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. 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.

Not all policies found in the Sunflower Health Plan Clinical Policy Manual apply to all Sunflower Health Plan members. Sunflower policies are applied according to member eligibility and medical necessity criteria as defined in policy CP.MP.68. Policies in the Sunflower Health Plan Clinical Policy Manual may have either a Sunflower or a “Centene” heading. Sunflower utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Sunflower 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 Sunflower. In addition, Sunflower 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 Sunflower Health Plan.

If you have any questions regarding these policies, please contact Customer Service and ask to be directed to the Medical Management department.

Policy Number Policy Title Effective Date of Revision
CP.MP.157 (PDF) 25-hydroxyvitamin D testing in children and adolescents 12/29/2017
CP.MP.92 (PDF) Acupuncture 11/30/2017
CP.MP.124 (PDF) ADHD Assessment and Treatment 5/31/2018
CP.MP.100 (PDF) Allergy Testing and Therapy 1/31/2018
CP.MP.108 (PDF) Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia 2/28/2018
CP.MP.96 (PDF) Ambulatory EEG 9/30/2017
CP.MP.158 (PDF) Ambulatory Surgery Center Optimization 2/16/2018
CP.MP.104 (PDF) Applied Behavioral Analysis for Autism 1/31/2018
CP.MP.26 (PDF) Articular Cartilage Defect Repairs 4/30/2018
CP.MP.55 (PDF) Assisted Reproductive Technology 3/31/2018
CP.MP.119 (PDF) Balloon sinus ostial dilation 11/30/2017
CP.MP.37 (PDF) Bariatric Surgery 11/29/2017
CP.MP.168 (PDF) Biofeedback 5/31/2018
CP.MP.93 (PDF) Bone-anchored hearing aid 12/31/2017
CP.MP.110 (PDF) Bronchial Thermoplasty 3/31/2018
CP.MP.156 (PDF) Cardiac biomarker testing 3/30/2018
CP.MP.83 (PDF) Carrier Screening in Pregnancy 5/31/2018
CP.MP.84 (PDF) Cell-free Fetal DNA Testing 4/30/2018
CP.MP.94 (PDF) Clinical Trials 11/30/2017
CP.MP.14 (PDF) Cochlear Implant Replacements 7/31/2018
CP.MP.31 (PDF) Cosmetic and Reconstructive Surgery 3/31/2018
CP.MP.61 (PDF) Dental Anesthesia 4/30/2018
CP.MP.90 (PDF) Digital breast tomosynthesis 10/31/2017
CP.MP.105 (PDF) Digital electroencephalography spike analysis 1/31/2018
CP.MP.114 (PDF) Disc Decompression Procedures 5/31/2018
CP.MP.115 (PDF) Discography 8/30/2017
CP.MP.125 (PDF) DNA analysis of stool to screen for colorectal cancer 7/31/2018
CP.MP.101 (PDF) Donor lymphocyte infusion 11/30/2017
CP.MP.107 (PDF) Durable Medical Equipment (DME) 1/30/2018
CP.MP.145 (PDF) Electric Tumor Treating Fields 3/31/2018
CP.MP.155 (PDF) Electroencephalography in the evaluation of headache 12/29/2017
CP.MP.106 (PDF) Endometrial ablation 7/31/2018
CP.MP.140 (PDF) EpiFix Wound Treatment 3/31/2018
CP.MP.131 (PDF) Essure Removal 11/30/2017
CP.MP.134 (PDF) Evoked Potential Testing 11/30/2017
CP.MP.36 (PDF) Experimental Technologies 9/30/2017
CP.MP.135 (PDF) Fecal calprotectin assay 11/30/2017
CP.MP.137 (PDF) Fecal incontinence treatments 12/29/2017
CP.MP.53 (PDF) Ferriscan R2-MRI 11/30/2017
CP.MP.130 (PDF) Fertility preservation 10/30/2017
CP.MP.129 (PDF) Fetal surgery in utero for prenatally diagnosed malformations 10/30/2017
CP.MP.103 (PDF) Fractional exhaled nitric oxide 12/29/2017
CP.MP.43 (PDF) Functional MRI 10/31/2017
CP.MP.40 (PDF) Gastric electrical stimulation 10/31/2017
CP.MP.95 (PDF) Gender reassignment surgery 11/30/2017
CP.MP.89 (PDF) Genetic Testing 4/30/2018
CP.MP.153 (PDF) H. Pylori serology testing 12/29/2017
CP.MP.132 (PDF) Heart-Lung Transplant 4/30/2018
CP.MP.113 (PDF) Holter Monitors 8/30/2017
CP.MP.136 (PDF) Home Birth 12/29/2017
CP.MP.150 (PDF) Home phototherapy for neonatal hyperbilirubinemia 12/21/2017
CP.MP.121 (PDF) Homocysteine testing 8/30/2017
CP.MP.54 (PDF) Hospice Services 4/30/2018
CP.MP.27 (PDF) Hyperbaric Oxygen Therapy 2/28/2018
CP.MP.34 (PDF) Hyperemesis gravidarum treatment 3/30/2018
CP.MP.62 (PDF) Hyperhidrosis treatments 2/28/2018
CP.MP.160 (PDF) Implantable Wireless Pulmonary Artery Pressure Monitoring  4/30/2018
CP.MP.87 (PDF) Inhaled nitric oxide 9/30/2017
