Clinical & Payment Policies
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 Louisiana Healthcare Connections Clinical Policy Manual apply to Louisiana Healthcare Connections members. Policies in the Louisiana Healthcare Connections Clinical Policy Manual may have either a Louisiana Healthcare Connections or a “Centene” heading. Louisiana Healthcare Connections utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Louisiana Healthcare Connections 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 Louisiana Healthcare Connections. In addition, Louisiana Healthcare Connections 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 Louisiana Healthcare Connections.
Use the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF) to find more information on the drugs that are covered.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- LA.CP.CPC.02 Clinical Policy Web Posting (PDF)
- LA.CP.CPC.04 State specific clinical policy process (PDF)
- LA.CP.CPC.05 Medical Necessity Criteria (PDF)
- LA.CP.MP.12 Vagus Nerve Stimulation (PDF)
- LA.CP.MP.14 Cochlear Implant Replacements (PDF)
- LA.CP.MP.22 Stereotactic Body Radiation Therapy (PDF)
- LA.CP.MP.24 Multiple Sleep Latency Testing (PDF)
- LA.CP.MP.26 Articular Cartilage Defect Repairs (PDF)
- CP.MP.27 Hyperbaric Oxygen Therapy (PDF)
- LA.CP.MP.31 Cosmetic and Reconstructive Surgery (PDF)
- LA.CP.MP.34 Hyperemesis Gravidarum Treatment (PDF)
- LA.CP.MP.36 Experimental Technologies (PDF)
- LA.CP.MP.37 Bariatric Surgery (PDF)
- LA.CP.MP.38 Ultrasound in Pregnancy (PDF)
- LA.CP.MP.40 Gastric electrical stimulation (PDF)
- LA.CP.MP.43 Functional MRI (PDF)
- LA.CP.MP.46 Ventricular Assist Devices (PDF)
- LA.CP.MP.49 Therapy Services (PT,OT,ST) (PDF)
- LA.CP.MP.50 Outpatient testing for drugs of abuse (PDF)
- LA.CP.MP.51 Reduction mammoplasty and gynecomastia surgery (PDF)
- LA.CP.MP.53 Ferriscan R2 MRI (PDF)
- LA.CP.MP.54 Hospice Services (PDF)
- LA.CP.MP.55 Assisted Reproductive Technology (PDF)
- LA.CP.MP.56 Ventriculectomy and Cardiomyoplasty (PDF)
- LA.CP.MP.57 Lung Transplntation (PDF)
- LA.CP.MP.58 Intestinal and multivisceral transplant (PDF)
- LA.CP.MP.61 Dental Anesthesia (PDF)
- LA.CP.MP.62 HyperhidrosisTreatments (PDF)
- LA.CP.MP.69 Intensity-Modulated Radiotherapy (PDF)
- LA.CP.MP.70 Proton and Neutron Beam Therapy (PDF)
- LA.CP.MP.71 Long Term Care Placement (PDF)
- LA.CP.MP.81 NICU discharge guidelines (PDF)
- LA.CP.MP.82 NICU Apnea Bradycardia Guidelines (PDF)
- LA.CP.MP.83 Carrier Screening in Pregnancy (PDF)
- LA.CP.MP.84 Cell-free Fetal DNA Testing (PDF)
- LA.CP.MP.85 Neonatal sepsis management (PDF)
