Official Louisiana State Websites use .la.gov 
Secure .gov websites use HTTPS 
| Item Number | Policy/Procedure | Date Posted | Comment Period Closed | Status | Document Links |
|---|---|---|---|---|---|
| 2022-LDH-14 | State Directed Payment Program | 10/17/22 | N/A | N/A | State Directed Payment Program Manual MCO Manual references to State Directed Payment Program Manua Imminent Peril Justification |
| 2022-UHC-523 | Intrauterine Fetal Surgery | 10/14/22 | 11/28/22 | Approved | Intrauterine Fetal Surgery |
| 2022-UHC-786 | Light and Laser Therapy | 10/14/22 | 11/28/22 | Approved | Light and Laser Therapy |
| 2022-UHC-794 | Noncontact warning therapy, ultrasound therapy, and Fluorescence Imaging for wounds | 10/14/22 | 11/28/22 | Approved | Noncontact warning therapy, ultrasound therapy, and Fluorescence Imaging for wounds |
| 2022-UHC-827 | Prolotherapy and Platelet Rich Plasma Therapies | 10/14/22 | 11/28/22 | Approved | Prolotherapy and Platelet Rich Plasma Therapies |
| 2022-LHCC-1216 | Bariatric Surgery | 10/14/22 | 11/28/22 | Approved | Bariatric Surgery |
| 2022-LHCC-1224 | Fetal Surgery in Utero | 10/14/22 | 11/28/22 | Approved | Fetal Surgery in Utero |
| 2022-LHCC-1452 | Caudal or Interlaminar Epidural Steroid Injections | 10/14/22 | 11/28/22 | Approved | Caudal or Interlaminar Epidural Steroid Injections |
| 2022-LHCC-1453 | Cochlear Implants Replacements | 10/14/22 | 11/28/22 | Approved | Cochlear Implants Replacements |
| 2022-LHCC-1454 | Facet Joint Interventions | 10/14/22 | 11/28/22 | Approved | Facet Joint Interventions |
| 2022-LHCC-1455 | Optic Nerve Decompression Surgery | 10/14/22 | 11/28/22 | Approved | Optic Nerve Decompression Surgery |
| 2022-LHCC-1456 | Fecal Incontinence Treatments | 10/14/22 | 11/28/22 | Approved | Fecal Incontinence Treatments |
| 2022-LHCC-1457 | Neuromuscular Electrical Stimulation | 10/14/22 | 11/28/22 | Approved | Neuromuscular Electrical Stimulation |
| 2022-UHC-1458 | Hepatitis Screening | 10/14/22 | 11/28/22 | Approved | Hepatitis Screening |
| 2022-UHC-1459 | Walkers and Walker Accessories | 10/14/22 | 11/28/22 | Approved | Walkers and Walker Accessories |
| 2022-ACLA-858 | Upper Extremity MRA/MRV | 10/13/22 | 11/27/22 | Approved | Upper Extremity MRA/MRV |
| 2022-ACLA-859 | Upper Extremity MRI | 10/13/22 | 11/27/22 | Approved | Upper Extremity MRI |
| 2022-ACLA-861 | Breast MRI | 10/13/22 | 11/27/22 | Approved | Breast MRI |
| 2022-ACLA-862 | Upper Extremity CT | 10/13/22 | 11/27/22 | Approved | Upper Extremity CT |
| 2022-ACLA-863 | Thoracic Spine MRI | 10/13/22 | 11/27/22 | Approved | Thoracic Spine MRI |
| 2022-ACLA-864 | Lower Extremity CTA/CTV | 10/13/22 | 11/27/22 | Approved | Lower Extremity CTA/CTV |
| 2022-ACLA-865 | Upper Extremity CTA/CTV | 10/13/22 | 11/27/22 | Approved | Upper Extremity CTA/CTV |
| 2022-ACLA-866 | Thoracic Spine CT | 10/13/22 | 11/27/22 | Approved | Thoracic Spine CT |
| 2022-ACLA-867 | Temporomandibular Joint (TMJ) MRI | 10/13/22 | 11/27/22 | Approved | Temporomandibular Joint (TMJ) MRI |
| 2022-ACLA-868 | Spinal Canal MRA | 10/13/22 | 11/27/22 | Approved | Spinal Canal MRA |
| 2022-ACLA-869 | Sinus & Maxillofacial CT Limited or Localized Follow Up Sinus CT | 10/13/22 | 11/27/22 | Approved | Sinus & Maxillofacial CT Limited or Localized Follow Up Sinus CT |
| 2022-ACLA-870 | Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT | 10/13/22 | 11/27/22 | Approved | Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT |
| 2022-ACLA-871 | Sinus Face Orbit MRI | 10/13/22 | 11/27/22 | Approved | Sinus Face Orbit MRI |
| 2022-ACLA-873 | CT Bone Density Study | 10/13/22 | 11/27/22 | Approved | CT Bone Density Study |
| 2022-ACLA-874 | CT (Virtual) Colonoscopy | 10/13/22 | 11/27/22 | Approved | CT (Virtual) Colonoscopy |
| 2022-ACLA-876 | Chest CTA | 10/13/22 | 11/27/22 | Approved | Chest CTA |
| 2022-ACLA-877 | Chest MRA | 10/13/22 | 11/27/22 | Approved | Chest MRA |
| 2022-ACLA-1147 | Brain PET Scan | 10/13/22 | 11/27/22 | Approved | Brain PET Scan |
| 2022-ACLA-1148 | Unlisted Studies | 10/13/22 | 11/27/22 | Approved | Unlisted Studies |
| 2022-ACLA-1448 | PET Scans | 10/13/22 | 11/27/22 | Approved | PET Scans |
| 2022-LHCC-1450 | Maintaining Confidentiality of Credentialing Information | 10/13/22 | 11/27/22 | Complete | Maintaining Confidentiality of Credentialing Information |
| 2022-ACLA-836 | Pelvis MRI | 10/13/22 | 11/27/22 | Approved | Pelvis MRI |
| 2022-ACLA-837 | Pelvis MRA | 10/13/22 | 11/27/22 | Approved | Pelvis MRA |
| 2022-ALCA-838 | Pelvis CT Angiography | 10/13/22 | 11/27/22 | Approved | Pelvis CT Angiography |
| 2022-ACLA-839 | Pelvis CT | 10/13/22 | 11/27/22 | Approved | Pelvis CT |
| 2022-ACLA-840 | Neck MRA/MRV | 10/13/22 | 11/27/22 | Approved | Neck MRA/MRV |
| 2022-ACLA-841 | Neck CTA | 10/13/22 | 11/27/22 | Approved | Neck CTA |
| 2022-ACLA-842 | MUGA (Multiple Gated Acquisition) Scan | 10/13/22 | 11/27/22 | Approved | MUGA (Multiple Gated Acquisition) Scan |
| 2022-ACLA-843 | Neck CT | 10/13/22 | 11/27/22 | Approved | Neck CT |
| 2022-ACLA-844 | Low Field MRI | 10/13/22 | 11/27/22 | Approved | Low Field MRI |
| 2022-ACLA-845 | MPI - Myocardial Perfusion Imaging | 10/13/22 | 11/27/22 | Approved | MPI - Myocardial Perfusion Imaging |
