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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) Heart-Lung Transplant (PDF) Optic Nerve Decompression Surgery (PDF)
Ambulatory Electroencephalography (PDF) Holter Monitoring (PDF) Pancreas Transplantation (PDF)
Articular Cartilage Defect Repairs (PDF) Home Birth (PDF) Panniculectomy (PDF)

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