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Medical Clinical Policies

Medical clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures. Medical clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.

Not all policies found in the Maryland Physicians Care Medical Clinical Policy Manual apply to all Maryland Physicians Care members. Maryland Physicians Care policies are applied according to member eligibility and medical necessity criteria as defined in policy CP.MP.68. Policies in the Maryland Physicians Care Medical Clinical Policy Manual may have either a Maryland Physicians Care or a “Centene” heading. Maryland Physicians Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Maryland Physicians Care medical clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Maryland Physicians Care. In addition, Maryland Physicians Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Medical Clinical Policy Manuals or InterQual® criteria is payable by Maryland Physicians Care.   

If you have any questions regarding these policies, please contact Customer Service and ask to be directed to the Medical Management department.

MPC Clinical Policies
A-F Policies G-N Policies O-Z Policies
2019 Novel Coronavirus Testing CP.MP.183 (PDF) Gastric Electrical Stimulation CP.MP.40 (PDF) Obstetrical Home Health Care Programs CP.MP.91 (PDF)
Allergy Testing and Therapy CP.MP.100 (PDF) Gender Reassignment Coverage PA 24 (PDF) OP Cardiac Rehabilitation CP.MP.176 (PDF)
Allogenic Hematopoietic Cell Transplants for Sickle Cell CP.MP.108 (PDF) Genetic Testing PA 25 (PDF) Optic Nerve Decompression Surgery CP.MP.128 (PDF)
Ambulatory EEG CP.MP.96 (PDF) Heart-Lung Transplant CP.MP.132 (PDF)
Pancreas Transplantation CP.MP.102 (PDF)
Articular Cartilage Defect Repairs CP.MP.26 (PDF) Holter Monitors CP.MP.113 (PDF)
Panniculectomy CP.MP.109 (PDF)
Assistive Reproductive Technology CP.MP.55 (PDF) Home Birth CP.MP.136 (PDF)

Pediatric Heart Transplant CP.MP.138 (PDF)
Audiology Services and Devices PA 21 (PDF) Homocysteine Testing CP.MP.121 (PDF)

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention CP.MP.147 (PDF)
Breast Pump PA 20 (PDF) Hospice Services CP.MP.54 (PDF)
Private Duty Nurse PA 22 (PDF)
Balloon Sinus Ostial Dilation CP.MP.119 (PDF) Hyperemesis Gravidarum Treatment CP.MP.34 (PDF)
Bariatric Surgery CP.MP.37 (PDF) Hyperhidrosis Treatments CP.MP.62 (PDF) Radial Head Implant CP.MP.148 (PDF)
Bronchial Thermoplasty CP.MP.110 (PDF) Inhaled Nitric Oxide CP.MP.87 (PDF) Reduction Mammaplasty and Gynecomastia Surgery CP.MP.51 (PDF)
Carrier Screening in Pregnancy CP.MP.83 (PDF) Intestinal & Multivisceral Transplant CP.MP.58 (PDF) Remote Patient Monitoring PA 23 (PDF)
Cell-Free Fetal DNA Testing CP.MP.83 (PDF) Intradiscal Steroid Injections CP.MP.167 (PDF)
Cosmetic and Reconstructive Surgery CP.MP.31 (PDF) Laser Therapy for Skin Conditions CP.MP.123 (PDF) Sclerotherapy for Varicose Veins CP.MP.146 (PDF)
Custodial Care UM 04 (PDF) Low-Frequency Ultrasound Therapy for Wound Management CP.MP.139 (PDF) Selective Rizotomy for spasticity in Cerebral Palsy CP.MP.174 (PDF)
Digital EEG Spike Analysis CP.MP.105 (PDF) Lung Transplantation CP.MP.57 (PDF) Testing for Rupture of Fetal Membranes CP.MP.149 (PDF)
Discography CP.MP.115 (PDF) Mechanical Stretch Devices for Joint Stiffness and Contracture CP.MP.144 (PDF) Testing for Select Genitourinary Conditions CP.MP.97 (PDF)
DME Coverage Guidelines CP.MP.107 (PDF) Multiple Sleep Latency Test CP.MP.24 (PDF) Therapy Services (PT/OT/ST) CP.MP.49 (PDF)
Electric Tumor Treating Fields  CP.MP.145 (PDF) Neonatal Abstinence Syndrome Guidelines CP.MP.86 (PDF) Total Artificial Heart CP.MP.127 (PDF)
Endometrial Ablation CP.MP.106 (PDF) Nerve Blocks CP.MP.170 (PDF) Trigger Point Injections CP.MP.169 (PDF)
EpiFix Wound Treatment CP.MP.140 (PDF) NICU Apnea Bradycardia Guidelines CP.MP.82 (PDF) Urinary Incontinence Devices and Treatments CP.MP.142 (PDF)
Essure Removal CP.MP.131 (PDF) NICU Discharge Guidelines CP.MP.81 (PDF) Urodynamic Testing CP.MP.98 (PDF)
Evoked Potentials CP.MP.134 (PDF)   Vagus Nerve Stimulation CP.MP.12 (PDF)
Experimental Technologies CP.MP.36 (PDF)   Ventricular Assist Devices CP.MP.46 (PDF)
Fecal Incontinence Treatments CP.MP.137 (PDF)   Ventriculectomy and Cardiomyoplasty CP.MP.56 (PDF)
Fetal Surgery in Utero for Prenatally Diagnosed Malformations CP.MP.129 (PDF)   Wheelchair Seating CP.MP.99 (PDF)
Fractionated Exhaled Nitric Oxide (FeNO) CP.MP.103 (PDF)