CP.MP.118 (PDF) Injections for Pain Management  6/30/2018
CP.MP.69 (PDF) Intensity-Modulated Radiotherapy 2/28/2018
CP.MP.58 (PDF) Intestinal and multivisceral transplant 9/30/2017
CP.MP.123 (PDF) Laser therapy for skin conditions 8/30/2017
CP.MP.71 (PDF) Long Term Care Placement Criteria 4/30/2018
CP.MP.139 (PDF) Low-frequency ultrasound therapy for wound management 1/31/2018
CP.MP.57 (PDF) Lung Transplantation 11/30/2017
CP.MP.116 (PDF) Lysis of Epidural Lesions 5/31/2018
CP.MP.152 (PDF) Measurement of serum 1,25-dihydroxyvitamin D 12/29/2017
CP.MP.144 (PDF) Mechanical Stretching Devices for Joint Stiffness and Contracture 3/31/2018
CP.MP.68 (PDF) Medical Necessity Criteria 9/30/2017
CP.MP.161 (PDF) Monitored Anesthesia Care for Gastrointestinal Endoscopy  5/31/2018
CP.MP.24 (PDF) Multiple Sleep Latency Testing 4/30/2018
CP.MP.86 (PDF) Neonatal abstinence syndrome guidelines 10/30/2017
CP.MP.85 (PDF) Neonatal sepsis management 9/30/2017
CP.MP.82 (PDF) NICU Apnea Bradycardia Guidelines 5/31/2018
CP.MP.81 (PDF) NICU discharge guidelines 9/30/2017
CP.MP.141 (PDF) Non-myeloablative allogeneic stem cell transplants 2/28/2018
CP.MP.91 (PDF) Obstetrical Home Health Care Programs 1/31/2018
CP.MP.128 (PDF) Optic nerve decompression surgery 9/30/2017
CP.MP.50 (PDF) Outpatient testing for drugs of abuse 9/30/2017
CP.MP.102 (PDF) Pancreas transplant 1/31/2018
CP.MP.109 (PDF) Panniculectomy 3/31/2018
CP.MP.138 (PDF) Pediatric heart transplant 1/31/2018
CP.MP.120 (PDF) Pediatric Liver Transplant 4/30/2018
CP.MP.147 (PDF) Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention 5/31/2018
CP.MP.133 (PDF) Posterior tibial nerve stimulation for voiding dysfunction 10/30/2017
CP.MP.70 (PDF) Proton and neutron beam therapy 2/28/2018
CP.MP.148 (PDF) Radial Head Implant 5/31/2018
CP.MP.51 (PDF) Reduction mammoplasty and gynecomastia surgery 9/30/2017
CP.MP.126 (PDF) Sacroiliac joint fusion 9/30/2017
CP.MP.146 (PDF) Sclerotherapy for Vericose Veins 4/30/2018
CP.MP.88 (PDF) Sickle cell disease observation 7/31/2018
CP.MP.117 (PDF) Spinal Cord Stimulation 5/31/2018
CP.MP.22 (PDF) Stereotactic Body Radiation Therapy 1/31/2018
CP.MP.149 (PDF) Testing for rupture of fetal membranes 8/30/2017
CP.MP.97 (PDF) Testing for select genitourinary conditions 9/30/2017
CP.MP.49 (PDF) Therapy Services (PT/OT/ST) 6/22/2018
CP.MP.154 (PDF) Thyroid hormones and insulin testing in pediatrics 12/29/2017
CP.MP.127 (PDF) Total artificial heart 12/29/2017
CP.MP.163 (PDF) Total Parenteral Nutrition and Intradialytic Parenteral Nutrition 4/30/2018
CP.MP.151 (PDF) Transcatheter closure of patent foramen ovale 12/29/2017
KS.CP.MP.38 (PDF) Ultrasound in Pregnancy 6/30/2018
CP.MP.142 (PDF) Urinary Incontinence Devices and Treatments 3/31/2018
CP.MP.98 (PDF) Urodynamic testing 10/30/2017
CP.MP.12 (PDF) Vagus Nerve Stimulation 10/31/2017
CP.MP.46 (PDF) Ventricular Assist Devices 2/28/2018
CP.MP.56 (PDF) Ventriculectomy and cardiomyoplasty 2/28/2018
CP.MP.99 (PDF) Wheelchair seating 10/31/2017
CP.MP.143 (PDF) Wireless Motility Capsule 3/31/2018
CP.MP.111 (PDF) Zika Virus Testing  5/31/2018

Please refer to the KDHE website for detailed information regarding clinical prior authorization criteria.

Policy Number Policy Title Effective Date
CP.PHAR.345 Abaloparatide (Tymlos) 2/28/2018
CP.PHAR.241 abatacept (Orencia) 5/31/2018
CP.PHAR.355 abemaciclib (Verzenio) 5/31/2018
CP.PHAR.84 Abiraterone (Zytiga) 5/31/2018
CP.PHAR.230 AbobotulinumtoxinA (Dysport) 5/31/2018
CP.PHAR.366 Acalabrutinib (Calquence) 2/28/2018
CP.PHAR.242 Adalimumab (Humira) 5/31/2018
CP.PHAR.229 Ado-Trastuzumab Emtansine (Kadcyla) 5/31/2018
CP.PHAR.298 afatinib (Gilotrif) 5/31/2018
CP.PHAR.184 Aflibercept (Eylea®) 2/28/2018
CP.PHAR.158 Agalsidase Beta (Fabrazyme) 5/31/2018
CP.PMN.138 Age Limit Override (Codeine, Tramadol, Hydrocodone) 5/31/2018
CP.PHAR.369 alectinib (Alecensa) 5/31/2018
CP.PHAR.243 Alemtuzumab (Lemtrada) 5/31/2018
CP.PMN.88 Alendronate (Binosto, Fosamax plus D) 2/28/2018
CP.PHAR.160 Alglucosidase Alfa (Lumizyme) 5/31/2018
CP.PHAR.124 Alirocumab (Praluent) 8/31/2017