- LA.CP.MP.86 Neonatal abstinence syndrome guidelines (PDF)
- LA.CP.MP.87 Inhaled nitric oxide (PDF)
- LA.CP.MP.88 Sickle cell disease observation (PDF)
- LA.CP.MP.89 Genetic Testing (PDF)
- CP.MP.90 Digital breast tomosynthesis (PDF)
- LA.CP.MP.91 Obstetrical Home Care Programs (PDF)
- CP.MP.92 Acupuncture (PDF)
- CP.MP.93 Bone-Anchored Hearing Aid (PDF)
- CP.MP.94 Clinical Trials (PDF)
- CP.MP.95 Gender Reassignment Surgery (PDF)
- CP.MP.96 Ambulatory EEG (PDF)
- CP.MP.97 Testing for Select Genitourinary Conditions (PDF)
- CP.MP.98 Urodynamic testing (PDF)
- CP.MP.99 Wheelchair seating (PDF)
- CP.MP.101 Donor Lymphocyte Infusion (PDF)
- CP.MP.102 Pancreas Transplantation (PDF)
- CP.MP.103 Fractional Exhaled Nitric Oxide (PDF)
- LA.CP.BH.104 Applied Behavioral Analysis (PDF)
- LA.CP.BH.300 Neurofeedback for Behavioral Health Disorders (PDF)
- CP.MP.105 Digital electroencephalography spike analysis (PDF)
- CP.MP.106 Endometrial ablation (PDF)
- CP.MP.107 Durable Medical Equipment (DME) (PDF)
- CP.MP.108 Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF)
- CP.MP.109 Panniculectomy (PDF)
- CP.MP.110 Bronchial Thermoplasty (PDF)
- CP.MP.111 Zika Virus Testing (PDF)
- CP.MP.113 Holter Monitors (PDF)
- CP.MP.114 Disc Decompression Procedure (PDF)
- CP.MP.115 Discography (PDF)
- CP.MP.116 Lysis Of Epidural Lesions (PDF)
- CP.MP.117 Spinal Cord Stimulation (PDF)
- CP.MP.118 Injections for Pain Management (PDF)
- CP.MP.119 Balloon Sinus Ostial Dilation (PDF)
- CP.MP.120 Pediatric Liver Transplant (PDF)
- CP.MP.121 Homocysteine testing (PDF)
- CP.MP.123 Laser therapy for skin conditions (PDF)
- CP.MP.124 ADHD Assessment and Treatment (PDF)
- CP.MP.125 DNA analysis of stool to screen for colorectal cancer (PDF)
- CP.MP.126 Sacroiliac joint fusion (PDF)
- CP.MP.127 Total Artificial Heart (PDF)
- CP.MP.128 Optic nerve decompression surgery (PDF)
- LA.MP.129 Fetal surgery in utero for prenatally diagnosed malformations (PDF)
- LA.MP.130 Fertility preservation (PDF)
- LA.MP.131 Essure Removal (PDF)
- LA.MP.132 Heart-Lung Transplant (PDF)
- LA.MP.133 Posterior tibial nerve stimulation for voiding dysfunction (PDF)
- LA.MP.134 Evoked Potential Testing (PDF)
- LA.MP.136 Home Birth (PDF)
- LA.MP.137 Fecal Incontinence Treatments (PDF)
- LA.MP.138 Pediatric Heart Transplant (PDF)
- LA.MP.139 Low-frequency ultrasound therapy for wound management (PDF)
- LA.MP.140 EpiFix Wound Treatment (PDF)
- LA.MP.141 Non-myeloablative allogeneic stem cell transplants (PDF)
- LA.MP.142 Urinary Incontinence Devices and Treatments (PDF)
- LA.MP.143 Wireless Motility Capsule (PDF)
