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