CP.PHAR.94 Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) 2/28/2018
CP.PMN.89 Amantadine ER (Gocovri) 2/28/2018
CP.PHAR.190 Ambrisentan (Letairis®) 2/28/2018
CP.PHAR.244 Anakinra (Kineret) 5/31/2018
CP.PHAR.376 Apalutamide (Erleada) 5/31/2018
CP.PHAR.245 apremilast (Otezla) 5/31/2018
HIM.PA.62 aprepitant (Emend®) 8/31/2017
CP.PMN.35 armodafinil (Nuvigil) 5/31/2018
CP.PMN.15 Asenapine (Saphris) 2/28/2018
CP.PMN.20 Aspirin-dipyridamole (Aggrenox) 2/28/2018
HIM.PA.66 atomoxetine (Strattera®) 8/31/2017
HIM.PA.59 Atypical antipsychotics 8/31/2017
CP.PHAR.362 axicabtagene ciloleucel (Yescarta®) 5/31/2018
CP.PHAR.100 Axitinib (Inlyta®) 2/28/2018
HIM.PA.119 Azelaic Acid (Finacea) 11/30/2017
CP.PHAR.88 Belimumab (Benlysta) 8/31/2017
CP.PHAR.373 benralizumab (Fasenra) 5/31/2018
CP.PMN.90 Benznidazole 2/28/2018
CP.PHAR.93 Bevacizumab (Avastin®) 2/28/2018
CP.PHAR.75 Bexarotene (Targretin) 5/31/2018
CP.PHAR.300 Bezlotoxumab (Zinplava) 2/28/2018
CP.PHAR.312 Blinatumomab (Blincyto) 8/31/2017
CP.PHAR.191 Bosentan (Tracleer®) 2/28/2018
CP.PHAR.105 Bosutinib (Bosulif) 5/31/2018
HIM.PA.103 Brand Name Override and Non-Formulary Medications 2/28/2018
CP.PHAR.303 Brentuximab Vedotin (Adcetris) 11/30/2017
CP.PMN.68 Brexpiprazole (Rexulti) 2/28/2018
CP.PHAR.342 Brigatinib (Alunbrig) 5/31/2018
CP.PMN.86 Brimonidine Tartrate (Mirvaso), Oxymetazoline (Rhofade) 5/31/2018
CP.PMN.82 Buprenorphine (Subutex) 2/28/2018
HIM.PA.35 buprenorphine and naloxone (Bunavail®, Suboxone®) 2/28/2018
CP.PHAR.289 buprenorphine implant (Probuphine) 5/31/2018
CP.PMN.133 Bupropion/naltrexone (Contrav) 5/31/2018
HIM.PA.46 Butorphanol Nasal Spray 5/31/2018
CP.PHAR.202 C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) 2/28/2018
CP.PHAR.111 Cabozantinib (Cometriq®, Cabometyx®) 2/28/2018
CP.PMN.76 calcifediol (Rayaldee®) 11/30/2017
CP.PHAR.246 Canakinumab (Ilaris) 5/31/2018
CP.PHAR.60 capecitabine (Xeloda) 5/31/2018
CP.PMN.137 Carbamazepine ER (Equetro) 5/31/2018
CP.PHAR.206 Carglumic acid (Carbaglu®) 2/28/2018
CP.PMN.91 Cariprazine (Vraylar) 2/28/2018
CP.PMN.122 Celecoxib (Celebrex) 5/31/2018
CP.PHAR.349 Ceritinib (Zykadia) 5/31/2018
CP.PHAR.338 Cerliponase alfa (Brineura) 5/31/2018
CP.PHAR.247 Certolizumab (Cimzia) 5/31/2018
HIM.PA.148 Cetrorelix (Cetrotide) and Ganirelix 5/31/2018
CP.PHAR.61 Cinacalcet (Sensipar) 2/28/2018
HIM.PA.120 Ciprofloxacin-Dexamethasone (Ciprodex) 11/30/2017
CP.PMN.54 clobazam (Onfi) 5/31/2018
HIM.PA.149 clomipramine (Anafranil) 5/31/2018
CP.PMN.92 CNS Stimulants 5/31/2018
HIM.PA.121 Colesevelam (Welchol) 11/30/2017
CP.PHAR.82 Collagenase (Xiaflex) 8/31/2017
HIM.PA.140 Conjugated Estrogens/Bazedoxifene (Duavee) 2/28/2018
CP.PHAR.168 Corticotropin (H.P. Acthar Gel®) 2/28/2018
CP.PMN.110 crisaborole (Eucrisa) 5/31/2018
CP.PHAR.90 Crizotinib (Xalkori) 5/31/2018
CP.PMN.48 Cyclosporine  (Restasis) 5/31/2018
CP.PMN.130 Cysteamine ophthalmic (Cystaran) 5/31/2018
CP.PHAR.155   Cysteamine oral (Cystagon, Procysbi) 5/31/2018
CP.PHAR.239 Dabrafenib (Tafinlar) 5/31/2018
HIM.PA.SP27 Daclatasvir (Daklinza) 5/31/2018
HIM.PA.SP6 daclizumab (Zinbryta) 5/31/2018
CP.PHAR.248 Dalfampridine (Ampyra) 5/31/2018
CP.PHAR.225 Dalteparin (Fragmin) 2/28/2018
CP.PHAR.310 Daratumumab (Darzalex) 11/30/2017
CP.PHAR.236 Darbepoetin alfa (Aranesp) 5/31/2018
CP.PHAR.72 Dasatinib (Sprycel) 5/31/2018
CP.PHAR.145 deferasirox (Exjade Jadenu) 8/31/2017
CP.PHAR.147 deferiprone (Ferriprox) 8/31/2017
CP.PHAR.146 deferoxamine (Desferal) 8/31/2017
CP.PHAR.331 Deflazacort (Emflaza) 2/28/2018
CP.PHAR.58 Denosumab (Prolia, Xgeva) 5/31/2018
CP.PHAR.214 Desmopressin (DDAVP, Stimate) 2/28/2018
CP.PHAR.341 deutetrabenazine (Austedo) 5/31/2018
CP.PMN.93 Dextromethorphan-Quinidine (Nuedexta) 2/28/2018
HIM.PA.SP44 Dichlorphenamide (Keveyis) 11/30/2017
HIM.PA.123 diclofenac sodium topical gel (Solaraze, Voltaren®) 2/28/2018
CP.PHAR.249 Dimethyl Fumarate (Tecfidera) 5/31/2018
HIM.PA.58 Dipeptidyl Peptidase-4 Inhibitors 2/28/2018
HIM.PA.85 dolastron (Anzemet®) 8/31/2017
CP.PHAR.212 Dornase alfa (Pulmozyme) 2/28/2018
CP.PMN.13 Dose Optimization 5/31/2018