- LA.MP.144 Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
- LA.MP.145 Electric Tumor Treating Fields (PDF)
- LA.MP.146 Sclerotherapy for Vericose Veins (PDF)
- LA.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
- LA.MP.148 Radial Head Implant (PDF)
- LA.MP.149 Testing for rupture of fetal membranes (PDF)
- LA.MP.150 Home phototherapy for neonatal hyperbilirubinemia (PDF)
- LA.MP.151 Transcatheter closure of patent foramen ovale (PDF)
- LA.MP.152 Measurement of serum 1,25-dihydroxyvitamin D (PDF)
- LA.MP.153 H. Pylori serology testing (PDF)
- LA.MP.154 Thyroid hormones and insulin testing in pediatrics (PDF)
- LA.MP.155 Electroencephalography in the evaluation of headache (PDF)
- LA.MP.156 Cardiac Biomarker Testing (PDF)
- LA.MP.157 25-hydroxyvitamin D testing in children and adolescents (PDF)
- LA.MP.158 Ambulatory Surgery Center Optimization (PDF)
- LA.MP.159 Infusion Therapy Site of Care Optimization (PDF)
- LA.MP.160 Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
- LA.MP.162 Tandem Transplant (PDF)
- LA.MP.163 TPN IDPN (PDF)
- LA.MP.164 Caudal or Interlaminar Epidural Steroid Injections (PDF)
- LA.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural (PDF)
- LA.MP.166 Sacroiliac Joint Interventions (PDF)
- LA.MP.167 Intradiscal Steroid Injections (PDF)
- LA.MP.168 Biofeedback (PDF)
- LA.MP.169 Trigger Point Injections for Pain Management (PDF)
- LA.MP.170 Nerve Blocks for Pain Management (PDF)
- LA.MP.171 Facet Joint Interventions (PDF)
- CP.MP.172 Transcranial Magnetic Stimulation (PDF)
- LA.MP.173 Implantable Intrathecal Pain Pump (PDF)
- LA.MP.174 Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
- LA.MP.175 Fixed Wing Air Transportation (PDF)
- LA.MP.176 Outpatient Cardiac Rehabilitation (PDF)
- LA.CP.MP.179 Antithrombin III (Thrombate III, Atryn) (PDF)
- LA.CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)
- LA.CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
- LA.CP.MP.182 Short Inpatient Hospital Stay (PDF)
- LA.CP.MP.184 Non-Invasive Home Ventilators (PDF)
- LA.CP.MP.185 Skin Substitutes for Chronic Wounds (PDF)
- LA.CP.MP.186 Burn Surgery (PDF)
- LA.CP.MP.187 Radiofrequency Ablation of Uterine Fibroids (PDF)
- LA.CP.MP.188 Pediatric Oral Function Therapy (PDF)
- LA.CP.MP.189 Thymus Transplant (PDF)
- LA.CP.MP.190 Oxygen Use and Concentrators (PDF)
- LA.CP.MP.90 MNC Policy for CPST and PSR (PDF)
- LA.CP.MP.100 Allergy Testing and Therapy (PDF)
- LA.CP.MP.500 Enteral and Oral Nutrition(CP) (PDF)
- LA.CP.MP.502 Ambulatory Insulin Pump (PDF)
- LA.UM.90 Mental Health Rehabilitation Medical Necessity (PDF)
- LA.UM.97_Homebuilders_Services (PDF)