| 2022-ACLA -846 | Lumbar Spine CT | 10/13/22 | 11/27/22 | Approved | Lumbar Spine CT |
| 2022-ACLA-848 | Lower Extremity MRI (foot, ankle, knee, leg, or hip MRI) | 10/13/22 | 11/27/22 | Approved | Lower Extremity MRI (foot, ankle, knee, leg, or hip MRI) |
| 2022-ACLA-849 | Lower Extremity MRA/MRV | 10/13/22 | 11/27/22 | Approved | Lower Extremity MRA/MRV |
| 2022-ACLA-850 | Lower Extremity CT | 10/13/22 | 11/27/22 | Approved | Lower Extremity CT |
| 2022-ACLA-851 | Low Dose CT for Lung Cancer Screening | 10/13/22 | 11/27/22 | Approved | Low Dose CT for Lung Cancer Screening |
| 2022-ACLA-852 | Heart (Cardiac) PET with CT for Attenuation | 10/13/22 | 11/27/22 | Approved | Heart (Cardiac) PET with CT for Attenuation |
| 2022-ACLA-853 | Heart MRI | 10/13/22 | 11/27/22 | Approved | Heart MRI |
| 2022-ACLA-854 | Electron-Beam Tomography (EBCT) or Non-Contrast Coronary Computed Tomography (Non-contrast CCT) | 10/13/22 | 11/27/22 | Approved | Electron-Beam Tomography (EBCT) or Non-Contrast Coronary Computed Tomography (Non-contrast CCT) |
| 2022-ACLA-855 | Heart (cardiac) PET | 10/13/22 | 11/27/22 | Approved | Heart (cardiac) PET |
| 2022-ACLA-856 | Functional Brain MRI | 10/13/22 | 11/27/22 | Approved | Functional Brain MRI |
| 2022-ACLA-857 | CT Heart, CT Heart Congenital (Not including coronary arteries) | 10/13/22 | 11/27/22 | Approved | CT Heart, CT Heart Congenital (Not including coronary arteries) |
| 2022-UHC-215 | Spinal Fusion and Bone Healing Enhancement Products | 10/12/22 | 11/26/22 | Approved | Spinal Fusion and Bone Healing Enhancement Products |
| 2022-UHC-486 | Abnormal Uterine Bleeding and Uterine Fibroids | 10/12/22 | 11/26/22 | Approved | Abnormal Uterine Bleeding and Uterine Fibroids |
| 2022-UHC-793 | Virtual Upper Gastrointestinal Endoscopy | 10/12/22 | 11/26/22 | Approved | Virtual Upper Gastrointestinal Endoscopy |
| 2022-ACLA-872 | CT Coronary Angiography (CCTA) | 10/12/22 | 11/26/22 | Approved | CT Coronary Angiography (CCTA) |
| 2022-ACLA-875 | Chest (Thorax) CT | 10/12/22 | 11/26/22 | Approved | Chest (Thorax) CT |
| 2022-ACLA-878 | Chest (Thorax) MRI | 10/12/22 | 11/26/22 | Approved | Chest (Thorax) MRI |
| 2022-ACLA-879 | Brain (Head) MRS | 10/12/22 | 11/26/22 | Approved | Brain (Head) MRS |
| 2022-ACLA-880 | Cervical Spine MRI | 10/12/22 | 11/26/22 | Approved | Cervical Spine MRI |
| 2022-ACLA-881 | Cervical Spine CT | 10/12/22 | 11/26/22 | Approved | Cervical Spine CT |
| 2022-ACLA-882 | Brain (Head) MRI, Brain (Head) MRI with IAC (Internal Auditory Canal) | 10/12/22 | 11/26/22 | Approved | Brain (Head) MRI, Brain (Head) MRI with IAC (Internal Auditory Canal) |
| 2022-ACLA-883 | Brain (Head) CT | 10/12/22 | 11/26/22 | Approved | Brain (Head) CT |
| 2022-ACLA-884 | Brain (Head) MRA/MRV | 10/12/22 | 11/26/22 | Approved | Brain (Head) MRA/MRV |
| 2022-ACLA-885 | Brain (Head) CTA | 10/12/22 | 11/26/22 | Approved | Brain (Head) CTA |
| 2022-ACLA-886 | Bone Marrow MRI | 10/12/22 | 11/26/22 | Approved | Bone Marrow MRI |
| 2022-ACLA-887 | Abdominal Arteries CT Angiography | 10/12/22 | 11/26/22 | Approved | Abdominal Arteries CT Angiography |
| 2022-ACLA-888 | Abdomen/Pelvis CTA Combo | 10/12/22 | 11/26/22 | Approved | Abdomen/Pelvis CTA Combo |
| 2022-ACLA-889 | Abdomen MRA (Angiography) | 10/12/22 | 11/26/22 | Approved | Abdomen MRA (Angiography) |
| 2022-ACLA-890 | Abdomen/Pelvis CT Combo | 10/12/22 | 11/26/22 | Approved | Abdomen/Pelvis CT Combo |
| 2022-ACLA-891 | Abdomen MRI, MRCP | 10/12/22 | 11/26/22 | Approved | Abdomen MRI, MRCP |
| 2022-ACLA-892 | Abdomen CT | 10/12/22 | 11/26/22 | Approved | Abdomen CT |
| 2022-ACLA-893 | Abdomen CT Angiography | 10/12/22 | 11/26/22 | Approved | Abdomen CT Angiography |
| 2022-ACLA-1442 | ACLA Prior Authorization Service List | 10/12/22 | 11/26/22 | Approved | ACLA Prior Authorization Service List |
| 2022-UHC-206 | Electric Tumor Treatment Field Therapy | 10/11/22 | 11/25/22 | Approved | Electric Tumor Treatment Field Therapy |
| 2022-HBL-318 | Clinical Information for Utilization Review | 10/11/22 | 11/25/22 | Approved | Clinical Information for Utilization Review |
| 2022-HBL-1264 | Lower Limb Prosthesis | 10/11/22 | 11/25/22 | Approved | Lower Limb Prosthesis |
| 2022-HBL-1311 | Bone Anchored and Bone Conduction Hearing Aids | 10/11/22 | 11/25/22 | Approved | Bone Anchored and Bone Conduction Hearing Aids |
| 2022-ABH-1374 | Rev code 370 | 10/11/22 | 11/25/22 | Approved | Rev code 370 |
| 2022-LHCC-1416 | Transportation Policy | 10/11/22 | 11/25/22 | Approved | Transportation Policy |
| 2022-HBL-1431 | Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver | 10/11/22 | 11/25/22 | Approved | Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver |
| 2022-UHC-1432 | Pediatric Gait Trainers and Standing Systems | 10/11/22 | 11/25/22 | Approved | Pediatric Gait Trainers and Standing Systems |
| 2022-ABH-1433 | Member Transition | 10/11/22 | 11/25/22 | Complete | Member Transition |
| 2022-HBL-1434 | Remote therapeutic and Physiologic Monitoring Services | 10/11/22 | 11/25/22 | Approved | Remote therapeutic and Physiologic Monitoring Services |