HIM.PA.147 Doxepin Hydrochloride Cream (Prudoxin, Zonalon) 2/28/2018
CP.PMN.79 doxycycline (Acticlate, Doryx, Oracea) 5/31/2018
CP.PHAR.336 Dupilumab (Dupixent) 2/28/2018
CP.PHAR.339 Durvalumab (Imfinzi) 5/31/2018
CP.PMN.128 dutasteride (Avodart) and dutasteride/tamsulosin (Jalyn) 5/31/2018
CP.PHAR.177 Ecallantide (Kalbitor®) 2/28/2018
CP.PHAR.97 Eculizumab (Soliris®) 2/28/2018
CP.PHAR.343 Edaravone (Radicava) 5/31/2018
HIM.PA.25 Efinaconazole (Jublia) 2/28/2018
CP.PHAR.153 Eliglustat (Cerdelga) 5/31/2018
CP.PHAR.162 Elosulfase Alfa (Vimizim) 5/31/2018
CP.PHAR.180 Eltrombopag (Promacta®) 2/28/2018
CP.PHAR.370 Emicizumab-kxwh (Hemlibra) 2/28/2018
HIM.PA.78 Emtricitabine/Tenofovir (Truvada®)  9/1/2017
CP.PHAR.363 enasidenib (Idhifa®) 11/30/2017
CP.PHAR.224 Enoxaparin (Lovenox) 2/28/2018
CP.PHAR.106 Enzalutamide (Xtandi) 11/30/2017
CP.PHAR.237 Epoetin Alfa (Epogen® and Procrit) 5/31/2018
CP.PHAR.192 Epoprostenol (Flolan®), Veletri®) 2/28/2018
CP.PHAR.74 Erlotinib (Tarceva) 2/28/2018
CP.PHAR.250 Etanercept (Enbrel) 5/31/2018
CP.PHAR.288 Eteplirsen (Exondys 51) 2/28/2018
CP.PHAR.63 everolimus (Afinitor®) 8/31/2017
HIM.PA.SP46 Evolocumab (Repatha) 11/30/2017
CP.PMN.77 Ezetimibe-Simvastatin (Vytorin) 2/28/2018
HIM.PA.60 ezogabine (Potiga®) 8/31/2017
HIM.PA.63 famciclovir (Famvir®) 8/31/2017
CP.PMN.57 febuxostat (Uloric) 5/31/2018
CP.PMN.127 Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) 5/31/2018
CP.PHAR.297 Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) 11/30/2017
CP.PHAR.251 Fingolimod (Gilenya) 5/31/2018
CP.PMN.95 Fluticasone propionate (Xhance) 2/28/2018
CP.PHAR.226 Fondaparinux (Arixtra) 2/28/2018
HIM.PA.33 Formulary Medications Without Specific Guidelines 5/31/2018
CP.PHAR.161  Galsulfase (Naglazyme) 5/31/2018
CP.PHAR.68 Gefitinib (Iressa) 5/31/2018
CP.PHAR.252 Glatiramer (Copaxone, Glatopa) 5/31/2018
HIM.PA.SP36 Glecaprevir-Pibrentasvir 5/31/2018
HIM.PA.53 Glucagon-Like Peptide-1 Receptor Agonists 2/28/2018
CP.PHAR.207 Glycerol phenylbutyrate (Ravicti®) 2/28/2018
CP.PHAR.253 Golimumab (Simponi, Simponi Aria). 5/31/2018
CP.PMN.74 granisetron (Sancuso®) 11/30/2017
HIM.PA.98 Guanfacine ER (Intuniv)  8/31/2017
CP.PMN.111 House dust mite allergen extract (Odactra®) 8/31/2017
CP.PHAR.05 Hyaluronate Derivatives 5/31/2018
HIM.PA.141 Hydrocodone-chlorpheniramine (Vituz) 2/28/2018
CP.PHAR.14 Hydroxyprogesterone Caproate (Makena®) 2/28/2018
CP.PHAR.378 ibalizumab-uiyk (Trogarzo) 5/31/2018
CP.PHAR.189 Ibandronate sodium (Boniva®) 2/28/2018
HIM.PA.SP48 Ibrutinib (Imbruvica) 11/30/2017
CP.PMN.120 Ibuprofen and Famotidine (Duexis) 5/31/2018
CP.PHAR.178 Icatibant (Firazyr®) 2/28/2018
HIM.PA.SP49 Idelalisib (Zydelig) 11/30/2017
CP.PHAR.156 Idursulfase (Elaprase) 5/31/2018
CP.PMN.32 Iloperidone (Fanapt) 2/28/2018
CP.PHAR.193 Iloprost (Ventavis®) 2/28/2018
CP.PHAR.65 Imatinib (Gleevec) 5/31/2018
CP.PHAR.154 Imiglucerase (Cerezyme) 5/31/2018
HIM.PA.SP47 Immune Globulin Infusion with Recombinant Human Hyaluronidase (Hyqvia®) 11/30/2017
CP.PHAR.103 Immune Globulins 8/31/2017
CP.PHAR.231 IncobotulinumtoxinA (Xeomin) 5/31/2018
HIM.PA.SP58 Infliximab (Remicade, Renflexis, Inflectra) 5/31/2018
HIM.PA.73 Inhaled Corticosteroids 8/31/2017
HIM.PA.SP14 interferon beta-1a (Avonex, Rebif) 5/31/2018
HIM.PA.SP15 interferon beta-1b (Betasero, Extavia) 5/31/2018
CP.PHAR.52 Interferon Gamma- 1b (Actimmune) 2/28/2018
CP.PHAR.319 Ipilimumab (Yervoy) 11/30/2017
HIM.PA.108 isavuconazonium (Cresemba®) 8/31/2017
HIM.PA.50 isotretinoin (Claravis®, Sotret®, Amnesteem®, Myorisan®) 8/31/2017
CP.PMN.124 Itraconazole (Sporanox, Onmel) 5/31/2018
CP.PMN.70 ivabradine (Corlanor) 5/31/2018
CP.PHAR.210 Ivacaftor (Kalydeco) 2/28/2018
HIM.PA.124 ivermectin (Sklice®) 11/30/2017
CP.PHAR.302 Ixazomib (Ninlaro) 8/31/2017
HIM.PA.49 lacosamide (Vimpat®) 8/31/2018
CP.PHAR.152 Laronidase (Aldurazyme) 5/31/2018
CP.PMN.108 Latanoprostene Bunod (Vyzulta) 2/28/2018
HIM.PA.SP3 ledipasvir sofosbuvir (Harvoni) 5/31/2018
CP.PHAR.71 lenalidomide (Revlimid) 5/31/2018
HIM.PA.SP50 Lenvatinib (Lenvima) 11/30/2017
CP.PHAR.367 Letermovir (Prevymis) 2/28/2018
HIM.PA.138 Leucovorin 11/30/2017