- LA.CP.MP.490 Outpatient Applied Behavior Analysis Medical Necessity (PDF)
- LA.CP.MP.503 OUD_Treatment_IN_OTPs (PDF)
- LA.CP.MP.504_MNC_Crisis_Intervention_(PDF)
- LA.CP.MP.505_Peer_Support_Services_(PDF)
- LA.PHAR.40 Octreotide (Sandostatin, Sandostatin LAR, Bynfezia, Mycapssa) (PDF)
- CP.PHAR.05 Hyaluronate Derivatives (PDF)
- CP.PHAR.11 Burosumab-twza (Crysvita) (PDF)
- CP.PHAR.40 Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF)
- CP.PHAR.52 Interferon Gamma- 1b (Actimmune) (PDF)
- CP.PHAR.55 Somatropin (Human Growth Hormone) (PDF)
- CP.PHAR.58 Denosumab (PDF)
- CP.PHAR.64 Topotecan (Hycamtin) (PDF)
- CP.PHAR.77 Temozolomide (Temodar) (PDF)
- CP.PHAR.82 Collagenase (PDF)
- CP.PHAR.88 Belimumab (PDF)
- CP.PHAR.93 Bevacizumab (Avastin) (PDF)
- CP.PHAR.94 Alpha-1 Proteinase Inhibitors (PDF)
- CP.PHAR.95 Thyrotropin alfa (PDF)
- CP.PHAR.97 Eculizumab (Soliris) (PDF)
- CP.PHAR.103 Immune Globulins (PDF)
- CP.PHAR.108 Omecetaxine (Synribo) (PDF)
- CP.PHAR.115 Pegloticase (Krystexxa) (PDF)
- CP.PHAR.119 Ramucirumab (Cyramza) (PDF)
- CP.PHAR.120 Sipuleucel-T (Provenge) (PDF)
- CP.PHAR.121 Nivolumab
- CP.PHAR.139 Mogamulizumab-kpkc (Poteligeo) (PDF)
- CP.PHAR.146 deferoxamine (PDF)
- CP.PHAR.149 Intrathecal Baclofen (Gablofen, Lioresal) (PDF)
- CP.PHAR.151 Levoleucovorin (Fusilev) (PDF)
- CP.PHAR.154 Imiglucerase (PDF)
- CP.PHAR.157 Taliglucerase Alfa
- CP.PHAR.158 Agalsidase Beta (PDF)
- CP.PHAR.159 Sebelipase Alfa (PDF)
- CP.PHAR.160 Alglucosidase Alfa (PDF)
- CP.PHAR.163 Velaglucerase Alfa (PDF)
- CP.PHAR.165 Ferumoxytol (Feraheme) (PDF)
- CP.PHAR.166 Ferric Gluconate (Ferrlecit) (PDF)
- CP.PHAR.167 Iron sucrose (Venofer) (Acthar Gel) (PDF)
- CP.PHAR.170 Degarelix Acetate (Firmagon) (PDF)
- CP.PHAR.171 Goserelin Acetate (Zoladex) (PDF)
- CP.PHAR.172 Histrelin Acetate (Vantas, Supprelin LA) (PDF)
- CP.PHAR.173 Leuprolide Acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF)
- CP.PHAR.175 Triptorelin Pamoate (Trelstar, Triptodur) (PDF)
- CP.PHAR.176 Paclitaxel Protein-Bound (PDF)
- CP.PHAR.179 Romiplostim (Nplate) (PDF)
- CP.PHAR.181 Hemin (Panhematin) (PDF)
- CP.PHAR.184 Aflibercept (Eylea) (PDF)
- CP.PHAR.185 Pegaptanib (Macugen) (PDF)
- CP.PHAR.186 Ranibizumab (Lucentis) (PDF)
- CP.PHAR.187 Verteporfin (Visudyne) (PDF)
- CP.PHAR.188 Teriparatide (Forteo) (PDF)
- CP.PHAR.189 Ibandronate sodium (Boniva) (PDF)
- CP.PHAR.192 Epoprostenol (Flolan, Veletri) (PDF)
- CP.PHAR.197 Sildenafil (Revatio) (PDF)
- CP.PHAR.199 Treprostinil (Orenitram, Remodulin, Tyvaso)
- CP.PHAR.201 Belatacept (Nulojix) (PDF)
- CP.PHAR.203 Cosyntropin (Cortrosyn) (PDF)
