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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
CP.CPC.01 Clinical Policy Committee
CP.CPC.02 Clinical Policy Web Posting
CP.CPC.03 Preventive Health and Clinical Practice Guideline Policy
CP.MP.124 ADHD Assessment and Treatment (PDF)
CP.MP.100 Allergy Testing and Therapy (PDF)
CP.MP.108 Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF)
CP.MP.96 Ambulatory EEG (PDF)
CP.MP.158 Ambulatory Surgery Center Optimization (PDF)
CP.MP.104 Applied Behavioral Analysis for Autism (PDF)
CP.MP.26 Articular Cartilage Defect Repairs (PDF)
CP.MP.55 Assisted Reproductive Technology (PDF)
CP.MP.119 Balloon sinus ostial dilation (PDF)
CP.MP.37 Bariatric Surgery (PDF)
CP.MP.168 Biofeedback (PDF)
CP.MP.93 Bone-anchored hearing aid (PDF)
CP.MP.110 Bronchial Thermoplasty (PDF)
CP.MP.156 Cardiac biomarker testing (PDF)
CP.MP.83 Carrier Screening in Pregnancy (PDF)
CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)
CP.MP.84 Cell-free Fetal DNA Testing (PDF)
CP.MP.94 Clinical Trials (PDF)
CP.MP.14 Cochlear Implant Replacements (PDF)
CP.MP.31 Cosmetic and Reconstructive Surgery (PDF)
CP.MP.61 Dental Anesthesia (PDF)
CP.MP.90 Digital breast tomosynthesis (Policy retired)
CP.MP.105 Digital electroencephalography spike analysis (PDF)
CP.MP.114 Disc Decompression Procedures (PDF)
CP.MP.115 Discography (PDF)
CP.MP.125 DNA analysis of stool to screen for colorectal cancer (PDF)
CP.MP.101 Donor lymphocyte infusion (PDF)
CP.MP.107 Durable Medical Equipment (DME) (PDF)
CP.MP.145 Electric Tumor Treating Fields (PDF)
CP.MP.155 Electroencephalography in the evaluation of headache (PDF)
CP.MP.106 Endometrial ablation (PDF)
CP.MP.140 EpiFix Wound Treatment (PDF)
CP.MP.131 Essure Removal (PDF)
CP.MP.134 Evoked Potential Testing (PDF)
CP.MP.36 Experimental Technologies (PDF)
CP.MP.135 Fecal calprotectin assay (PDF)
CP.MP.137 Fecal incontinence treatments (PDF)
CP.MP.53 Ferriscan R2-MRI (PDF)
CP.MP.130 Fertility preservation (PDF)
CP.MP.129 Fetal surgery in utero for prenatally diagnosed malformations (PDF)
CP.MP.103 Fractional exhaled nitric oxide (PDF)
CP.MP.43 Functional MRI (PDF)
CP.MP.40 Gastric electrical stimulation (PDF)
CP.MP.95 Gender reassignment surgery (PDF)
CP.MP.89 Genetic Testing (PDF)
CP.MP.153 H. Pylori serology testing (PDF)
CP.MP.132 Heart-Lung Transplant (PDF)
CP.MP.113 Holter Monitors (PDF)
CP.MP.136 Home Birth (PDF)
CP.MP.150 Home phototherapy for neonatal hyperbilirubinemia (PDF)
CP.MP.121 Homocysteine testing (PDF)
CP.MP.54 Hospice Services (PDF)
CP.MP.27 Hyperbaric Oxygen Therapy (PDF)
CP.MP.34 Hyperemesis gravidarum treatment (PDF)
CP.MP.62 Hyperhidrosis treatments (PDF)
CP.MP.160 Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
CP.MP.87 Inhaled nitric oxide (PDF)
CP.MP.118 Injections for Pain Management (Policy retired)
CP.MP.69 Intensity-Modulated Radiotherapy (PDF)
CP.MP.58 Intestinal and multivisceral transplant (PDF)
CP.MP.167 Intradiscal Steroid Injections for Pain Management (PDF)
CP.MP.123 Laser therapy for skin conditions (PDF)
CP.MP.71 Long Term Care Placement Criteria (PDF)
CP.MP.139 Low-frequency ultrasound therapy for wound management (PDF)
CP.MP.57 Lung Transplantation (PDF)
CP.MP.116 Lysis of Epidural Lesions (PDF)
CP.MP.152 Measurement of serum 1,25-dihydroxyvitamin D (PDF)
CP.MP.144 Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.68 Medical Necessity Criteria (PDF)
CP.MP.161 Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
CP.MP.24 Multiple Sleep Latency Testing (PDF)
CP.MP.86 Neonatal abstinence syndrome guidelines (PDF)
CP.MP.85 Neonatal sepsis management (PDF)
CP.MP.170 Nerve Blocks for Pain Management (PDF)
CP.MP.82 NICU Apnea Bradycardia Guidelines (PDF)
CP.MP.81 NICU discharge guidelines (PDF)
CP.MP.141 Non-myeloablative allogeneic stem cell transplants (PDF)
CP.MP.91 Obstetrical Home Health Care Programs (PDF)
CP.MP.128 Optic nerve decompression surgery (PDF)
CP.MP.50 Outpatient testing for drugs of abuse (PDF)
CP.MP.102 Pancreas transplant (PDF)
CP.MP.109 Panniculectomy (PDF)
CP.MP.138 Pediatric heart transplant (PDF)
CP.MP.120 Pediatric Liver Transplant (PDF)
CP.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
CP.MP.133 Posterior tibial nerve stimulation for voiding dysfunction (PDF)
CP.MP.70 Proton and neutron beam therapy (PDF)
CP.MP.148 Radial Head Implant (PDF)
CP.MP.51 Reduction mammoplasty and gynecomastia surgery (PDF)
CP.MP.126 Sacroiliac joint fusion (PDF)
CP.MP.166 Sacroiliac Joint Interventions for Pain Management (PDF)
CP.MP.146 Sclerotherapy for Vericose Veins (PDF)
CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
CP.MP.88 Sickle cell disease observation (PDF)
CP.MP.117 Spinal Cord Stimulation (PDF)
CP.MP.22 Stereotactic Body Radiation Therapy (PDF)
CP.MP.162 Tandem Transplant (PDF)        
CP.MP.149 Testing for rupture of fetal membranes (PDF)
CP.MP.97 Testing for select genitourinary conditions (PDF)
CP.MP.49 Therapy Services (PT/OT/ST) (PDF)
CP.MP.154 Thyroid hormones and insulin testing in pediatrics (PDF)
CP.MP.127 Total artificial heart (PDF)
CP.MP.163 Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
CP.MP.151 Transcatheter closure of patent foramen ovale (PDF)
CP.MP.169 Trigger Point Injections for Pain Management (PDF)
KS.CP.MP.38 Ultrasound in Pregnancy (PDF)
CP.MP.142 Urinary Incontinence Devices and Treatments (PDF)
CP.MP.98 Urodynamic testing (PDF)
CP.MP.12 Vagus Nerve Stimulation (PDF)
CP.MP.46 Ventricular Assist Devices (PDF)
CP.MP.56 Ventriculectomy and cardiomyoplasty (PDF)
CP.MP.99 Wheelchair seating (PDF)
CP.MP.143 Wireless Motility Capsule (PDF)
CP.MP.111 Zika Virus Testing (PDF)

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

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

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.