HIM.PA.SP51 Leuprolide Acetate Norethindrone Acetate (Lupaneta Pack) 11/30/2017
CP.PMN.07 Levalbuterol (Xopenex) 2/28/2018
HIM.PA.125 Levomilnacipran (Fetzima) 11/30/2017
CP.PMN.116 l-glutamine (Endari) 11/30/2017
HIM.PA.126 lidocaine transdermal (Lidoderm®) 11/30/2017
CP.PMN.73 lifitegrast (Xiidra®) 11/30/2017
CP.PMN.71 Linaclotide (Linzess) 2/28/2018
CP.PMN.27 linezolid (Zyvox) 5/31/2018
CP.PHAR.283 Lomitapide (Juxtapid) 8/31/2017
HIM.PA.74 long acting beta agonists and combination products 8/31/2017
HIM.PA.99 Long Acting Injectable Atypical Antipsychotics 8/31/2017
CP.PCH.03 Lorcaserin (Belviq®, Belviq XR) 5/31/2018
HIM.PA.127 Lovastatin ER (Altoprev) 11/30/2017
HIM.PA.79 lubiprostone (Amitiza®) 8/31/2017
CP.PHAR.213 Lumacaftor-ivacaftor (Orkambi) 2/28/2018
CP.PMN.50 Lurasidone (Latuda) 2/28/2018
CP.PHAR.194 Macitentan (Opsumit®) 2/28/2018
CP.PMN.136 Mecamylamine (Vecamyl) 5/31/2018
CP.PHAR.150 Mecasermin (Increlex) 8/31/2017
HIM.PA.128 Megestrol acetate oral suspension (Megace ES) 11/30/2017
CP.PHAR.200 Mepolizumab (Nucala) 5/31/2018
CP.PMN.72 Metformin ER (Glumetza) 5/31/2018
CP.PHAR.238 Methoxy polyethylene glycol-epoetin beta (Mircera) 5/31/2018
CP.PHAR.344 Midostaurin (Rydapt) 5/31/2018
CP.PHAR.101 Mifepristone (Korlym) 2/28/2018
CP.PHAR.164 Miglustat (Zavesca) 5/31/2018
CP.PMN.125 Milnacipran (Savella) 5/31/2018
CP.PMN.80 Minocycline ER and Microspheres (Solodyn) 5/31/2018
CP.PHAR.284 Mipomersen (Kynamro) 8/31/2017
HIM.PA.SP53 Mitoxantrone (Novantrone) 5/31/2018
CP.PMN.85 Mixed pollens allergen extract (Oralair®) 8/31/2017
CP.PMN.39 modafinil (Provigil) 5/31/2018
HIM.PA.93 Mometasone (Nasonex) 8/31/2017
HIM.PA.129 Montelukast oral granules (Singulair) 11/30/2017
CP.PMN.112 Naldemedine (Symproic) 5/31/2018
CP.PMN.117 Naproxen and Esomeprazole magnesium (Vimovo) 5/31/2018
HIM.PA.130 Naproxen oral suspension (Naprosyn) 11/30/2017
HIM.PA.SP17 natalizumab (Tysabri) 5/31/2018
HIM.PA.131 Nebivolol (Bystolic) 11/30/2017
CP.PHAR.365 neratinib (Nerlynx®) 11/30/2017
CP.PMN.118 Netarsudil (Rhopressa) 5/31/2018
HIM.PA.113 netupitant; palonosetron (Akynzeo) 5/31/2018
CP.PHAR.76 nilotinib (Tasigna) 5/31/2018
CP.PHAR.285 Nintedanib (Ofev) 8/31/2017
CP.PHAR.121  Nivolumab (Opdivo) 2/28/2018
CP.PMN.04 Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) 5/31/2018
HIM.PA.100 Non-Formulary and Formulary Contraceptives 5/31/2018
HIM.PA.34 Non-Formulary Test Strips 2/28/2018
CP.PHAR.327 nusinersen (Spinraza®) 8/31/2017
CP.PHAR.287 Obeticholic (Ocaliva) 8/31/2017
CP.PHAR.40 Octreotide (Sandostatin, Sandostatin LAR) 2/28/2018
HIM.PA.SP34 olaparib (Lynparza) 11/30/2017
CP.PHAR.108 Omacetaxine (Synribo) 5/31/2018
CP.PHAR.01 Omalizumab (Xolair®) 2/28/2018
CP.PHAR.232 OnabotulinumtoxinA (Botox) 5/31/2018
HIM.PA.139 Opioid Analgesics 5/31/2018
CP.PHAR.294 Osimertinib (Tagrisso) 8/31/2017
HIM.PA.40 Overactive Bladder Agents 5/31/2018
CP.PMN.119 Ozenoxacin (Xepi) 5/31/2018
CP.PHAR.176 Paclitaxel, protein-bound (Abraxane) 5/31/2018
CP.PMN.30 Paliperidone (Invega) 2/28/2018
CP.PHAR.16 Palivizumab (Synagis) 5/31/2018
CP.PHAR.270 Paricalcitol Injection (Zemplar) 5/31/2018
HIM.PA.SP54 Pasireotide (Signifor) 11/30/2017
CP.PHAR.81 Pazopanib (Votrient) 8/31/2017
CP.PHAR.185 Pegaptanib (Macugen®) 2/28/2018
CP.PHAR.296 Pegfilgrastim (Neulasta) 8/31/2017
CP.PHAR.89 peginterferon alfa-2b (Sylatron®) 8/31/2017
HIM.PA.SP18 peginterferon beta-1a (Plegridy) 5/31/2018
CP.PHAR.115 Pegloticase (Krystexxa®) 2/28/2018
HIM.PA.142 Penicillamine (Cuprimine) 2/28/2018
HIM.PA.132 Perampanel (Fycompa) 8/31/2017
CP.PHAR.227 Pertuzumab (Perjeta) 5/31/2018
HIM.PA.114 Phendimetrazine IR (Bontril PDM) 5/31/2018
CP.PMN.135 Phentermine (Adipex-P, Lomaira) 5/31/2018
CP.PMN.98 Pimecrolimus (Elidel) 2/28/2018
CP.PHAR.286 Pirfenidone (Esbriet) 8/31/2017
CP.PMN.87 plecanatide (Trulance) 5/31/2018
CP.PHAR.323 Plerixafor (Mozobil) 8/31/2017
CP.PHAR.116 Pomalidomide (Pomalyst) 5/31/2018
CP.PHAR.112 Ponatinib (Iclusig) 5/31/2018
HIM.PA.143 Potassium (Klor-Con) 2/28/2018
CP.PMN.129 Pramlintide (Symlin) 5/31/2018
CP.PMN.99 Prasterone (Intrarosa) 2/28/2018