- CP.PHAR.204 Trabectedin (Yondelis) (PDF)
- CP.PHAR.215 Factor VIII (Human Recombinant) (PDF)
- CP.PHAR.216 Factor VIII von Willebrand Factor Complex (PDF)
- CP.PHAR.217 Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)
- CP.PHAR.218 Factor IX (Human, Recombinant) (PDF)
- CP.PHAR.219 Factor IX Complex, Human (Bebulin, Profilnine) (PDF)
- CP.PHAR.220 Factor VIIa, Recombinant (NovoSeven RT) (PDF)
- CP.PHAR.221 Factor XIII, Human (Corifact) (PDF)
- CP.PHAR.222 Factor XIII A-Subunit, Recombinant (Tretten) (PDF)
- CP.PHAR.225 Dalteparin (PDF)
- CP.PHAR.226 Fondaparinux (PDF)
- CP.PHAR.227 Pertuzumab (PDF)
- CP.PHAR.228 Trastuzumab, Trastuzumab-dkst (PDF)
- CP.PHAR.229 Ado-Trastuzumab Emtansine (PDF)
- CP.PHAR.230 AbobotulinumtoxinA (PDF)
- CP.PHAR.231 IncobotulinumtoxinA (PDF)
- CP.PHAR.232 OnabotulinumtoxinA (PDF)
- CP.PHAR.233 RimabotulinumtoxinB (PDF)
- CP.PHAR.234 Ferric Carboxymaltose (Injectafer) (PDF)
- CP.PHAR.235 Atezolizumab (Tecentriq) (PDF)
- CP.PHAR.236 Darbepoetin Alfa (PDF)
- CP.PHAR.237 Epoetin Alfa (PDF)
- CP.PHAR.238 Methoxy polyethylene glycol-epoetin beta (PDF)
- CP.PHAR.241 Abatacept (PDF)
- CP.PHAR.242 Adalimumab (PDF)
- CP.PHAR.243 Alemtuzumab (PDF)
- CP.PHAR.246 Canakinumab (PDF)
- CP.PHAR.247 Certolizumab (PDF)
- CP.PHAR.250 Etanercept (PDF)
- CP.PHAR.252 Glatiramer Acetate (PDF)
- CP.PHAR.253 Golimumab (PDF)
- CP.PHAR.254 Infliximab (PDF)
- CP.PHAR.255 Interferon Beta-1a (PDF)
- CP.PHAR.256 Interferon Beta-1b (PDF)
- CP.PHAR.258 Mitoxantrone (PDF)
- CP.PHAR.259 Natalizumab (PDF)
- CP.PHAR.260 Rituximab, Rituxan and Hyaluronidase (PDF)
- CP.PHAR.263 Tocilizumab (PDF)
- CP.PHAR.264 Ustekinumab (PDF)
- CP.PHAR.265 Vedolizumab (PDF)
- CP.PHAR.266 Rilonacept (PDF)
- CP.PHAR.270 Paricalcitol Injection (PDF)
- CP.PHAR.277 Cytomegalovirus Immune Globulin (CytoGam) (PDF)
- CP.PHAR.295 Sargramostim (PDF)
- CP.PHAR.296 Pegfilgrastim (PDF)
- CP.PHAR.297 Filgrastim (PDF)
- CP.PHAR.300 Bezlotoxumab (PDF)
- CP.PHAR.301 Erwinia Asparaginase (Erwinaze) (PDF)
- CP.PHAR.303 Brentuximab (PDF)
- CP.PHAR.304 irinotecan Liposome (PDF)
- CP.PHAR.305 obinutuzumab (PDF)
- CP.PHAR.306 ofatumumab (PDF)
- CP.PHAR.307 bendamustine (PDF)
- CP.PHAR.308 elotuzumab (PDF)
- CP.PHAR.309 carfilzomib (PDF)
- CP.PHAR.310 Daratumumab (PDF)
- CP.PHAR.311 belinostat (PDF)
- CP.PHAR.312.Blinatumomab (PDF)
- CP.PHAR.313 pralatrexate (PDF)
- CP.PHAR.314 romidepsin (PDF)
- CP.PHAR.315 vincristine sulfate liposome injection (PDF)
- CP.PHAR.316 cabazitaxel (PDF)
- CP.PHAR.317cetuximab (PDF)
- CP.PHAR.318- eribulin Mesylate (PDF)
- CP.PHAR.319 Ipilimumab (PDF)
- CP.PHAR.320 necitumumab (PDF)
