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Medicaid Clinical Coverage Policies and Provider Manuals

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) information is not included in all provider manuals.  For information about EPSDT:

• EPSDT Provider Page
• EPSDT Policy Instructions (updated November 24, 2008)

The free Adobe Acrobat Reader is required to view and print these PDF files.

CPT codes, descriptors, and other data only are copyright 2009 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

General Clinical Coverage Policies

• A1, Special Services: After Hours (1/1/06)
• A2, Over-the-Counter Products (7/17/09)
• A3, Prior Authorization for Outpatient Pharmacy Point-of-Sale Medications (2/16/07)
• A4, Services for Individuals with Mental Retardation/Developmental Disabilities and Mental Health/Substance Abuse Co-occurring Disorders (7/1/06)
• A5, Mental Health Drug Management Program Administrative Procedures (10/1/08)

Program-Specific Clinical Coverage Policies

Practitioners/Clinics (1A through 1R)

• Physicians
  • 1A-1, Compression Garments (8/1/05)
  • 1A-2, Preventive Medicine Annual Health Assessment (5/1/07)
  • 1A-3, Noninvasive Pulse Oximetry (5/1/07)
  • 1A-4, Cochlear and Auditory Brainstem Implants (1/1/10)
  • 1A-5, Case Conference for Sexually Abused Children (11/1/08)
  • 1A-6, Electrical Osteogenic Stimulators (5/1/07)
  • 1A-7, Neonatal and Pediatric Critical and Intensive Care Services (5/1/07)
  • 1A-8, Hyberbaric Oxygenation Therapy (5/1/07)
  • 1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair) (5/1/07)
  • 1A-10, Panniculectomy (5/1/07)
  • 1A-11, Extracorporeal Shock Wave Lithotripsy (5/1/07)
  • 1A-12, Breast Surgeries (7/1/08)
  • 1A-13, Ocular Photodynamic Therapy (5/1/07)
  • 1A-14, Gender Transformation (5/1/07)
  • 1A-15, Surgery for Clinically Severe Obesity (7/1/08)
  • 1A-16, Surgery of the Lingual Frenulum (7/1/07)
  • 1A-17, Stereotactic Pallidotomy (5/1/07)
  • 1A-18, Scanning Laser Glaucoma Test (5/1/07)
  • 1A-19, Transcranial Doppler Studies (5/1/07)
  • 1A-20, Sleep Studies and Polysomnography Services (9/1/08)
  • 1A-21, Endovascular Repair of Aortic Aneurysm (5/1/07)
  • 1A-22, Medically Necessary Circumcision (7/1/07)
  • 1A-23, Physician Fluoride Varnish Services (11/1/07)
  • 1A-24, Diabetes Outpatient Self-Management Education (5/1/09)
  • 1A-25, Spinal Cord Stimulation (posted 2/1/10; eff. 1/1/10)
• Physicians Drug Program
  • 1B-1, Botulinum Toxin Treatment: Type A (Botox) and Type B (Myobloc) (posted 3/1/09; eff. 11/1/08)
• Podiatry
  • 1C-1, Podiatry Services (5/1/07)
  • 1C-2, Medically Necessary Routine Foot Care (8/1/07)
• Clinics
  • 1D-1, Refugee Health Assessments Provided in Health Departments (5/1/07)
  • 1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments (5/1/07)
  • 1D-3, Tuberculosis Control and Treatment Provided in Health Departments (5/1/07)
  • 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics (posted 10/1/09; eff. 9/1/09)
• Obstetrics & Gynecology
  • 1E-1, Hysterectomy (5/1/07)
  • 1E-2, Therapeutic and Non-therapeutic Abortions (5/1/07)
  • 1E-3, Sterilization Procedures (7/1/08)
  • 1E-4, Fetal Surveillance (4/1/07)
  • 1E-5, Obstetrics (8/1/09)
• 1F, Chiropractic Services (11/1/07)
• Burn Treatments
  • 1G-1, Burn Treatment (5/1/07)
  • 1G-2, Bioengineered Skin (5/1/09)
• 1H, Telemedicine and Telepsychiatry (6/1/07)
• 1-I, Dietary Evaluation and Counseling (11/1/09)
• Radiology
  • 1K-1, Breast Imaging (3/1/08)
  • 1K-2, Bone Mass Measurement (posted 3/1/09; effective 2/1/09)
  • 1K-6, Radiation Oncology (10/1/09)
• Anesthesia
  • 1L-1, Anesthesia Services (7/1/09)
  • 1L-2, Moderate (Conscious) Sedation (4/1/08)
• Baby Love/Child Service Coordination
  • 1M-1, Child Service Coordination (5/1/07)
  • 1M-2, Childbirth Education (8/1/08)
  • 1M-3, Health and Behavior Intervention (5/1/07)
  • 1M-4, Home Visit for Newborn Care and Assessment (5/1/07)
  • 1M-5, Home Visit for Postnatal Assessment and Follow-up Care (5/1/07)
  • 1M-6, Maternal Care Skilled Nurse Home Visit (5/1/07)
  • 1M-7, Baby Love Maternal Outreach Worker Program (5/1/07)
  • 1M-8, Maternity Care Coordination (5/1/07)
• Allergies
  • 1N-1, Allergy Testing (4/1/09)
  • 1N-2, Allergen Immunotherapy (4/1/09)
• Reconstructive Surgery
  • 1-O-1, Reconstructive and Cosmetic Surgery (10/1/08)
  • 1-O-2, Craniofacial Surgery (12/1/08)
  • 1-O-3, Keloid Excision and Scar Revision (8/1/08)
  • 1-O-5, Rhinoplasty and/or Septorhinoplasty (10/1/08)
• Cardiac Procedures
  • 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs (8/1/08)
  • 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound (2/1/09)
• Laboratory Services
  • 1S-1, Genotyping and Phenotyping for HIV Drug Resistance Testing (posted 6/1/09; eff. 7/1/08)
  • 1S-2, HIV Tropism Assay (posted 5/1/09; eff. 1/1/09)
  • 1S-4, Cytogenetic Studies (4/1/09)

