Medical Clinical Policies
Medical Clinical Policies
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, as well as pharmacy policies.
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.
All policies found in the Absolute Total Care Clinical Policy Manual apply to Absolute Total Care members. Policies in the Absolute Total Care Clinical Policy Manual may have either an Absolute Total Care or a “Centene” heading. Absolute Total Care utilizes InterQual® criteria for those medical technologies, procedures, or pharmaceutical treatments for which an Absolute Total Care 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 in to the Secure Provider Portal or by calling Absolute Total Care.
In addition, Absolute Total 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 Clinical Policy Manuals or InterQual criteria is payable by Absolute Total Care.
If you have any questions regarding these policies, please contact Provider Services at 1-866-433-6041 and ask to be directed to the Medical Management Department.
For Ambetter from Absolute Total Care Premier, please visit our Ambetter from Absolute Total Care Premier website.
For Ambetter Health Solutions, please visit our Ambetter from Ambetter Health Solutions website.
Navigate directory by letter:
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | #
A
- Abortions (SC.CP.MP.01) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (CP.MP.108) (PDF)
- Allogeneic Hematopoietic Progenitor Cell Therapy (CP.MP.249) (PDF)
- Assisted Reproductive Technology (CP.MP.55) (PDF)
B
- Bariatric Surgery (CP.MP.37) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
C
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Concert Genetic Testing: Cardiovascular (V2.2025) (PDF)
- Concert Genetic Testing: Dermatology (V2.2025) (PDF)
- Concert Genetic Testing: Endocrinology (V2.2025) (PDF)
- Concert Genetic Testing: Gastroenterology (V2.2025) (PDF)
- Concert Genetic Testing: General Approach to Genetic and Molecular Testing (V2.2025) (PDF)
- Concert Genetic Testing: Hematology (V2.2025) (PDF)
- Concert Genetic Testing: Hereditary Cancer (V2.2025) (PDF)
- Concert Genetic Testing: Immunology and Rheumatology (V2.2025) (PDF)
- Concert Genetic Testing: Identity and Forensics (V2.2025) (PDF)
- Concert Genetic Testing: Multisystem Genetic Conditions (V2.2025) (PDF)
- Concert Genetic Testing: Nephrology (V2.2025) (PDF)
- Concert Genetic Testing: Neurology (V2.2025) (PDF)
- Concert Genetic Testing: Nutrition and Metabolism (V2.2025) (PDF)
- Concert Genetic Testing: Ophthalmology (V2.2025) (PDF)
- Concert Genetic Testing: Orthopedics (V2.2025) (PDF)
- Concert Genetic Testing: Otolaryngology (V2.2025) (PDF)
- Concert Genetic Testing: Preimplantation Genetic Testing (V2.2025) (PDF)
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening (V2.2025) (PDF)
- Concert Genetic Testing: Prenatal Diagnosis (V2.2025) (PDF)
- Concert Genetic Testing: Prenatal Screening (V2.2025) (PDF)
- Concert Genetic Testing: Respiratory (V2.2025) (PDF)
- Concert Genetic Testing: Toxicology and Pharmcogenetics Version B (V2.2025) (PDF)
- Concert Genetic Testing: Transplant (V2.2025) (PDF)
- Concert Genetics Oncology: Algorithmic Assays (V2.2025) (PDF)
- Concert Genetics Oncology: Cancer Screening and Surveillance (V2.2025) (PDF)
- Concert Genetics Oncology: Hematologic Maligancy (V2.2025) (PDF)
- Concert Genetics Oncology: Solid Tumor Molecular Diagnostics (V2.2025) (PDF)
- Continuous Glucose Monitors (SC.CP.MP.02) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
D
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Drugs of Abuse: Definitive Testing (CP.MP.50) (PDF)
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines (CP.MP.107) (PDF)
E
- Electric Tumor Treating Fields (Optune) (CP.MP.145) (PDF)
- Excimer Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
F
- Facet Joint Interventions (CP.MP.171) (PDF)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (CP.MP.129) (PDF)
G
H
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Births (CP.MP.136) (PDF)
- Home Ventilators (CP.MP.184) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
I
- Immobilized Lipase Cartridges (Relizorb) (CP.MP.252) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal or Epidural Pain Pump (CP.MP.173) (PDF)
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (SC.CP.MP.03) (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
J
K
L
- Lantidra (donislecel): Allogenic Pancreatic Islet Cellular Therapy (CP.MP.250) (PDF)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement (CP.MP.71) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
M
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (PDF)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
N
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Nerve Blocks and Neurolysis for Pain Management (CP.MP.170) (PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Nonmyeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
O
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Osteogenic Stimulation (CP.MP.194) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Outpatient Oxygen Use (CP.MP.190) (PDF)
P
- Pancreas Transplantation (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Pediatric Kidney Transplant (CP.MP.246) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (CP.MP.147) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
Q
R
- Radiation Therapy for Skin Cancer (CP.MP.251) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
S
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (CP.MP.165) (PDF)
- Skin and Soft Tissue Substitutes (CP.MP.185) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22)
T
- Tandem Transplant (CP.MP.162) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transplant Service Documentation Requirements (CP.MP.247) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
U
V
W
X
Y
Z
#
Please review Section 4, Utilization Management, of the Wellcare By Absolute Total Care Dual Align (HMO D-SNP) Provider Manual for clinical policy guidance and information.
For Medicare information, please visit our Medicare Clinical Guidelines website.