CP.PMN.33 pregabalin (Lyrica) 5/31/2018
CP.PMN.58 propranolol HCL solution (Hemangeol)   5/31/2018
HIM.PA.133 Pyrimethamine (Daraprim) 11/30/2017
CP.PMN.64 Quetiapine ER (Seroquel XR) 5/31/2018
HIM.PA.144 Quinine Sulfate (Qualaquin) 2/28/2018
CP.PHAR.186 Ranibizumab (Lucentis®) 2/28/2018
CP.PMN.34 ranolazine (Ranexa) 2/28/2018
HIM.PA.89 rasagiline (Azilect®) 8/31/2017
CP.PHAR.107 Regorafenib (Stivarga) 5/31/2018
CP.PHAR.223 Reslizumab (Cinqair) 2/28/2018
CP.PHAR.334 Ribociclib (Kisqali, Kisqali Femara) 2/28/2018
HIM.PA.68 rifaximin (Xifaxan®) 8/31/2017
CP.PHAR.266 Rilonacept (Arcalyst) 5/31/2018
CP.PHAR.233 RimabotulinumtoxinB (Myobloc) 5/31/2018
CP.PHAR.195 Riociguat (Adempas®) 2/28/2018
CP.PMN.100 Risedronate (Actonel, Atelvia) 2/28/2018
CP.PHAR.293 Risperidone Long-Acting Injection (Risperdal Consta) 11/30/2017
HIM.PA.81 Risperidone ODT, Risperidone solution (Risperdal) 8/31/2017
CP.PHAR.260 Rituximab (Rituxan), Rituximab and hyaluronidase (Rituxan Hycela) 5/31/2018
CP.PMN.102 Rolapitant (Varubi) 2/28/2018
CP.PHAR.179 Romiplostim (Nplate®) 2/28/2018
CP.PHAR.350 rucaparib (Rucaparib®) 8/31/2017
HIM.PA.90 Rufinamide (Banzel) 8/31/2017
CP.PMN.67 Sacubitril/Valsartan (Entresto) 5/31/2018
CP.PMN.113 Safinamide (Xadago) 5/31/2018
CP.PHAR.295 Sargramostim (Leukine) 11/30/2017
CP.PHAR.159 Sebelipase Alfa (Kanuma) 5/31/2018
CP.PMN.103 Secnidazole (Solosec) 2/28/2018
CP.PHAR.261 Secukinumab (Cosentyx) 5/31/2018
CP.PHAR.196 Selexipag (Uptravi®) 2/28/2018
CP.PMN.83 Short ragweed pollen allergen extract (Ragwitek®) 8/31/2017
CP.PHAR.197 Sildenafil (Revatio®) 2/28/2018
CP.PMN.131 Sildenafil (Viagra) 5/31/2018
CP.PHAR.120 Sipuleucel-T (Provenge) 5/31/2018
HIM.PA.69 sodium oxabate (Xyrem®) 8/31/2017
HIM.PA.91 Sodium-Glucose Co-Transporter 2  Inhibitors 2/28/2018
HIM.PA.SP2 Sofosbuvir (Sovaldi) 5/31/2018
HIM.PA.SP1 Sofosbuvir-Velpatasvir (Epclusa) 5/31/2018
CP.PHAR.55 somatropin (Growth Hormone) 5/31/2018
CP.PHAR.272 Sonidegib (Odomzo) 5/31/2018
CP.PHAR.69 sorafenib (Nexavar) 5/31/2018
HIM.PA.134 Spinosad (Natroba) 11/30/2017
HIM.PA.109 Step Therapy 5/31/2018
HIM.PA.SP30 sucroferric oxyhydoxide (Velphoro) 2/28/2018
HIIM.PA.145 Sulfacetamide Sodium Sulfur (Sumadan) 2/28/2018
CP.PHAR.73 sunitinib (Sutent) 5/31/2018
CP.PMN.109 Suvorexant (Belsomra®) 2/28/2018
CP.PHAR.198 Tadalafil (Adcirca®) 2/28/2018
CP.PMN.132 Tadalafil BHP - ED (Cialis) 5/31/2018
CP.PHAR.157 Taliglucerase Alfa (Elelyso) 5/31/2018
HIM.PA.86 tapentadol (Nucynta®) 8/31/2017
CP.PMN.104 Tasimelteon (Hetlioz) 2/28/2018
HIM.PA.117 tavaborole (Kerydin®) 2/28/2018
CP.PMN.62 Tedizolid (Sivextro) 2/28/2018
CP.PHAR.114 Teduglutide (Gattex) 8/31/2017
HIM.PA.95 Telbivudine (Tyzeka) 8/31/2017
CP.PHAR.337 Telotristat Ethyl (Xermelo) 5/31/2018
CP.PHAR.109 Temasmorelin (Egrifta) 8/31/2017
CP.PHAR.77 Temozolomide (Temodar) 5/31/2018
CP.PCH.02 Teriflunomide (Aubagio) 5/31/2018
CP.PHAR.188 Teriparatide (Forteo®) 2/28/2018
CP.PHAR.92 tetrabenazine (Xenazine) 5/31/2018
CP.PHAR.377 tezacaftor/iv acafter; ivacaftor (Symdeko) 5/31/2018
CP.PHAR.78 Thalidomide (Thalomid) 5/31/2018
CP.PHAR.95 Thyrotropin Alfa (Thyrogen) 11/30/2017
HIM.PA.137 Timothy Grass Pollen Allergen Extract (Grastek) 11/30/2017
CP.PHAR.361 Tisagenlecleucel (Kymriah) 11/30/2017
CP.PHAR.211 Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) 2/28/2018
CP.PHAR.263 Tocilizumab (Actemra) 5/31/2018
CP.PHAR.267 Tofacitinib (Xeljanz, Xeljanz XR) 5/31/2018
HIM.PA.71 Topical Acne Treatment 2/28/2018
HIM.PA.56 Topical Immunomodulators 8/31/2017
HIM.PA.87 topical testosterone 8/31/2017
CP.PHAR.64 Topotecan (Hycamtin) 5/31/2018
CP.PMN.126 Toremifene (Fareston) 5/31/2018
CP.PHAR.240 Trametinib (Mekinist) 5/31/2018
CP.PHAR.228 Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) 5/31/2018
HIM.PA.SP25 tresprostinil (Orenitram®, Romodulin®) 8/31/2017
CP.PHAR.371 Triamcinolone ER Injection (Zilretta) 2/28/2018
HIM.PA.SP55 Uridine acetate (Vistogard) 11/30/2017
CP.PHAR.264 Ustekinumab (Stelara) 5/31/2018
CP.PHAR.340 Valbenazine (Ingrezza) 5/31/2018
CP.PHAR.80 Vandetanib (Caprelsa®) 2/28/2018
CP.PHAR.163 Velaglucerase Alfa (VPRIV) 5/31/2018