| 2022-HBL-1435 | Opthalmic use of Nd:YAG Laser for Posterior Capsulotomy | 10/11/22 | 11/25/22 | Approved | Opthalmic use of Nd:YAG Laser for Posterior Capsulotomy |
| 2022-HBL-1436 | Remote Devices for Intermittent Monitoring of Intraocular Pressure | 10/11/22 | 11/25/22 | Approved | Remote Devices for Intermittent Monitoring of Intraocular Pressure |
| 2022-HBL-1437 | External Upper Limb Stimulation for the Treatment of Tremors | 10/11/22 | 11/25/22 | Approved | External Upper Limb Stimulation for the Treatment of Tremors |
| 2022-LHCC-1438 | Credentialing Program and Quality Compliant Monitoring | 10/11/22 | 11/25/22 | Complete | Credentialing Program and Quality Compliant Monitoring |
| 2022-LHCC-1439 | Credentialing System Controls | 10/11/22 | 11/25/22 | Complete | Credentialing System Controls |
| 2022-LHCC-1440 | Secure Messaging and General Email Handling | 10/11/22 | 11/25/22 | Complete | Secure Messaging and General Email Handling |
| 2022-LHCC-1441 | Professional Competence and Board Certification Criteria | 10/11/22 | 11/25/22 | Complete | Professional Competence and Board Certification Criteria |
| 2022-HBL-1443 | Artificial Intelligence-Based Software for Prostate Cancer Detection | 10/11/22 | 11/25/22 | Approved | Artificial Intelligence-Based Software for Prostate Cancer Detection |
| 2022-HBL-1444 | Gene Therapy for Beta Thalassemia | 10/11/22 | 11/25/22 | Approved | Gene Therapy for Beta Thalassemia |
| 2022-HBL-1445 | High-volume Colonic Irrigation | 10/11/22 | 11/25/22 | Approved | High-volume Colonic Irrigation |
| 2022-HBL-1446 | Hand Transplantation | 10/11/22 | 11/25/22 | Approved | Hand Transplantation |
| 2022-HBL-1447 | Ankle-Foot & Knee-Ankle-Foot Orthoses | 10/11/22 | 11/25/22 | Approved | Ankle-Foot & Knee-Ankle-Foot Orthoses |
| 2022-LHCC-689 | Outpatient Habilitative PT and OT Therapy Final | 9/28/22 | 11/12/22 | Approved | Outpatient Habilitative PT and OT Therapy Final |
| 2022-LHCC-691 | Paddive Treatment | 9/28/22 | 11/12/22 | Approved | Paddive Treatment |
| 2022-LHCC-692 | Plain Film X-rays | 9/28/22 | 11/12/22 | Approved | Plain Film X-rays |
| 2022-LHCC-694 | Record Keeping and Documentation Standards: Chiropractic Care | 9/28/22 | 11/12/22 | Approved | Record Keeping and Documentation Standards: Chiropractic Care |
| 2022-LHCC-746 | Neck CTA | 9/28/22 | 11/12/22 | Approved | Neck CTA |
| 2022-LHCC-747 | Neck MRA/MRV | 9/28/22 | 11/12/22 | Approved | Neck MRA/MRV |
| 2022-LHCC-748 | Oncology PET Scans | 9/28/22 | 11/12/22 | Approved | Oncology PET Scans |
| 2022-LHCC-749 | Pelvis CT | 9/28/22 | 11/12/22 | Approved | Pelvis CT |
| 2022-LHCC-750 | Pelvis CT Angiography | 9/28/22 | 11/12/22 | Approved | Pelvis CT Angiography |
| 2022-LHCC-751 | Pelvis MRA | 9/28/22 | 11/12/22 | Approved | Pelvis MRA |
| 2022-LHCC-752 | Pelvis MRI | 9/28/22 | 11/12/22 | Approved | Pelvis MRI |
| 2022-LHCC-753 | Orbit, Face, Neck, Sinus MRI | 9/28/22 | 11/12/22 | Approved | Orbit, Face, Neck, Sinus MRI |
| 2022-LHCC-754 | Sinus & Maxillofacial CT limited or localized f/u Sinus CT | 9/28/22 | 11/12/22 | Approved | Sinus & Maxillofacial CT limited or localized f/u Sinus CT |
| 2022-LHCC-755 | Spinal Canal MRA | 9/28/22 | 11/12/22 | Approved | Spinal Canal MRA |
| 2022-LHCC-756 | Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Cancal CT | 9/28/22 | 11/12/22 | Approved | Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Cancal CT |
| 2022-LHCC-775 | Stress Echocardiography | 9/28/22 | 11/12/22 | Approved | Stress Echocardiography |
| 2022-LHCC-776 | Transesophageal (TEE) Echo | 9/28/22 | 11/12/22 | Approved | Transesophageal (TEE) Echo |
| 2022-LHCC-778 | Transthoracic (TTE) Echo | 9/28/22 | 11/12/22 | Approved | Transthoracic (TTE) Echo |
| 2022-LHCC-1430 | Record Keeping and Documentation Standards: Physical Medicine | 9/28/22 | 11/12/22 | Approved | Record Keeping and Documentation Standards: Physical Medicine |
| 2022-LHCC-687 | Measurable Progressive Improvement | 9/27/22 | 11/11/22 | Approved | Measurable Progressive Improvement |
| 2022-LHCC-690 | Outpatient Habilitative Speech Therapy | 9/27/22 | 11/11/22 | Approved | Outpatient Habilitative Speech Therapy |
| 2022-LHCC-730 | Heart MRI | 9/27/22 | 11/11/22 | Approved | Heart MRI |
| 2022-LHCC-738 | Lower Extremity MRA/MRV | 9/27/22 | 11/11/22 | Approved | Lower Extremity MRA/MRV |
| 2022-LHCC-739 | Lower Extremity MRI | 9/27/22 | 11/11/22 | Approved | Lower Extremity MRI |
| 2022-LHCC-740 | Lumbar Spine CT | 9/27/22 | 11/11/22 | Approved | Lumbar Spine CT |
| 2022-LHCC-741 | Lumbar Spine MRI | 9/27/22 | 11/11/22 | Approved | Lumbar Spine MRI |
| 2022-LHCC-742 | Myocardial Perfusion Imaging (Nuclear Cardiac Imaging Study) | 9/27/22 | 11/11/22 | Approved | Myocardial Perfusion Imaging (Nuclear Cardiac Imaging Study) |
| 2022-LHCC-743 | Low Field MRI | 9/27/22 | 11/11/22 | Approved | Low Field MRI |
| 2022-LHCC-744 | Multiple Gated Acquisition (MUGA) | 9/27/22 | 11/11/22 | Approved | Multiple Gated Acquisition (MUGA) |
| 2022-LHCC-745 | Neck CT (soft tissue) | 9/27/22 | 11/11/22 | Approved | Neck CT (soft tissue) |
| 2022-LHCC-757 | Temporomandibular Joint (TMJ) MRI | 9/27/22 | 11/11/22 | Approved | Temporomandibular Joint (TMJ) MRI |
| 2022-LHCC-758 | Thoracic Spine CT | 9/27/22 | 11/11/22 | Approved | Thoracic Spine CT |