- CP.PHAR.321 panitumumab (PDF)
- CP.PHAR.322 pembrolizumab (PDF)
- CP.PHAR.323.Plerixafor (PDF)
- CP.PHAR.324 temsirolimus (PDF)
- CP.PHAR.325 ziv-aflibercept (PDF)
- CP.PHAR.326 olaratumab (PDF)
- CP.PHAR.328 asfotase alfa (PDF)
- CP.PHAR.329 Siltuximab (Sylvant) (PDF)
- CP.PHAR.330 Protein C Concentrate, Human (Ceprotin) (PDF)
- CP.PHAR.332 pasireotide (PDF)
- CP.PHAR.333 Avelumab (Bavencio) (PDF)
- CP.PHAR.335 Ocrelizumab (PDF)
- CP.PHAR.338 Cerliponase Alfa (PDF)
- CP.PHAR.339 Durvalumab (PDF)
- CP.PHAR.343 Edaravone (PDF)
- CP.PHAR.345 Abaloparatide (PDF)
- CP.PHAR.346 Sarilumab (PDF)
- CP.PHAR.351 daptomycin (PDF)
- CP.PHAR.352 daunorubicin cytarabine (PDF)
- CP.PHAR.353 pegaspargase (PDF)
- CP.PHAR.357 copanlisib (PDF)
- CP.PHAR.358 gemtuzumab ozogamicin (PDF)
- CP.PHAR.359 inotuzumab ozogamicin (PDF)
- CP.PHAR.361 Tisagenlecleucel (PDF)
- CP.PHAR.362 Axicabtagene ciloleucel (PDF)
- CP.PHAR.367 Letermovir (PDF)
- CP.PHAR.368 Pemetrexed (Alimta) (PDF)
- CP.PHAR.370 Emicizumab-kxwh (PDF)
- CP.PHAR.371 Triamcinolone ER Injection (PDF)
- CP.PHAR.372 Voretigene neparvovec-rzyl (PDF)
- CP.PHAR.375 Brodalumab (PDF)
- CP.PHAR.378 Ibalizumab-uiyk (PDF)
- CP.PHAR.379 Etelcalcetide (Parsabiv) (PDF)
- CP.PHAR.384 Lutetium Lu 177 Dotatate (Lutathera) (PDF)
- CP.PHAR.385 Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF)
- CP.PHAR.386 Tildrakizumab-asmn (Ilumya) (PDF)
- CP.PHAR.387 Azacitidine (Vidaza) (PDF)
- CP.PHAR.388 Chloramphenicol Sodium Succinate (PDF)
- CP.PHAR.389 Pegvisomant (Somavert) (PDF)
- CP.PHAR.391 Lanreotide (Somatuline Depot) (PDF)
- CP.PHAR.392 Pegademase Bovine (Adagen) (PDF)
- CP.PHAR.393 Leucovorin Injection (PDF)
- CP.PHAR.395 Patisiran (Onpattro) (PDF)
- CP.PHAR.397 Cemiplimab-rwlc (Libtayo) (PDF)
- CP.PHAR.398 Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)
- CP.PHAR.402 Emapalumab-Izsg (Gamifant) (PDF)
- CP.PHAR.405 Inotersen (Tegsedi) (PDF)
- CP.PHAR.410 Bortezomib (Velcade) (PDF)
- CP.PHAR.415 Ravulizumab-cwvz (Ultomiris) (PDF)
- CP.PHAR.418 Dexrazoxane (Zinecard, Totect) (PDF)
- CP.PHAR.419 Elapegademase-lvlr (Revcovi) (PDF)
- CP.PMN.19 Aprepitant (Emend) (PDF)
- CP.PMN.27 Linezolid (PDF)
- CP.PMN.53 No Coverage Criteria-Off-Label Use (PDF)
- CP.PMN.62 Tedizolid (PDF)
- CP.PMN.102 Rolapitant (PDF)
- CP.PMN.154 Isavuconazonium (Cresemba) (PDF)
- CP.PMN.158 Netupitant and Palonosetron (Akynzeo) (PDF)