CP.PHAR.91 Vemurafenib (Zelboraf®) 2/28/2018
CP.PHAR.187 Verteporfin (Visudyne®) 2/28/2018
CP.PHAR.374 vestronidase alfa-vjbk (Mepsevii) 5/31/2018
CP.PHAR.169 Vigabatrin (Sabril) 11/30/2017
HIM.PA.135 viladazone (Viibryd®) 11/30/2017
CP.PHAR.273 Vismodegib (Erivedge) 5/31/2018
HIM.PA.146 Vorapaxar (Zontivity) 2/28/2018
CP.PHAR.372 Voretigene neparvovec-rzyl (Luxturna) 2/28/2018
CP.PHAR.83 Vorinostat (Zolinza) 8/31/2017
HIM.PA.136 vortioxetine (Trintellex®) 11/30/2017
CP.PHAR.59 zoledronic acid (Reclast, Zometa) 2/28/2018

Please refer to the Allwell website for detailed information regarding Allwell pharmacy policies. 

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 Sunflower Health Plan Payment Policy Manual apply with respect to Sunflower Health Plan members. Policies in the Sunflower Health Plan Payment Policy Manual may have either a Sunflower Health Plan or a “Centene” heading.  In addition, Sunflower Health Plan 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 Sunflower Health Plan.     

If you have any questions regarding these policies, please contact Customer Service and ask to be directed to the Medical Management department.

Policy # Title Description
KS.PP.501 15-Day Readmission (PDF) Aims to incentivize providers to increase quality of care by denying payment to providers for preventable readmissions within 15 days of initial discharge.
CC.PP.500 3-Day Payment Window (PDF) Aims to ensure that payment for the technical component of all outpatient diagnostic services and related non-diagnostic services are bundled with the claim for an inpatient stay when services are furnished within 3 calendar days. 
CC.PP.030 Add-on Code Billed Without Primary Code (PDF) The purpose of this policy is explain the parameters for add-on codes submitted on physician claims.
CC.PP.029 Assistant Surgeon (PDF) The purpose of this policy is to define payment criteria for procedures which are appropriate to be billed with the assistant surgeon modifier to be used in making payment decisions and administering benefits.
CC.PP.037 Bilateral Procedures (PDF) The purpose of this policy is to define the appropriate billing criteria for bilateral services.
CC.PP.008 Cerumen Removal (PDF) The purpose of this policy is to define separate payment criteria for removal of impacted cerumen to be used by Health Plan in making payment decisions and administering benefits.
CC.PP.021 Clean Claims (PDF) The purpose of this policy is to define the minimum claim submission requirements for claims submitted to the health plan for processing from all providers, including facilities (e.g., hospitals, ambulatory surgery centers) and professional providers (e...
CC.PP.022 Clinical Laboratory Improvement Amendments (CLIA) (PDF) In an effort to ensure quality lab testing and reporting, Congress passed the Clinical Laboratory Improvement Amendments (CLIA). CLIA was established in 1988 and mandates that all laboratories, (including physician’s office laboratories), which perform n...
CC.PP.013 Clinical Validation of Modifier 25 (PDF) The policy applies to the use of modifier 25; which should only be used to indicate that a “significant, separately identifiable evaluation and management service (was provided) by the same physician on the same day of the procedure or other service.”
CC.PP.014 Clinical Validation of Modifier 59 (PDF) The policy applies to the use of modifier 59; which should only be used to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. 
CC.PP.011 Coding Overview (PDF) The purpose of this policy is to serve as a reference guide for general coding and claims editing information.
CC.PP.024 Cosmetic Procedures (PDF) Cosmetic procedures or procedures connected with the cosmetic surgery are not reimbursable. The Centers for Medicare and Medicaid Services (CMS) define cosmetic procedures as “any surgical procedure, directed at improving appearance, except when required ...
CC.PP.020 Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF) The policy applies to use of 4 new modifiers to be used in place of modifier 59.
