Health Departments
  • 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics

 

Solid Organ Transplants

  • 11B-1, Lung Transplantation
  • 11B-2, Heart Transplantation
  • 11B-3, Islet Cell Transplantation
  • 11B-4, Kidney (Renal) Transplantation
  • 11B-5, Liver Transplantation
  • 11B-6, Heart/Lung Transplantation
  • 11B-7, Pancreas Transplant
  • 11B-8, Small Bowel and Small Bowel/Liver and Multivisceral Transplants

 

Specialized Therapies

  • 10A, Outpatient Specialized Therapies
  • 10B, Independent Practitioners (IP)
  • 10C, Local Education Agencies (LEAs)
  • 10D, Independent Practitioners Respiratory Therapy Services

 

Stem Cell Transplants

  • 11A-1, Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)
  • 11A-2, Hematopoietic Stem-Cell Transplant for Acute Myeloid Leukemia
  • 11A-3, Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia
  • 11A-5, Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemias
  • 11A-6, Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors
  • 11A-7, Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma
  • 11A-8, Hematopoietic Stem-Cell Transplantation For Multiple Myeloma and Primary Amyloidosis
  • 11A-9, Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms
  • 11A-10, Hematopoietic Stem-Cell Transplantation (HSCT) for Central Nervous System (CNS) Embryonal Tumors & Ependymoma
  • 11A-11, Hematopoietic Stem-Cell Transplant for Non-Hodgkin’s Lymphoma
  • 11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells
  • 11A-15, Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
  • 11A-16, Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
  • 11A-17, CAR-T Cell Therapy

 

Targeted Case Management

  • 12B, Human Immunodeficiency Virus (HIV) Case Management

 

Telehealth

  • 1H, Telehealth, Virtual Communications and Remote Patient Monitoring

 

Ventricular Assist Device

  • 11C, Ventricular Assist Device

 

Vision Services

  • 6A, Routine Eye Exam and Visual Aids for Recipients Under Age 21
  • 6B, Routine Eye Examination and Visual Aids for Beneficiaries 21 Years of Age and Older