| 2022-LHCC-759 | Thoracic Spine MRI | 9/27/22 | 11/11/22 | Approved | Thoracic Spine MRI |
| 2022-LHCC-763 | Unlisted Studies | 9/27/22 | 11/11/22 | Approved | Unlisted Studies |
| 2022-LHCC-764 | Upper Extremity CT | 9/27/22 | 11/11/22 | Approved | Upper Extremity CT |
| 2022-LHCC-765 | Upper Extremity CT Angiography | 9/27/22 | 11/11/22 | Approved | Upper Extremity CT Angiography |
| 2022-LHCC-766 | Upper Extremity MRA/MRV | 9/27/22 | 11/11/22 | Approved | Upper Extremity MRA/MRV |
| 2022-LHCC-767 | Upper Extremity MRI | 9/27/22 | 11/11/22 | Approved | Upper Extremity MRI |
| 2022-LHCC-768 | Urgent/Emergent Criteria | 9/27/22 | 11/11/22 | Approved | Urgent/Emergent Criteria |
| 2022-LHCC-683 | Chiro Infant Care Policy - Clinical Decision Making | 9/27/22 | 11/11/22 | Approved | Chiro Infant Care Policy - Clinical Decision Making |
| 2022-LHCC-685 | Experimental, Unproven, or Investigational Services | 9/27/22 | 11/11/22 | Approved | Experimental, Unproven, or Investigational Services |
| 2022-LHCC-686 | Durable Medical Equipment | 9/27/22 | 11/11/22 | Approved | Durable Medical Equipment |
| 2022-LHCC-717 | Chest (Thorax) CT | 9/27/22 | 11/11/22 | Approved | Chest (Thorax) CT |
| 2022-LHCC-718 | Chest (Thorax) MRI | 9/27/22 | 11/11/22 | Approved | Chest (Thorax) MRI |
| 2022-LHCC-719 | Chest CTA | 9/27/22 | 11/11/22 | Approved | Chest CTA |
| 2022-LHCC-720 | Chest MRA | 9/27/22 | 11/11/22 | Approved | Chest MRA |
| 2022-LHCC-721 | CT (Virtual) Colonoscopy | 9/27/22 | 11/11/22 | Approved | CT (Virtual) Colonoscopy |
| 2022-LHCC-722 | CT (Virtual) Colonoscopy - Screening | 9/27/22 | 11/11/22 | Approved | CT (Virtual) Colonoscopy - Screening |
| 2022-LHCC-723 | CT Bone Density Study | 9/27/22 | 11/11/22 | Approved | CT Bone Density Study |
| 2022-LHCC-726 | Coronary Artery Calcium Scoring by: EBCT or Non-Contrast CCT | 9/27/22 | 11/11/22 | Approved | Coronary Artery Calcium Scoring by: EBCT or Non-Contrast CCT |
| 2022-LHCC-727 | Fetal MRI | 9/27/22 | 11/11/22 | Approved | Fetal MRI |
| 2022-LHCC-728 | Functional Brain MRI | 9/27/22 | 11/11/22 | Approved | Functional Brain MRI |
| 2022-LHCC-729 | Heart CT | 9/27/22 | 11/11/22 | Approved | Heart CT |
| 2022-LHCC-732 | Heart (cardiac) PET | 9/27/22 | 11/11/22 | Approved | Heart (cardiac) PET |
| 2022-LHCC-735 | Low Dose CT for Lung Cancer Screening | 9/27/22 | 11/11/22 | Approved | Low Dose CT for Lung Cancer Screening |
| 2022-LHCC-736 | Lower Extremity CT (foot, ankle, leg or hip) | 9/27/22 | 11/11/22 | Approved | Lower Extremity CT (foot, ankle, leg or hip) |
| 2022-LHCC-737 | Lower Extremity CT Angiography | 9/27/22 | 11/11/22 | Approved | Lower Extremity CT Angiography |
| 2022-LHCC-771 | Heart Catheterization | 9/27/22 | 11/11/22 | Approved | Heart Catheterization |
| 2022-LHCC-1429 | Heart PET with CT Attenuation | 9/27/22 | 11/11/22 | Approved | Heart PET with CT Attenuation |
| 2022-LHCC-682 | Active Procedures in Physical Medicine | 9/26/22 | 11/10/22 | Approved | Active Procedures in Physical Medicine |
| 2022-LHCC-696 | Abdomen Ct Angiography | 9/26/22 | 11/10/22 | Approved | Abdomen Ct Angiography |
| 2022-LHCC-697 | Abdomen MRA (Angiography) | 9/26/22 | 11/10/22 | Approved | Abdomen MRA (Angiography) |
| 2022-LHCC-698 | Abdomen MRI | 9/26/22 | 11/10/22 | Approved | Abdomen MRI |
| 2022-LHCC-699 | Abdomen/Pelvis CT Combo | 9/26/22 | 11/10/22 | Approved | Abdomen/Pelvis CT Combo |
| 2022-LHCC-700 | Abdomen/Pelvis CTA | 9/26/22 | 11/10/22 | Approved | Abdomen/Pelvis CTA |
| 2022-LHCC-701 | Abdominal Arteries CT Angiography | 9/26/22 | 11/10/22 | Approved | Abdominal Arteries CT Angiography |
| 2022-LHCC-703 | Bone Marrow MRI | 9/26/22 | 11/10/22 | Approved | Bone Marrow MRI |
| 2022-LHCC-704 | Brain (Head) CT | 9/26/22 | 11/10/22 | Approved | Brain (Head) CT |
| 2022-LHCC-705 | Brain (Head) CTA | 9/26/22 | 11/10/22 | Approved | Brain (Head) CTA |
| 2022-LHCC-706 | Brain (Head) MRA/MRV | 9/26/22 | 11/10/22 | Approved | Brain (Head) MRA/MRV |
| 2022-LHCC-707 | Brain (Head) MRI/Brain (Head) MRI w Internal Auditory Canal | 9/26/22 | 11/10/22 | Approved | Brain (Head) MRI/Brain (Head) MRI w Internal Auditory Canal |
| 2022-LHCC-708 | Brain (Head) MRS | 9/26/22 | 11/10/22 | Approved | Brain (Head) MRS |
| 2022-LHCC-709 | Brain PET Scan | 9/26/22 | 11/10/22 | Approved | Brain PET Scan |
| 2022-LHCC-711 | Breast MRI | 9/26/22 | 11/10/22 | Approved | Breast MRI |
| 2022-LHCC-712 | CT Coronary Angiography (CCTA) | 9/26/22 | 11/10/22 | Approved | CT Coronary Angiography (CCTA) |
| 2022-LHCC-713 | Cerebral Perfusion CT | 9/26/22 | 11/10/22 | Approved | Cerebral Perfusion CT |
| 2022-LHCC-715 | Cervical Spine CT | 9/26/22 | 11/10/22 | Approved | Cervical Spine CT |
| 2022-LHCC-716 | Cervical Spine MRI | 9/26/22 | 11/10/22 | Approved | Cervical Spine MRI |
| 2022-LHCC-769 | Cardiac Resynchronization Therapy (CRT) | 9/26/22 | 11/10/22 | Approved | Cardiac Resynchronization Therapy (CRT) |
| 2022-LHCC-1410 | Neurofeedback for Behavioral Health Disorders | 9/26/22 | 11/10/22 | Withdrawn | Neurofeedback for Behavioral Health Disorders |
| 2022-UHC-555 | Orthognathic (Jaw) Surgery | 9/26/22 | 11/10/22 | Approved | Orthognathic (Jaw) Surgery |