CC.PP.044 Duplicate Primary Code Billing (PDF) The purpose of this policy is to define payment criteria when a primary procedure code is billed in multiple quantities instead of the more appropriate "add-on" code.
CC.PP.051 E&M Medical Decision-Making (PDF) The policy discusses the appropriate assignment of moderate to high complexity E&M services with an emphasis on medical decision making as a key component of the assignment process.
CC.PP.010 E&M Bundling (PDF) The purpose of this policy is to define payment criteria for those physician services included in the payment for E/M services to be used by Health Plan in making payment decisions and administering benefits.
CC.PP.016 Global Maternity Package (PDF) The purpose of this policy is to serve as a reference guide for coding global obstetrical package for reimbursement.
CC.PP.023 Hospital Visit Codes Billed with Labs (PDF) The purpose of this policy is to serve as a reference guide for coding hospital visits with laboratory tests.
CC.PP.038 Inpatient Consultation (PDF) The purpose of this policy is to outline how the health plan evaluates CPT consultation codes 99251-99255 and HCPCS codes G0406-G0408 for reimbursement, particularly identifying those that should have been billed at the appropriate level of subsequent hos...
CC.PP.018 Inpatient Only Procedures (PDF) The purpose of this policy is to serve as a reference guide on procedures that will reimbursed as inpatient only services.
CC.PP.012 Intravenous Hydration (PDF) According to the American Medical Association (AMA), CPT code 96360 is used to report intravenous (IV) infusions for hydration purposes. The code is used to report the first 31 minutes to 1 hour of hydration therapy. CPT code 96361 is used to report eac...
CC.PP.007 Maximum Units (PDF) The purpose of this policy is to define payment criteria for the maximum units of service billed on a claim to be used by Health Plan in making payment decisions and administering benefits. 
CC.PP.015 Moderate Conscious Sedation (PDF) The purpose of this policy is to serve as a reference guide for coding drug induced depression of consciousness for reimbursement.
CC.PP.034 Modifier DOS Validation (PDF) Providers append modifiers to procedures and services to indicate that a procedure or service has been altered by some circumstance, but the definition of the procedure or the procedure code itself is unchanged.
CC.PP.028 Modifier to Procedure Code Validation (PDF) Providers append modifiers to procedures codes to indicate that a procedure or service has been altered by some circumstance, but the definition of the procedure or the procedure code itself is unchanged. This policy is relevant to modifiers identified a...
CC.PP.033 Multiple CPT Code Replacement (PDF) When a single, more comprehensive procedure code exists to describe a service, the single more comprehensive code should be used versus multiple CPT codes.
CC.PP.031 NCCI Unbundling (PDF) The health plan administers unbundling edits based on the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI).  The NCCI edit reimbursement methodologies dictate that when two relatable procedure codes are billed for...
CC.PP.017 Never Paid Events (PDF) The purpose of this policy is to serve as a reference guide for Never Events for non-payment.
CC.PP.036 New Patient (PDF) The purpose of this policy is to define payment criteria and appropriate use of the new patient evaluation and management (E&M) procedure codes.
CC.PP.039 Outpatient Consultations (PDF) The purpose of this policy is to outline how the health plan evaluates CPT consultation codes 99241-99245 and HCPS codes G0425-G0427 for reimbursement, particularly identifying those that should have been billed at the appropriate level of office visit, e...
CC.PP.041 Pre-operative Visits (PDF) The purpose of this policy is to define payment criteria for E&M services when billed with surgical procedures having a 000, 010 or 090, MMM, and ZZZ global period to be used in making payment decisions and administering benefits.
CC.PP.042 Post-operative Visits (PDF) The purpose of this policy is to define payment criteria for E&M services when billed with surgical procedures having a 000, 010 or 090, MMM, and ZZZ global period to be used in making payment decisions and administering benefits.
CC.PP.027 Professional Component (PDF)  Certain procedure codes represent both the technical and professional component of a procedure or service.
CC.PP.019 Professional Services (Visit Codes) Billed With Labs (PDF) Providers may receive reimbursement for visit codes (evaluation and management services) in addition to a laboratory test, but only when the provider performs a distinct and separately identifiable service in addition to the test.
CC.PP.025 Pulse Oximetry (PDF) The purpose of this policy is to define payment criteria for pulse oximetry testing when billed separately from an office visit.
CC.PP.035 Sleep Studies Place of Service (PDF) The purpose of this policy is to define the appropriate place of service for sleep studies.
CC.PP.049 Status B Bundled Services (PDF) The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another procedure or service to be used in making payment decisions and administering benefits.
CC.PP.046 Status P Bundled Services (PDF) The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another physician's procedure or service to be used in making payment decisions and administering benefits.
CC.PP.032 Supplies Billed on Same Day As Surgery (PDF) The purpose of this policy is to define payment criteria for supplies billed on the same date as a surgical procedure to be used by the health plan in making payment decisions.
KS.CP.MP.38 Ultrasound in Pregnancy - KS (PDF) This policy outlines the medical necessity criteria for ultrasound use in pregnancy. 
CC.PP.043 Unbundled Professional Services (PDF) The purpose of this policy is to define payment criteria for national specialty society surgical code pair edit relationships to be used in making payment decisions and administering benefits
CC.PP.045 Unbundled Surgical Procedures (PDF) The purpose of this policy is to define payment criteria for national specialty society surgical code pair edit relationships to be used in making payment decisions and administering benefits
CC.PP.009 Unlisted Procedure Codes (PDF) Outlines the parameters and documentation requirements necessary when an unlisted or unspecified procedure code is utilized. 
CC.PP.040 Visits On Same Day As Surgery (PDF) For purposes of this policy, “same day visits” address evaluation and management services that occur on the same day as the surgical procedure.
CC.PP.502 Wheelchairs and Accessories (PDF) The purpose of this policy is to define coverage criteria for options and accessories for manual and powered wheelchairs to be used by the Health Plan in making coverage decisions and administering benefits. 
Policy # Title Description
CC.PP.501  30-Day Readmission (PDF) The purpose of this policy is to promote more clinically effective, cost efficient and improved health care through appropriate and safe hospital discharge of patients.