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Medical Policy Manual

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Presbyterian Health Plan, Inc. Medical Policy Manual

The Medical Policy Manual is updated on a routine basis. Please click on the link below for a current summary of updates.

Download Summary of Updates

All services provided must be medically necessary as determined by the member's practitioner or provider in consultation with PHP.

Behavioral Health Clinical Medical Necessity Criteria (Medicaid Centennial Care)

Behavioral Health Medical Necessity Criteria (Medicare/Commercial) Magellan NIA Medical Necessity Criteria


Acupuncture for Chronic Lower Back Pain, (Dry Needling), MPM 57.0Allergen Immunotherapy, MPM 44.0Allergy Testing, MPM 45.0Ambulance Services, MPM 1.1Autism Spectrum Disorders: Diagnosis and Treatment, MPM 1.4Autologous Chondrocyte Implantation (Carticel), MPM 3.2


Balloon Dilation for ENT Procedures, MPM 2.12Bariatric Surgery (Weight Loss Surgery) for Medicare, MPM 2.82Bariatric Surgery (Weight Loss Surgery) for Non-Medicare, MPM 2.81Bariatric Surgery for Pediatric Population, MPM 40.0Blepharoplasty/Ptosis Surgery, MPM 2.7Breast Surgical Procedures, MPM 27.0Breast Ultrasound, MPM 24.1Bronchial Thermoplasty For Treatment of Asthma, See MPM 36.0


Cancer Clinical Trials, Routine Patient Care Costs- Coverage for Medicaid, MPM 3.7Capsule Endoscopy, MPM 24.0Chimeric Antigen Receptor (CAR) T-cell Therapy, MPM 32.0Cholecystectomy, MPM 3.9Clinical Trial, Routine Patient Care Costs for Medicare, MPM 3.8Clinical Trials, Routine Patient Care Costs for Commercial, MPM 3.6Continuous Glucose Monitoring Systems (See DME: Diabetic Equipment, MPM 4.4)Corneal Cross-Linking for Keratoconus and Ectasia, MPM 28.0COVID-19 Testing, MPM 43.0Cranial Orthotic Devices, (See DME: Orthotics and Prosthetics, MPM 4.6)


Diapers for Centennial Care Members, MPM 4.8Durable Medical Equipment: Alternating Electromagnetic Field Therapy for Glioblastoma, MPM 34.0Durable Medical Equipment: Bath Aids for Medicaid, MPM 48.0Durable Medical Equipment: For Individuals with Diabetes (Formerly Durable Medical Equipment: Diabetic Equipment), MPM 4.4Durable Medical Equipment: Miscellaneous, MPM 4.5Durable Medical Equipment: Orthotics and Prosthetics, MPM 4.6Durable Medical Equipment: Positive Airway Pressure (PAP) and Oral Appliances for Treatment of Obstructive Sleep Apnea, MPM 49.1Durable Medical Equipment: Pneumatic Compression Devices, MPM 5.0Durable Medical Equipment: Rehabilitation and Mobility Devices, MPM 4.2Durable Medical Equipment: Respiratory Devices, MPM 4.3


Epidural Corticosteroid Injections, MPM 5.9Exhaled Nitric Oxide Testing for the Diagnosis/Management of Asthma, See MPM 36.0Extracorporeal Photopheresis, MPM 5.7Extracorporeal Shock Wave Therapy for Musculoskeletal Disorders, MPM 5.6


Facet Joint Interventions for Pain Management (Formerly Paravertebral Facet Joint Denervation), MPM 16.6Foot Splints for Club Foot (See DME: Orthotics and Prosthetics, MPM 4.6)


Gastric Electric Stimulation for the Treatment of Chronic Gastroparesis, MPM 7.2Gender Affirming Treatment and Surgery (Adult, 18 years of age and older), MPM 7.3Gender Affirming Treatment for Children and Adolescent (17 y/o and under), MPM 7.31Genetic and Genomic Testing (Disease Specific), MPM 7.1Genetic Testing: Cologuard for Colorectal Cancer Screening, MPM 7.4Genetic Testing for Breast Cancer Recurrence and Predictive, MPM 33.0Genetic Testing for Circulating Tumor DNA Tests for Management of Cancer, MPM 54.0Genetic Testing for Cutaneous Melanoma, MPM 7.7Genetic Testing: Hypercoagulability/Thrombophilia, MPM 7.11Genetic Testing, InvisionFirst Liquid Biopsy for Lung Cancer, MPM 39.1 (Formerly MPM 37.0)Genetic Testing for Lynch Syndrome, MPM 7.5Genetic Testing for Multi-biomarker (Vectra™ DA) for Rheumatoid Arthritis, MPM 42.0Genetic Testing: Next Generation Sequencing, MPM 29.0Genetic Testing for Non-Invasive Prenatal Testing (NIPT) (Formerly Non-Invasive Prenatal Testing (NIPT)), MPM 20.15Genetic Testing for Pancreatic Cyst (PathfinderTG®/PancraGen™), MPM 7.6Genetic Testing, Plasma-Based Genomic Profiling in Solid Tumors, MPM 39.0Genetic Testing for Prostate Cancer, MPM 7.8Genetic Testing for Uveal Melanoma, MPM 7.9Genetic Testing for Whole Exome Sequencing, MPM 7.12