| 2022-LHCC-695 | Abdomen CT | 9/26/22 | 11/10/22 | Approved | Abdomen CT |
| 2022-UHC-1170 | Prostate Surgeries and Interventions | 9/26/22 | 11/10/22 | Approved | Prostate Surgeries and Interventions |
| 2022-LHCC-1405 | Grievance and Non-coverage Appeal Process | 9/26/22 | 11/10/22 | Approved | Grievance and Non-coverage Appeal Process |
| 2022-LHCC-1406 | Peer Review Committee and Process | 9/26/22 | 11/10/22 | Approved | Peer Review Committee and Process |
| 2022-UHC-1422 | Left artrial appendage closure | 9/26/22 | 11/10/22 | Approved | Left artrial appendage closure |
| 2022-UHC-1423 | Total Artificial Heart and Ventricular Assist Devices | 9/26/22 | 11/10/22 | Approved | Total Artificial Heart and Ventricular Assist Devices |
| 2022-UHC-1424 | Intraoperative Hyperthermic Intraperitoneal Chemotherapy | 9/26/22 | 11/10/22 | Approved | Intraoperative Hyperthermic Intraperitoneal Chemotherapy |
| 2022-UHC-1425 | Neuropsychological Testing under the Medical Benefit | 9/26/22 | 11/10/22 | Approved | Neuropsychological Testing under the Medical Benefit |
| 2022-UHC-1426 | Genetic Testing for Cardiac Disease | 9/26/22 | 11/10/22 | Approved | Genetic Testing for Cardiac Disease |
| 2022-UHC-474 | Rhinoplasty and Other Nasal Surgeries | 9/12/22 | 10/27/22 | Approved | Rhinoplasty and Other Nasal Surgeries |
| 2022-UHC-1123 | Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds | 9/12/22 | 10/27/22 | Approved | Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds |
| 2022-LHCC-1168 | Allergy Testing & Therapy | 9/12/22 | 10/27/22 | Approved | Allergy Testing & Therapy |
| 2022-LHCC-1213 | Sacroiliac Joint Fusion | 9/12/22 | 10/27/22 | Approved | Sacroiliac Joint Fusion |
| 2022-LHCC-1224 | Fetal Surgery in Utero | 9/12/22 | 10/27/22 | Withdrawn | Fetal Surgery in Utero |
| 2022-LHCC-1268 | Bone-Anchored Hearing Aid | 9/12/22 | 10/27/22 | Approved | Bone-Anchored Hearing Aid |
| 2022-HBL-1408 | Test for Biochemical Markers for Alzheimer’s Disease | 9/12/22 | 10/27/22 | Approved | Test for Biochemical Markers for Alzheimer’s Disease |
| 2022-LHCC-1411 | Medical Necessity Criteria | 9/12/22 | 10/27/22 | Approved | Medical Necessity Criteria |
| 2022-LHCC-1412 | Clinical Policy: Clinical Trials | 9/12/22 | 10/27/22 | Approved | Clinical Policy: Clinical Trials |
| 2022-LHCC-1413 | Discography | 9/12/22 | 10/27/22 | Approved | Discography |
| 2022-LHCC-1414 | Genetic Testing Prenatal and Precon Carrier Screening | 9/12/22 | 10/27/22 | Approved | Genetic Testing Prenatal and Precon Carrier Screening |
| 2022-LHCC-1415 | Pulmonary Function Testing | 9/12/22 | 10/27/22 | Approved | Pulmonary Function Testing |
| 2022-UHC-1418 | Autologous Cellular Therapy | 9/12/22 | 10/27/22 | Approved | Autologous Cellular Therapy |
| 2022-UHC-1419 | Carrier Testing for Genetic Diseases | 9/12/22 | 10/27/22 | Approved | Carrier Testing for Genetic Diseases |
| 2022-Humana-1420 | Humana onboarding Code edits | 9/12/22 | 10/27/22 | Pending | Humana onboarding Code edits |
| 2022-HHH-1428 | HHH Preauthorization and Notification List | 10/11/22 | 10/27/22 | Withdrawn | HHH Preauthorization and Notification List |
| 2022-UHC-783 | Electrical Bioimpedancefor Cardiac Output Measurement | 8/29/22 | 10/13/22 | Approved | Electrical Bioimpedancefor Cardiac Output Measurement |
| 2022-ABH-1335 | In Lieu of Service Doula Care | 8/29/22 | 10/13/22 | Approved | In Lieu of Service Doula Care |
| 2022-UHC-1402 | Clinical Trials | 8/29/22 | 10/13/22 | Approved | Clinical Trials |
| 2022-LHCC-1403 | Continuity and Coordination of Medical Care | 8/29/22 | 10/13/22 | Approved | Continuity and Coordination of Medical Care |
| 2022-UHC-1404 | Breast Imaging for Screening and Diagnosing Cancer | 8/29/22 | 10/13/22 | Approved | Breast Imaging for Screening and Diagnosing Cancer |
| 2022-UHC-379 | Brow Ptosis and Eyelid Repair | 8/24/22 | 10/8/22 | Approved | Brow Ptosis and Eyelid Repair |
| 2022-UHC-1398 | Meniscus Implant and Allograft | 8/24/22 | 10/8/22 | Approved | Meniscus Implant and Allograft |
| 2022-UHC-1399 | Glaucoma Surgical Treatment | 8/24/22 | 10/8/22 | Approved | Glaucoma Surgical Treatment |
| 2022-UHC-1400 | Occipital Nerve Injections and Ablations | 8/24/22 | 10/8/22 | Approved | Occipital Nerve Injections and Ablations |
| 2022-UHC-1401 | Manipulative Therapy | 8/24/22 | 10/8/22 | Approved | Manipulative Therapy |
| 2022-UHC-1395 | Motorized Spinal Traction | 8/22/22 | 10/6/22 | Approved | Motorized Spinal Traction |
| 2022-UHC-1394 | Transpupillary Thermotherapy | 8/22/22 | 10/6/22 | Approved | Transpupillary Thermotherapy |
| 2022-UHC-1393 | Panniculectomy and Body Contouring Procedures | 8/22/22 | 10/6/22 | Approved | Panniculectomy and Body Contouring Procedures |
| 2022-UHC-1392 | Gastrointestinal Motility Disorders | 8/22/22 | 10/6/22 | Approved | Gastrointestinal Motility Disorders |
| 2022-UHC-1391 | Intraocular Pressure Measurement | 8/22/22 | 10/6/22 | Approved | Intraocular Pressure Measurement |
| 2022-HBL-1390 | Hybrid Personalized Molecular Residual Disease Testing for Cancer | 8/22/22 | 10/6/22 | Approved | Hybrid Personalized Molecular Residual Disease Testing for Cancer |