Ambulance Services

• Ambulance Services Provider Manual (7/1/99)

Facility Services

• Hospital Services Provider Manual (11/1/99)
• 2B-1, Nursing Facilities (11/1/09)
• 2B-2, Geropsychiatric Units in Nursing Facilities (12/1/09)

Community Based Services (3A through 3J)

• From the 10/1/01 Community Care Provider Manual:
  • Section 09 - Private Duty Nursing (PDN)
  • Section 11 - Community Alternatives Program for Children (CAP/C) (see CAP/C page for more CAP/C policies and manuals)
  • Section 12 - Community Alternatives Program for Disabled Adults (CAP/DA)
  • Appendix E - MPW Prior Appproval Instructions
• 3A, Home Health Services (12/1/09)
• 3B, PACE (Program of All-Inclusive Care for the Elderly) (3/1/08)
• 3C, Personal Care Services (8/1/07)
• 3D, Hospice Services (12/1/09; eff. 12/2/08)
• Home Infusion Therapy Services
  • 3H-1, Home Infusion Therapy (8/1/07)
  • 3H-2, Home Tocolytic Infusion Therapy (2/4/09; eff. 1/1/09)
• 3J, Personal Care Services–Plus (8/1/07)

Dental Program (4A and 4B)

• 4A, Dental Services (10/13/09; eff. 11/1/09)
• 4B, Orthodontics (6/1/07)

Medical Equipment (5A through 5C)

• 5A, Durable Medical Equipment (11/1/09)
• 5B, Orthotics & Prosthetics (5/1/09)
• 5C, Repairs and Replacement Parts
  • Note: Clinical Coverage Policy 5C-1, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair, has been updated and reposted as Clinical Coverage Policy 13A.

Vision Services

• Optical Services Provider Manual (12/1/01)

Hearing Aid Services

• 7, Hearing Aid Services (5/1/07)

Behavioral Health (8A through 8J)

• 8A, Enhanced Mental Health and Substance Abuse Services   
  • Current Version (8/1/09)   
  • Revised Version (effective 4/1/10; posted 2/1/10)
• 8B, Inpatient Behavioral Health Services (8/1/07)
• 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers (6/1/07)
• 8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of 21 (5/1/07)
• 8D-2, Residential Treatment Services (8/1/07)
• 8E, Intermediate Care Facilities for Individuals with Mental Retardation (8/1/07)
• 8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population (5/1/07)
• 8J, Children's Developmental Service Agencies (CDSAs) (5/1/07)

Pharmacy Services

• 9, Outpatient Pharmacy Program (12/1/09)
• A2, Over-the-Counter Products (7/17/09)
• A3, Prior Authorization for Outpatient Pharmacy Point-of-Sale Medications (2/16/07)

