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Clinical Coverage Policies

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Partners is committed to the care of the members and recipients we serve. Clinical coverage policies are the primary criteria used to assist in administering health plan benefits. 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.

As part of the Partners Benefit Plan, below you will find a list of Medicaid and Health Choice Clinical Coverage Policies by which Partners has adopted Clinical Criteria to make Medical Necessity Decisions.  The full policies can be found here: medicaid.ncdhhs.gov/providers/clinical-coverage-policies

For more information, or if you have questions about clinical coverage policies, please email UMquestions@partnersbhm.org

Allergies

  • 1N-1, Allergy Testing
  • 1N-2, Allergy Immunotherapy

Ambulance

  • 15, Ambulance Services

Anesthesia

  • 1L-1, Anesthesia Services
  • 1L-2, Moderate (Conscious) Sedation, AKA Procedural Sedation and Analgesia(PSA)

Auditory Implants External Parts

  • 13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair
  • 13B, Soft Band and Implantable Bone Conduction Hearing Aid External Parts Replacement and Repair

Behavioral Health

  • 8A, Enhanced Mental Health and Substance Abuse Services
  • 8A-1, Assertive Community Treatment (ACT) Program
  • 8A-2, Facility-Based Crisis Service for Children and Adolescents
  • 8A-5, Diagnostic Assessment
  • 8A-6, Community Support Team (CST)
  • 8B, Inpatient Behavioral Health Services
  • 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers
  • 8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of21
  • 8D-2, Residential Treatment Services
  • 8E, Intermediate Care Facilities for Individuals with Intellectual Disabilities
  • 8F, Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD
  • 8G, Peer Support Services
  • 8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population
  • 8L, Mental Health/Substance Abuse Targeted Case Management
  • 8N, NC Health Choice Intellectual and Developmental Disabilities Targeted Case Management
  • 8-O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders
  • 8-P, North Carolina Innovations

Burn Treatments & Skin Substitutes & Skin Substitutes

  • 1G-1, Burn Treatment
  • 1G-2, Skin Substitutes

Cardiac Procedures

  • 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs
  • 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound

Chiropractic Services

  • 1F, Chiropractic Services

Community Based Services

  • 3A, Home Health Services
  • 3D, Hospice Services
  • 3G-1, Private Duty Nursing for Beneficiaries Age 21 and Older
  • 3G-2, Private Duty Nursing for Beneficiaries Under 21 years of Age
  • 3H-1, Home Infusion Therapy
  • 3L, State Plan Personal Care Services (PCS)

Dietary Evaluation and Counseling

  • 1-I, Dietary Evaluation and Counseling and Medical Lactation Services

Facility Services

  • 2A-1, Acute Inpatient Hospital Services
  • 2A-2, Long Term Care Hospital Services
  • 2A-3, Out-of-State Services
  • 2B-1, Nursing Facilities
  • 2B-2, Geropsychiatric Units in Nursing Facilities

Hearing Aid Services

  • 7, Hearing Aid Services

Laboratory Services

  • 1S-1, Genotyping and Phenotyping for HIV Drug Resistance Testing
  • 1S-2, HIV Tropism Assay
  • 1S-3, Laboratory Services
  • 1S-4, Genetic Testing
  • 1S-5, Genetic Testing for Susceptibility to Breast and Ovarian Cancer (BRCA)
  • 1S-7, Gene Expression Profiling for Breast Cancer
  • 1S-8, Drug Testing for Opioid Treatment and Controlled Substance  Monitoring

Maternal Support Services (Baby Love)

  • 1M-2, Childbirth Education
  • 1M-3, Health and Behavior Intervention
  • 1M-4, Home Visit for Newborn Care and Assessment
  • 1M-5, Home Visit for Postnatal Assessment and Follow-up Care
  • 1M-6, Maternal Care Skilled Nurse Home Visit

Medical Equipment

  • 5A-1, Physical Rehabilitation Equipment and Supplies
  • 5A-2, Respiratory Equipment and Supplies
  • 5A-3, Nursing Equipment and Supplies
  • 5B, Orthotics & Prosthetics

Obstetrics & Gynecology

  • 1E-1, Hysterectomy
  • 1E-2, Therapeutic and Non-therapeutic Abortions
  • 1E-3, Sterilization Procedures
  • 1E-4, Fetal Surveillance
  • 1E-5, Obstetrics
  • 1E-6, Pregnancy Management Program
  • 1E-7, Family Planning Services

Ophthalmological Services

  • 1T-1, General Ophthalmological Services
  • 1T-2, Special Ophthalmological Services

Pharmacy Services

  • 9, Outpatient Pharmacy Program
  • 9A, Over-The-Counter Products
  • 9B, Hemophilia Specialty Pharmacy Program
  • 9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17
  • 9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older
  • Aduhelm Injection
  • Agents for Duchenne Muscular Dystrophy
  • Antifungal Agents – Vusion
  • Antinarcolepsy/Antihyperkinesis Agents
  • Behavioral Health Clinical Edits Criteria – Adults
  • Behavioral Health Clinical Edits Criteria – Pediatrics
  • Cialis
  • Crinone
  • Cystic Fibrosis
  • Emend
  • Emflaza
  • Entresto
  • Epidiolex Initial PA Criteria
  • Epinephrine Auto-Injections
  • Evrysdi
  • Gattex
  • Gocovri and Osmolex ER
  • Growth Hormones
  • Hematinics (Procrit, Epogen, Aranesp, Mircera, Retacrit)
  • Hepatitis C Medications
  • Hetlioz
  • Immunomodulators
  • Ivermectin
  • Juxtapid
  • Lupus Medications
  • Migraine Therapy – Calcitonin Gene-Related Inhibitors
  • Monoclonal Antibodies
  • Movement Disorders
  • Neuromuscular Blocking Agents (Botox, Myobloc, Dysport, Xeomin)
  • Opioid Analgesics
  • Opioid Dependence Therapy Agents
  • PCSK9 Inhibitors
  • Mu-Opioid Receptor Antagonists, Peripherally-Acting (Relistor)
  • Sedative Hypnotics
  • Synagis
  • Therapeutic Continuous Glucose Monitoring Systems (CGM) and Related Supplies
  • Topical Antihistamines
  • Topical Anti-Inflammatories
  • Topical Local Anesthetics
  • Triptans
  • Zolgensma