- CP.PMN.169 Methylnaltrexone Bromide (Relistor) (PDF)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Louisiana Healthcare Connections Payment Policy Manual apply with respect to Louisiana Healthcare Connections members. Policies in the Louisiana Healthcare Connections Payment Policy Manual may have either a Louisiana Healthcare Connections or a “Centene” heading. In addition, Louisiana Healthcare Connections may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Louisiana Healthcare Connections.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- LA.PP.007 Maximum Units (PDF)
- LA.PP.009 Unlisted Procedure Codes (PDF)
- LA.PP.010 EM Bundling Edits (PDF)
- LA.PP.011 Coding Overview (PDF)
- LA.PP.012 IV Hydration (PDF)
- LA.PP.013 Modifier -25 clinical validation (PDF)
- LA.PP.014 Modifier -59 clinical validation (PDF)
- LA.PP.015 Moderate Conscious Sedation (PDF)
- LA.PP.016 Global Maternity Billing (PDF)
- LA.PP.017 Never Paid Events (PDF)
- LA.PP.018 Inpatient Only Procedures (PDF)
- LA.PP.019 Physician Visit Codes Billed with Labs (PDF)
- LA.PP.020 Distinct Procedural Modifiers (PDF)
- LA.PP.021 Clean Claims (PDF)
- LA.PP.023 Hospital Visit Codes Billed with Labs (PDF)
- LA.PP.024 Cosmetic Procedures (PDF)
- LA.PP.025 Pulse Oximetry (PDF)
- LA.PP.027 Professional Component (PDF)
- LA.PP.028 Modifier to Procedure Code Validation (PDF)
- LA.PP.029 Assistant Surgeon (PDF)
- LA.PP.030 Add on Code Billed Without Primary Code (PDF)
- LA.PP.031 NCCI Unbundling (PDF)
- LA.PP.032 Supplies Billed on Same Day As Surgery (PDF)
- LA.PP.033 Multiple CPT Code Replacement (PDF)
- LA.PP.034 Modifier DOS Validation (PDF)
- LA.PP.035 Sleep Studies Place of Services (PDF)
- LA.PP.036 New Patient (PDF)
- LA.PP.037 Bilateral Procedures (PDF)
- LA.PP.038 Inpatient Consultation (PDF)
- LA.PP.039 Outpatient Consultation (PDF)
- LA.PP.040 Same Day Visits (PDF)
- LA.PP.041 Pre-Operative Visits (PDF)
- LA.PP.042 Post-Operative Visits (PDF)
- LA.PP.043 Unbundled Professional Services (PDF)
- LA.PP.044 Duplicate Primary Code Billing (PDF)
- LA.PP.045 Unbundled Surgical Procedures (PDF)
- LA.PP.046 Status "B" Bundled Services (PDF)
- LA.PP.047 Transgender Related Services (PDF)
- LA.PP.049 Status "P" Bundled Services (PDF)
- LA.PP.051 E&M Medical Decision-Making (PDF)
- LA.PP.056 Urine Specimen Validity Testing (PDF)
- LA.PP.060 Not Medically Necessary Inpatient Professional Services (PDF)
- LA.PP.061 Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
- LA.PP.063 Place of Service Mismatch (PDF)
- LA.PP.499 Vitamin D Testing Policy (PDF)
- LA.PP.500 3-Day Payment Window (PDF)
- LA.PP.501 CLIA Editing (PDF)
- LA.CCM.08.19 Claim Coding Decisions Claim Xten (CXT) (PDF)
- LA.PI.05.13.01 CPT 33999 (PDF)
- LA.CLSY.13 Authorization Check Run and Pend Report (PDF)
- LA.IA.11 Claims Audit Department (PDF)