| 2022-LHCC-1378 | Wheelchair Seating | 8/22/22 | 10/6/22 | Approved | Wheelchair Seating |
| 2022-ABH-1333 | Reimbursement Policy for Itemized Bill Review | 8/22/22 | 10/6/22 | Approved | Reimbursement Policy for Itemized Bill Review |
| 2022-UHC-825 | Cardiac Event Monitoring | 8/22/22 | 10/6/22 | Approved | Cardiac Event Monitoring |
| 2022-UHC-582 | Cosmetic and Reconstructive Procedures | 8/22/22 | 10/6/22 | Approved | Cosmetic and Reconstructive Procedures |
| 2022-UHC-492 | Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins | 8/22/22 | 10/6/22 | Approved | Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins |
| 2022-UHC-207 | Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation | 8/22/22 | 10/6/22 | Approved | Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation |
| 2022-LDH-13 | MCO Manual > Part 11: Program Integrity (Proposed effective date = 8/1/2022) | 8/15/22 | 9/29/22 | Approved | Prepayment Review |
| 2022-LHCC-1389 | Endometrial Ablation | 8/12/22 | 9/26/22 | Approved | Endometrial Ablation |
| 2022-LHCC-1387 | Percutaneous LAAD Stroke Prevention | 8/12/22 | 9/26/22 | Approved | Percutaneous LAAD Stroke Prevention |
| 2022-LHCC-1386 | Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins | 8/12/22 | 9/26/22 | Approved | Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins |
| 2022-LHCC-1385 | Implantable Wireless PAP Monitoring | 8/12/22 | 9/26/22 | Approved | Implantable Wireless PAP Monitoring |
| 2022-LHCC-1384 | Radial Head Implant | 8/12/22 | 9/26/22 | Approved | Radial Head Implant |
| 2022-LHCC-1383 | Disc Decompression Procedures | 8/12/22 | 9/26/22 | Approved | Disc Decompression Procedures |
| 2022-LHCC-1382 | Lysis of Epidural Lesions | 8/12/22 | 9/26/22 | Approved | Lysis of Epidural Lesions |
| 2022-LHCC-1381 | Bronchial Thermoplasty | 8/12/22 | 9/26/22 | Approved | Bronchial Thermoplasty |
| 2022-LHCC-1380 | Multiple Sleep Latency Testing | 8/12/22 | 9/26/22 | Approved | Multiple Sleep Latency Testing |
| 2022-LHCC-1379 | Inhaled Nitric Oxide | 8/12/22 | 9/26/22 | Approved | Inhaled Nitric Oxide |
| 2022-UHC-1376 | Computerized Dynamic Posturography | 8/12/22 | 9/26/22 | Approved | Computerized Dynamic Posturography |
| 2022-LHCC-1360 | Heart & Lung Transplant | 8/12/22 | 9/26/22 | Approved | Heart & Lung Transplant |
| 2022-LHCC-1357 | Intestinal and Multivisceral Transplant | 8/12/22 | 9/26/22 | Approved | Intestinal and Multivisceral Transplant |
| 2022-LHCC-1217 | Ultrasound in Pregnancy | 8/12/22 | 9/26/22 | Approved | Ultrasound in Pregnancy |
| 2022-LHCC-1214 | TPN IDPN | 8/12/22 | 9/26/22 | Approved | TPN IDPN |
| 2022-LDH-12 | MCO Manual > Part 4: Services > Professional Services > Routine Care Provided to Enrollees Participating in Clinical Trials (Proposed effective date = 10/30/2022) | 8/9/22 | 9/23/22 | Complete | Routine Care Provided to Enrollees Participating in Clinical Trials |
| 2022-UHC-1367 | Patient Lifts | 8/1/22 | 9/15/22 | Approved | Patient Lifts |
| 2022-ACLA-1370 | EPSDT PCS | 8/1/22 | 9/15/22 | Approved | EPSDT PCS |
| 2022-UHC-1371 | Athletic Pubalgia Surgery | 8/1/22 | 9/15/22 | Approved | Athletic Pubalgia Surgery |
| 2022-LDH-11 | MCO Manual > Part 4: Services > Medical Transportation > Non-Emergency Medical Transportation (Proposed effective date = 10/15/2022) | 7/25/22 | 9/8/2022 | Complete | Non-Emergency Medical Transportation |
| 2022-UHC-585 | Chelation Therapy | 7/8/22 | 8/22/22 | Approved | Chelation Therapy |
| 2022-UHC-1350 | Gender Dysphoria Treatment | 7/6/22 | 8/20/22 | Approved | Gender Dysphoria Treatment |
| 2022-ABH-1368 | Spine Services | 7/6/22 | 8/20/22 | Approved | Spine Services |
| 2022-HBL-1369 | Written Material Guidelines | 7/6/22 | 8/20/22 | Approved | Written Material Guidelines |
| 2022-LDH-9 | MCO Manual > Part 4: Services > Professional Services > Community Health Workers | 6/30/22 | N/A | N/A | Community Health Workers Imminent Peril Justification |
| 2022-LDH-10 | MCO Manual > Part 4: Services > Professional Services > “Incident To” Services | 6/30/22 | N/A | N/A | "Incident To" Services Imminent Peril Justification |
| 2022-LHCC-1110 | SNF Leveling | 6/30/22 | 8/14/22 | Approved | SNF Leveling |
| 2022-LHCC-1352 | Deep TMS for OCD | 6/30/22 | 8/14/22 | Approved | Deep TMS for OCD |
| 2022-LHCC-1354 | Substance Use Disorders | 6/30/22 | 8/14/22 | Approved | Substance Use Disorders |
| 2022-LHCC-1365 | GI Pathogen Nucleic Acid and Detection Panel Testing | 6/30/22 | 8/14/22 | Approved | GI Pathogen Nucleic Acid and Detection Panel Testing |
| 2022-LHCC-1366 | Post Acute Care | 6/30/22 | 8/14/22 | Approved | Post Acute Care |
| 2022-IB-1 | Prior Authorization of Reimbursement for Non-invasive and Invasive Ventilators | 6/30/22 | 8/14/22 | Approved | Informational Bulletin: Prior Authorization of Reimbursement for Non-invasive and Invasive Ventilators |
| 2022-LHCC-1108 | Pediatric Liver Transplant | 6/29/22 | 8/13/22 | Approved | Pediatric Liver Transplant |
| 2022-HBL-1199 | Continuous Glucose Monitoring Devices and External Insulin Pumps | 6/29/22 | 8/13/22 | Approved | Continuous Glucose Monitoring Devices and External Insulin Pumps |