Specialized Therapies (10A through 10C)

• 10A, Outpatient Specialized Therapies (12/1/09)
• 10B, Independent Practitioners (IP) (1/1/10)
• 10C, Local Education Agencies (LEAs) (1/1/10)

Transplants and Transplant-Related Services (11A through 11H)

• Stem Cell Transplants
  • 11A-1, High Dose Chemotherapy +/- Total Body Irradiation Including Autologous and Allogeneic Stem Cell Support for Acute Lymphocytic Leukemia (5/1/07)
  • 11A-2, High Dose Chemotherapy + Total Body Irradiation Including Autologous and Allogeneic Stem Cell Support in Acute Myelogenous Leukemia (5/1/07)
  • 11A-3, High Dose Chemotherapy +/- Total Body Irradiation and Allogeneic Stem Cell Support in Chronic Myelogenous Leukemia (5/1/07)
  • 11A-4, Donor Leukocyte, Donor Lymphocyte or Buffy Coat Infusion for Hematologic Malignancies that Relapse or at a High Risk for Relapse after Allogeneic Stem Cell Transplantation (5/1/07)
  • 11A-5, High Dose Chemotherapy +/- Total Body Irradiation Including Allogeneic Stem Cell Support for Genetic Diseases and Acquired Anemias (5/1/07)
  • 11A-6, High Dose Chemotherapy with Autologous and Allogeneic Stem Cell Support for Germ Cell Tumors (5/1/07)
  • 11A-7, High Dose Chemotherapy Bone Marrow or Autologous/Allogeneic Peripheral Stem Cell Transplant for Hodgkin's Disease (5/1/07)
  • 11A-8, High Dose Chemotherapy for Multiple Myeloma and Primary Amyloidosis (5/1/07)
  • 11A-9, High Dose Chemotherapy +/- Total Body Irradiation Including Allogeneic Bone Marrow and Peripheral Stem Cell Support for Myelodysplastic Diseases (5/1/07)
  • 11A-10, High Dose Chemotherapy and Autologous Stem Cell Support for Neuroectodermal Tumors and Ependymoma (5/1/07)
  • 11A-11, High Dose Chemotherapy, Bone Marrow or Peripheral Stem Cell Transplant for Non-Hodgkins Lymphoma (5/1/07)
  • 11A-12, Non-Myeloablative Allogeneic Stem Cell Transplant (Mini-Transplant, Mini-Allograft Reduced Intensity Conditioning) for Treatment of Malignancies (5/1/07)
  • 11A-13, High Dose Chemotherapy, Bone Marrow or Peripheral Stem Cell Transplant for Ovarian Cancer and Germ Cell Tumors Arising in the Ovaries (5/1/07)
  • 11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells (5/1/07)
  • 11A-15, High Dose Chemotherapy + Total Body Irradiation with Autologous/Allogeneic Stem Cell Support for Solid Tumors of Childhood (5/1/07)
• Solid Organ Transplants
  • 11B-1, Lung Transplantation (5/1/07)
  • 11B-2, Heart Transplantation (5/1/07)
  • 11B-3, Islet Cell Transplantation (5/1/07)
  • 11B-4, Kidney Transplantation (5/1/07)
  • 11B-5, Liver Transplantation (5/1/07)
  • 11B-6, Heart/Lung Transplantation (5/1/07)
  • 11B-7, Pancreas Transplantation (5/1/07)
  • 11B-8, Small Bowel and Small Bowel/Liver and Multivisceral Transplants (5/1/07)
• 11C, Ventricular Assist Device (5/1/07)
• 11D, Biventricular Pacemaker for the Treatment of Congestive Heart Failure (5/1/07)
• 11E, Implantable Cardioverter Defibrillator (5/1/07)
• 11F, Extracorporeal Membrane Oxygenation/Extracorporeal Life Support (5/1/07)
• 11G, Photophoresis for Solid Organ Rejection Autoimmune Disease and GVHD (5/1/07)
• 11H, Bone Morphogenic Protein-2 (5/1/07)

Targeted Case Management

• 12A, Case Management Services for Adults and Children at Risk for Abuse, Neglect, or Exploitation (5/1/07)

Auditory Implant External Parts

• 13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair (1/1/10)

Additional Medicaid Information:

• Laboratory Services - Provider Seminar Handout (38 KB)