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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
Allergy Testing and Therapy (PDF)
Gastric Electrical Stimulation (PDF) OB Home Health Programs (PDF)
Allogenic Hematopoietic Cell Transplants for Sickle Cell  (PDF) Genetic Testing (PDF) Optic Nerve Decompression Surgery (PDF)
Ambulatory Electroencephalography (PDF) Heart-Lung Transplant (PDF) Pancreas Transplantation (PDF)
Articular Cartilage Defect Repairs (PDF) Holter Monitoring (PDF) Panniculectomy (PDF)

Assistive Reproductive Technology (PDF) Home Birth (PDF) Pediatric Heart Transplant (PDF)
Balloon Sinus Ostial Dilation (PDF) Home Sleep Testing (PDF) Percutaneous Left Atrial Appendage Closure Device (PDF)
Bariatric Surgery (PDF) Homocysteine Testing (PDF) Posterior Nerve Stimulation for Voiding Dysfunction (PDF)
Biofeedback (PDF) Hospice Clinical Coverage (PDF) Proton Beam and Neutron Beam Therapy (PDF)
Bronchial Thermoplasty (PDF) Hyperbaric Oxygen Therapy (PDF) Radial Head Implant (PDF)
Carrier Screening in Pregnancy (PDF) Hyperemesis Gravidarum Treatment (PDF) Reduction Mammaplasty (PDF)
Cosmetic and Reconstructive Surgery (PDF) Hyperhidrosis Treatments (PDF) Sclerotherapy for Varicose Veins (PDF)
Digital Breast Tomosynthesis (PDF) Inhaled Nitric Oxide (PDF)
Stereotactic Body Radiation Therapy (PDF)
Digital EEG Spike Analysis (PDF) Injections for Radiofrequency Neurotomy for Pain Management (PDF) Testing for Rupture of Fetal Membranes (PDF)
Discography (PDF) Intensity-Modulated Radiotherapy (PDF) Testing for Select Genitourinary Conditions (PDF)
DME Coverage Guidelines (PDF) Intestinal & Multivisceral Transplant (PDF) Therapy Services (PT/OT/ST) (PDF)
Laser Therapy for Skin Conditions (PDF)
DNA Analysis of Stool (PDF) Low-Frequency Ultrasound Therapy for Wound Management (PDF) Total Artificial Heart (PDF)
Electric Tumor Treating Fields (PDF) Lung Transplantation (PDF) Ultrasonography In Pregnancy (PDF)
Endometrial Ablation (PDF) Mechanical Stretch Devices (PDF) Urinary Incontinence Devices and Treatments (PDF)
EpiFix Wound Treatment (PDF) Medical Necessity Criteria (PDF) Urodynamic Testing (PDF)
Essure Removal (PDF) Multiple Sleep Latency Test (PDF) Vagus Nerve Stimulation (PDF)
Evoked Potentials (PDF) Neonatal Abstinence Syndrome Guidelines (PDF) Ventricular Assist Devices (PDF)
Experimental Technologies (PDF) Neonatal Sepsis Management Guidelines (PDF) Ventriculectomy and Cardiomyoplasty (PDF)
Fecal Calprotectin Assay (PDF) NICU Apnea Bradycardia (PDF) Wheelchair Seating (PDF)
Fecal Incontinence Treatments (PDF) NICU Discharge Guidelines (PDF) Wireless Motility Capsule (PDF)
Ferriscan R2-MRI (PDF) Non-myeloablative Allogenic Stem Cell Transplants (PDF) Zika Virus Testing (PDF)
Fetal Surgery in Utero (PDF)    
Flu and Strep Testing (PDF)    
Fractionated Exhaled Nitric Oxide (FeNO) measurement (PDF)    
Functional MRI (PDF)