Physician Administered Drug Program

  • 1B, Physician’s Drug Program

Physician Clinical Coverage Policies

  • 1A-2, Preventive Medicine Annual Health Assessment
  • 1A-3, Noninvasive Pulse Oximetry
  • 1A-4, Cochlear and Auditory Brainstem Implants
  • 1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment
  • 1A-6, Invasive Electrical Bone Growth Stimulation
  • 1A-7, Neonatal and Pediatric Critical and Intensive Care Services
  • 1A-8, Hyperbaric Oxygenation Therapy
  • 1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)
  • 1A-11, Extracorporeal Shock Wave Lithotripsy
  • 1A-12, Breast Surgeries
  • 1A-13, Ocular Photodynamic Therapy
  • 1A-14, Surgery for Ambiguous Genitalia
  • 1A-15, Surgery for Clinically Severe or Morbid Obesity
  • 1A-16, Surgery of the Lingual Frenulum
  • 1A-17, Stereotactic Pallidotomy
  • 1A-19, Transcranial Doppler Studies
  • 1A-20, Sleep Studies and Polysomnography Services
  • 1A-21, Endovascular Repair of Aortic Aneurysm
  • 1A-22, Medically Necessary Circumcision
  • 1A-23, Physician Fluoride Varnish Services
  • 1A-24, Diabetes Outpatient Self-Management Education
  • 1A-25, Spinal Cord Stimulation
  • 1A-26, Deep Brain Stimulation
  • 1A-27, Electrodiagnostic Studies
  • 1A-28, Visual Evoked Potential (VEP)
  • 1A-30 Spinal Surgeries
  • 1A-31, Wireless Capsule Endoscopy
  • 1A-32, Tympanometry and Acoustic Reflex Testing
  • 1A-33, Vagus Nerve Stimulation for the Treatment of Seizures
  • 1A-34, Dialysis Services
  • 1A-36, Implantable Bone Conduction Hearing Aids (BAHA)
  • 1A-38, Special Services: After Hours
  • 1A-39, Routine Costs in Clinical Trial Services for Life Threatening Conditions
  • 1A-40, Fecal Microbiota Transplantation
  • 1A-41- Office Based Opioid Treatment: Use of Buprenorphine and Buprenorphine-Naloxone
  • 1A-42, Balloon Ostial Dilation

Podiatry

  • 1C-1, Podiatry Services
  • 1C-2, Medically Necessary Routine Foot Care

Radiology

  • 1K-1, Breast Imaging Procedures
  • 1K-2, Bone Mass Measurement
  • 1K-6, Radiation Oncology
  • 1K-7, Prior Approval for Imaging Services

Reconstructive Surgery

  • 1-O-1, Reconstructive and Cosmetic Surgery
  • 1-O-2, Craniofacial Surgery
  • 1-O-3, Keloid Excision and Scar Revision
  • 1-O-5, Rhinoplasty and/or Septorhinoplasty

Rural Health Clinics, FQHC and Health Departments. (RHC, FQHC, Health Depts)

  • 1D-1, Refugee Health Assessments Provided in Health Departments
  • 1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments
  • 1D-3, Tuberculosis Control and Treatment Provided in Health Departments
  • 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics

Solid Organ Transplants

  • 11B-1, Lung Transplantation
  • 11B-2, Heart Transplantation
  • 11B-3, Islet Cell Transplantation
  • 11B-4, Kidney (Renal) Transplantation
  • 11B-5, Liver Transplantation
  • 11B-6, Heart/Lung Transplantation
  • 11B-7, Pancreas Transplant
  • 11B-8, Small Bowel and Small Bowel/Liver and Multivisceral Transplants

Specialized Therapies

  • 10A, Outpatient Specialized Therapies
  • 10B, Independent Practitioners (IP)
  • 10D, Independent Practitioners Respiratory Therapy Services

Stem Cell Transplants

  • 11A-1, Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)
  • 11A-2, Hematopoietic Stem-Cell Transplant for Acute Myeloid Leukemia
  • 11A-3, Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia
  • 11A-5, Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemias
  • 11A-6, Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors
  • 11A-7, Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma
  • 11A-8, Hematopoietic Stem-Cell Transplantation For Multiple Myeloma and Primary Amyloidosis
  • 11A-9, Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms
  • 11A-10, Hematopoietic Stem-Cell Transplantation (HSCT) for Central Nervous System (CNS) Embryonal Tumors & Ependymoma
  • 11A-11, Hematopoietic Stem-Cell Transplant for Non-Hodgkin’s Lymphoma
  • 11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells
  • 11A-15, Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
  • 11A-16, Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
  • 11A-17, CAR-T Cell Therapy

Targeted Case Management

  • 12B, Human Immunodeficiency Virus (HIV) Case Management

Telehealth

  • 1H, Telehealth, Virtual Communications and Remote Patient Monitoring

Ventricular Assist Device

  • 11C, Ventricular Assist Device

Vision Services

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