Home Health Care, for Medicare and Commercial, MPM 47.0Hyperbaric or Topical Oxygen Therapy (HBOT), MPM 8.6Hypoglossal Nerve Stimulator, MPM 46.0Hysterectomy and Radiofrequency Ablation for Uterine Fibroid, MPM 8.9


Implantable Cardioverter Defibrillators (ICD), MPM 9.5Interspinous Process Decompression (IPD) System (Formerly X-STOP® Interspinous Process Decompression (IPD) System), See MPM 36.0Intervertebral Differential Dynamics Therapy (IDD Therapy), See MPM 36.0Investigative & New Technology Assessment List (Non-Covered Services), MPM 36.0


LINX Reflux Management System for the Treatment of GERD, See MPM 36.0Lumbar Artificial Disc Replacement, MPM 56.0


Medicaid Home Health Services, MPM 13.6Meniscal Allograft Transplantation, MPM 13.3Minimally Invasive Lumbar Decompression MILD and Percutaneous Image Guided Lumbar Decompression (PILD), MPM 13.5Mobile Cardiac Outpatient Telemetry™ (MCOT™) and Real-time Continuous Attended Cardiac Monitoring Systems, MPM 13.2


Non-Invasive Prenatal Testing (NIPT), MPM 20.15


Obstetric US 3D, 4D, 5D, MPM 15.4Osteogenic Bone Growth Stimulators, MPM 15.2Outpatient (in Facility) Observation, MPM 50.0


Panniculectomy and Abdominoplasty, MPM 16.5Paravertebral Facet Joint Denervation (See Facet Joint Interventions for Pain Management, MPM 16.6)Percutaneous Arteriovenous Fistula (pAVF) for Hemodialysis, MPM 55.0Percutaneous Coronary Interventions, MPM 9.7Percutaneous Neuromodulation Therapy, See MPM 36.0Peripheral Nerve Stimulation (Formerly Peripheral Nerve Stimulation for Occipital Neuralgia), MPM 53.0Pharmacogenetic Testing for Warfarin Dosing (See Genetic and Genomic Testing, MPM 7.1)Pharmacogenomics Testing: Behavioral Health, for Medicare (Formerly Genesight Assay for Refractory Major Depression for Medicare), MPM 30.0Photodynamic Therapy for Ocular Conditions, MPM 16.15Plasma Exchange: Therapeutic Apheresis, MPM 16.11Platelet-Rich Plasma and Platelet-Derived Growth Factor Products, for the Treatment of Wounds and Other Injuries, MPM 16.16Prophylactic, Risk Reduction Surgery, MPM 16.10Prostate: Surgical Treatment for Benign Prostate Hyperplasia, MPM 12.3Proton Beam Therapy (See Radiation Oncology: Proton Beam Therapy, MPM 16.14)


Radiation Oncology: Proton Beam Therapy, MPM 16.14Restorative/Reconstructive/Cosmetic Surgery and Treatment, MPM 18.5


Sacral Nerve Stimulation for Urinary and Fecal Incontinence, MPM 51.0Secca® Procedure for Fecal Incontinence, See MPM 36.0Sleep Studies, Attended (In-Laboratory) Full-Channel Polysomnography, MPM 49.0Specialized Specimen Procedures, MPM 60.0Subtalar Arthroereisis Implants for Pediatric Patients, See MPM 36.0


Thermal Intradiscal Procedures (TIP), (includes IDET and Nucleoplasty) AKI: Intradiscal Electrothermal Therapy (IDET), See MPM 36.0Thoracic Spinal Surgeries, MPM 58.0Tissue-Engineered/Bioengineered Skin Substitutes (Application and Use), MPM 35.0Tonsillectomy, MPM 20.0Total Ankle Replacement, MPM 20.10Total Hip Resurfacing, MPM 20.9Total Joint Replacement Hip and Knee for Non-Medicare, MPM 20.14Total Joint Replacement Hip and Knee for Medicare, MPM 20.13Transcranial Magnetic Stimulation for Treatment Resistant Depression for Commercial, MPM 20.16Transcranial Magnetic Stimulation (TMS) for Treatment Resistant Depression for Medicare and Medicaid, MPM 20.11Transoral Incisionless Fundoplication (TIF) for Treatment of GERD, MPM 20.12Transplants, Bone Marrow and Peripheral Stem Cell, MPM 20.3Transplants, Organ, MPM 20.6


Unicompartmental Knee Replacement, MPM 41.0


Vagus Nerve Stimulation for Epilepsy and Depression, MPM 22.4Varicose Vein and Venous Stasis Disease of Lower Extremity Procedures, MPM 22.1


Water Vapor Thermal Therapy for LUTS/BPH, MPM 52.0Whole Breast Ultrasound, Semi-Automatic, See MPM 36.0

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