| 2022-LHCC-1212 | Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulator | 6/29/22 | 8/13/22 | Approved | Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulator |
| 2022-LHCC-1218 | Ventricular Assist Devices | 6/29/22 | 8/13/22 | Approved | Ventricular Assist Devices |
| 2022-ABH-1351 | Elective Abortion | 6/29/22 | 8/13/22 | Approved | Elective Abortion |
| 2022-LHCC-1353 | Articular Cartilage Defect Repairs | 6/29/22 | 8/13/22 | Approved | Articular Cartilage Defect Repairs |
| 2022-LHCC-1355 | Functional MRI | 6/29/22 | 8/13/22 | Approved | Functional MRI |
| 2022-LHCC-1356 | Lung Transplantation | 6/29/22 | 8/13/22 | Approved | Lung Transplantation |
| 2022-LHCC-1358 | Pancreas Transplantation | 6/29/22 | 8/13/22 | Approved | Pancreas Transplantation |
| 2022-LHCC-1359 | Testing for Select Genitourinary Conditions | 6/29/22 | 8/13/22 | Approved | Testing for Select Genitourinary Conditions |
| 2022-LHCC-1361 | Pediatric Heart Transplant | 6/29/22 | 8/13/22 | Approved | Pediatric Heart Transplant |
| 2022-LHCC-1362 | Nonmyeloablative allogeneic SCT | 6/29/22 | 8/13/22 | Approved | Nonmyeloablative allogeneic SCT |
| 2022-LHCC-1363 | Tandem Transplant | 6/29/22 | 8/13/22 | Approved | Tandem Transplant |
| 2022-LHCC-1364 | Radiofrequency Ablation of Uterine Fibroids | 6/29/22 | 8/13/22 | Approved | Radiofrequency Ablation of Uterine Fibroids |
| 2022-LHCC-1360 | Heart & Lung Transplant | 6/29/22 | 8/13/22 | Withdrawn | Heart & Lung Transplant |
| 2022-LHCC-1357 | Intestinal and Multivisceral Transplant | 6/29/22 | 8/13/22 | Withdrawn | Intestinal and Multivisceral Transplant |
| 2022-HBL-798 | Gene Expression Profiling of Melanomas | 6/15/22 | 7/30/22 | Approved | Gene Expression Profiling of Melanomas |
| 2022-HBL-1088 | Scoliosis Surgery | 6/15/22 | 7/30/22 | Approved | Scoliosis Surgery |
| 2022-UHC-1342 | Pectus Deformity Repair | 6/15/22 | 7/30/22 | Approved | Pectus Deformity Repair |
| 2022-HBL-1344 | Rehabilitative Devices with Remote Monitoring | 6/15/22 | 7/30/22 | Approved | Rehabilitative Devices with Remote Monitoring |
| 2022-HBL-1345 | Pain Management Biomarker Analysis | 6/15/22 | 7/30/22 | Approved | Pain Management Biomarker Analysis |
| 2022-HBL-1346 | Virtual Reality-Assisted Therapy Systems | 6/15/22 | 7/30/22 | Approved | Virtual Reality-Assisted Therapy Systems |
| 2022-HBL-1347 | Electrical Impendance Scanning for Cancer Detection | 6/15/22 | 7/30/22 | Approved | Electrical Impendance Scanning for Cancer Detection |
| 2022-HBL-1348 | Portable Normothermic Organ Perfusion Systems | 6/15/22 | 7/30/22 | Pending | Portable Normothermic Organ Perfusion Systems |
| 2022-HBL-1349 | Outpatient Rehabilitative and Habilitative AIM | 6/15/22 | 7/30/22 | Pending | Outpatient Rehabilitative and Habilitative AIM |
| 2022-HBL-597 | Electric Tumor Treatment Field | 6/1/22 | 7/16/22 | Approved | Electric Tumor Treatment Field |
| 2022-ABH-1336 | Duplicate Medications Policy | 6/1/22 | 7/16/22 | Approved | Duplicate Medications Policy |
| 2022-HBL-1339 | Prior Authorization Changes UM AROW 2892 | 6/1/22 | 7/16/22 | Approved | Prior Authorization Changes UM AROW 2892 |
| 2022-UHC-1340 | Gynecomastia Surgery | 6/1/22 | 7/16/22 | Approved | Gynecomastia Surgery |
| 2022-HBL-1025 | Measurable Residual Disease Assessment in Lumphoid Cancers Using Next Generation Sequencing | 5/23/22 | 7/7/22 | Approved | Measurable Residual Disease Assessment in Lumphoid Cancers Using Next Generation Sequencing |
| 2022-ABH-1329 | PCS-BH | 5/23/22 | 7/7/22 | Approved | PCS-BH |
| 2022-ABH-1330 | Community Brief Crisis Support and Behaviral Health Crisis Care | 5/23/22 | 7/7/22 | Approved | Community Brief Crisis Support and Behaviral Health Crisis Care |
| 2022-ABH-1331 | Supporting Members in Crisis Amendment | 5/23/22 | 7/7/22 | Approved | Supporting Members in Crisis Amendment |
| 2022-ABH-1333 | OOS hospital stays | 5/6/22 | 6/20/22 | Denied | OOS hospital stays |
| 2022-HBL-1302 | Prior Authorization Update Select DME Code | 5/5/22 | 6/19/22 | Approved | Prior Authorization Update Select DME Code |
| 2022-HBL-1310 | Cell-free Fetal DNA Testing | 5/5/22 | 6/19/22 | Approved | Cell-free Fetal DNA Testing |
| 2022-LDH-8 | MCO Manual > Part 4: Services > Medical Transportation (Proposed effective date = 7/24/2022) | 5/5/22 | 6/19/22 | Pending | MCO Manual > Part 4: Services > Medical Transportation (Proposed effective date = 7/24/2022) |
| 2022-UHC-509 | Breast Reconstruction | 6/15/22 | 7/30/22 | Withdrawn | Breast Reconstruction |
| 2022-LDH-7 | MCO Manual > Part 4: Services > Professional Services > Allergy Testing and Allergen Immunotherapy (Proposed effective date = 7/20/2022) | 4/29/22 | 6/13/22 | Complete | MCO Manual > Professional Services > Allergy Testing and Allergen Immunotherapy |
| 2022-HBL-1023 | Genetic Testing for Inherited Diseases | 4/27/22 | 6/11/22 | Approved | Genetic Testing for Inherited Diseases |
| 2022-HBL-1024 | Gene Mutat Test for Solid Tumor Cancer Susceptibility and Management | 4/27/22 | 6/11/22 | Approved | Gene Mutat Test for Solid Tumor Cancer Susceptibility and Management |
| 2022-HBL-1049 | Reduction Mammaplasty | 4/27/22 | 6/11/22 | Approved | Reduction Mammaplasty |
| 2022-HBL-1058 | Whole Genome Sequ. Whole Exome Sequ. Gene Panels and Molecular Prof | 4/27/22 | 6/11/22 | Approved | Whole Genome Sequ. Whole Exome Sequ. Gene Panels and Molecular Prof |
| 2022-HBL-1102 | Allogen, Xeno, Synthc and Composite Products for Wound Healing and Soft Tissue Grafting | 4/27/22 | 6/11/22 | Approved | Allogen, Xeno, Synthc and Composite Products for Wound Healing and Soft Tissue Grafting |
| 2022-HBL-1301 | Sacroilac Joint Fusion | 4/27/22 | 6/11/22 | Approved | Sacroilac Joint Fusion |
| 2022-HBL-1303 | Thyroid Testing | 4/27/22 | 6/11/22 | Approved | Thyroid Testing |
| 2022-HBL-1304 | Immune Biomarker Tests for Cancer | 4/27/22 | 6/11/22 | Approved | Immune Biomarker Tests for Cancer |
| 2022-HBL-1305 | Implant Port Delivery Systems to treat Ocular Disease | 4/27/22 | 6/11/22 | Approved | Implant Port Delivery Systems to treat Ocular Disease |
| 2022-HBL-1306 | Serum Iron Testing | 4/27/22 | 6/11/22 | Approved | Serum Iron Testing |
| 2022-ACLA-1307 | PA Service list change | 4/27/22 | 6/11/22 | Approved | PA Service list change |
| 2022-HBL-1308 | Quantitative Ultrasound for Tissue Characterization | 4/27/22 | 6/11/22 | Approved | Quantitative Ultrasound for Tissue Characterization |
| 2022-HBL-1309 | BRCA Genetic Testing | 4/27/22 | 6/11/22 | Approved | BRCA Genetic Testing |
| 2022-HBL-1311 | Bone Anchored and Bone Conduction Hearing Aids | 4/27/22 | 6/11/22 | Approved | Bone Anchored and Bone Conduction Hearing Aids |
| 2022-HBL-1312 | Genetic Testing for CHARGE syndrome | 4/27/22 | 6/11/22 | Approved | Genetic Testing for CHARGE syndrome |
| 2022-HBL-1313 | Electrical Nerve Stimulation, Transcutaneous, Percutaneous CG | 4/27/22 | 6/11/22 | Approved | Electrical Nerve Stimulation, Transcutaneous, Percutaneous CG |
| 2022-HBL-1314 | Saliva-based Testing to Determine Drug-Metabolizer | 4/27/22 | 6/11/22 | Approved | Saliva-based Testing to Determine Drug-Metabolizer |
| 2022-HBL-1315 | Select Tests Eval Mngmnt of Infertility | 4/27/22 | 6/11/22 | Approved | Select Tests Eval Mngmnt of Infertility |
| 2022-HBL-1316 | Acupuncture | 4/27/22 | 6/11/22 | Approved | Acupuncture |
| 2022-HBL-1317 | Transrectal Ultrasonography | 4/27/22 | 6/11/22 | Approved | Transrectal Ultrasonography |
| 2022-HBL-1318 | EEG and Video EEG Monitoring | 4/27/22 | 6/11/22 | Approved | EEG and Video EEG Monitoring |
| 2022-HBL-1319 | Imaging of the Extremeties | 4/27/22 | 6/11/22 | Approved | Imaging of the Extremeties |
| 2022-HBL-1320 | Joint Surgery | 4/27/22 | 6/11/22 | Approved | Joint Surgery |
| 2022-HBL-1321 | Vascular Imaging | 4/27/22 | 6/11/22 | Approved | Vascular Imaging |
| 2022-HBL-1322 | Imaging of the Spine | 4/27/22 | 6/11/22 | Approved | Imaging of the Spine |
| 2022-HBL-1323 | Hyperbaric Oxygen Therapy | 4/27/22 | 6/11/22 | Approved | Hyperbaric Oxygen Therapy |
| 2022-HBL-1324 | Spine Surgery | 4/27/22 | 6/11/22 | Approved | Spine Surgery |
| 2022-HBL-1325 | Sleep Disorder Management | 4/27/22 | 6/11/22 | Approved | Sleep Disorder Management |
| 2022-HBL-1326 | Thymus Tissue Transplantation | 4/27/22 | 6/11/22 | Approved | Thymus Tissue Transplantation |
| 2022-HBL-1327 | Advanced Imaging-Oncologic Imaging | 4/27/22 | 6/11/22 | Approved | Advanced Imaging-Oncologic Imaging |
| 2022-HBL-1093 | Microsurgical Procedures for the treatment of Lymphedema | 4/12/22 | 5/27/22 | Approved | Microsurgical Procedures for the treatment of Lymphedema |
| 2022-HBL-1293 | Laser Trabeculoplasty and Laser Peripheral Iridotomy | 4/12/22 | 5/27/22 | Approved | Laser Trabeculoplasty and Laser Peripheral Iridotomy |
| 2022-HBL-1294 | Adenoidectomy | 4/12/22 | 5/27/22 | Approved | Adenoidectomy |
| 2022-HBL-1295 | Non-invasive Measurement of (AGEs) in the Skin | 4/12/22 | 5/27/22 | Approved | Non-invasive Measurement of (AGEs) in the Skin |
| 2022-HBL-1296 | Surgical and Ablative Treatments for Chronic Headaches | 4/12/22 | 5/27/22 | Approved | Surgical and Ablative Treatments for Chronic Headaches |
| 2022-HBL-1297 | Cell Transp (Mesencephalic, Adrenal-Brain and Fetal Xenograft) | 4/12/22 | 5/27/22 | Approved | Cell Transp (Mesencephalic, Adrenal-Brain and Fetal Xenograft) |
| 2022-HBL-1298 | Proprietary Algor for Liver Fibrosis in the Eval Monit of Chron Liver Dis | 4/12/22 | 5/27/22 | Approved | Proprietary Algor for Liver Fibrosis in the Eval Monit of Chron Liver Dis |
| 2022-HBL-1299 | Endov/Endolum Rpr Aortic Aneur, Aorto Dis, Aortic Dissect and Aortic Tran | 4/12/22 | 5/27/22 | Approved | Endov/Endolum Rpr Aortic Aneur, Aorto Dis, Aortic Dissect and Aortic Tran |
| 2022-HBL-1300 | Fetal Surgery for Prenatally Diagnosed Malf | 4/12/22 | 5/27/22 | Approved | Fetal Surgery for Prenatally Diagnosed Malf |
Medicaid Managed Care Policies & Procedures Archive (2022) continued
"Policy or procedure" shall mean a requirement governing the administration of managed care organizations specific to billing guidelines, medical management and utilization review guidelines, case management guidelines, claims processing guidelines and edits, grievance and appeals procedures and process, other guidelines or manuals containing pertinent information related to operations and pre-processing claims, and core benefits and services.
Below are items previously posted for public comment:
Related Info