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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, 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 Nebraska Total Care Clinical Policy Manual apply to Nebraska Total Care members. Policies in the Nebraska Total Care Clinical Policy Manual may have either a Nebraska Total Care or a “Centene” heading.  Nebraska Total Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Nebraska Total Care clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Nebraska Total Care. In addition, Nebraska Total Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Nebraska Total Care.   

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

Clinical Policies
Policy Title Policy Number Effective Date
2019-Novel Coronavirus (COVID-19) Testing (PDF) CP.MP.183 04/01/2020
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 12/2017
Acupuncture (PDF) CP.MP.92 11/2016
Air Ambulance (previously Fixed Wing Air Transportation) (PDF) CP.MP.175 04/2019
Allergy Testing and Therapy (PDF) CP.MP.100 02/2016
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (PDF) CP.MP.108 03/2016
Ambulatory Electroencephalography EEG (PDF) CP.MP.96 09/2015 - 09/14/2020
Ambulatory Electroencephalography EEG (PDF) CP.MP.96 09/15/2020
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 01/2018
Antithrombin III (Thrombate III, Atryn) (PDF)
CP.MP.179 10/31/2019
Applied Behavioral Analysis for Autism (PDF) CP.BH.104 08/2009
Articular Cartilage Defect Repairs (PDF) CP.MP.26 10/2008
Assisted Reproductive Technology (PDF) CP.MP.55 03/2014
Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis (PDF) CP.MP.119 07/2016
Bariatric Surgery (PDF) CP.MP.37 08/2014
Biofeedback (PDF) CP.MP.168 07/2017
Bone-Anchored Hearing Aid (PDF) CP.MP.93 12/2013
Bronchial Thermoplasty (PDF) CP.MP.110 05/2016
Burn Surgery (PDF) CP.MP.186 05/31/2020
Cardiac Biomarker Testing (PDF) CP.MP.156 12/2017
Carrier Screening in Pregnancy (PDF) CP.MP.83 07/2013
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 08/2018
Cell-free Fetal DNA Testing (PDF) CP.MP.84 08/2013
Clinical Trials (PDF) CP.MP.94 01/2014
Cochlear Implant Replacements (PDF) CP.MP.14 02/2009
Cosmetic and Reconstructive Surgery (PDF) CP.MP.31 03/2009
Dental Anesthesia (PDF) CP.MP.61 06/2013
Diagnostic Testing Guidelines for 2019-Novel Coronavirus (COVID-19) (PDF) CP.MP.183 04/01/2020
Digital EEG Spike Analysis (PDF) CP.MP.105 01/2016
Disc Decompression Procedures (PDF) CP.MP.114 07/2016
Discography (PDF) CP.MP.115 07/2016
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) CP.MP.125 09/2016 - 09/14/2020
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) CP.MP.125 09/15/2020
Donor Lymphocyte Infusion (PDF) CP.MP.101 11/2015
Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines (PDF) CP.MP.107 06/2009
Electric Tumor Treating Fields (Optune) (PDF) CP.MP.145 05/2017
EEG in the Evaluation of Headache (PDF) CP.MP.155 12/2017
Endometrial Ablation (PDF) CP.MP.106 01/2016
EpiFix Wound Treatment (PDF)
CP.MP.140 01/1/2019 - 07/23/2020
Essure Removal (PDF) CP.MP.131 11/2016
Evoked Potential Testing (PDF) CP.MP.134 11/2016
Experimental Technologies (PDF) CP.MP.36 06/2009
Facet Joint Interventions (PDF) CP.MP.171 09/2018
Fecal Incontinence Treatments (PDF) CP.MP.137 12/2016
Ferriscan R2-MRI (PDF) CP.MP.53 11/2012
Fertility Preservation (PDF) CP.MP.130 10/2016
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 10/2016
Fractional Exhaled Nitric Oxide FeNo (PDF) CP.MP.103 01/2016
Functional MRI (PDF) CP.MP.43 10/2013
Gastric Electrical Stimulation (PDF) CP.MP.40 11/2011
Genetic and Pharmacogenetic Testing (PDF) CP.MP.89 11/2013
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 12/2017
Heart-Lung Transplant (PDF) CP.MP.132 06/2017
Holter Monitors (PDF) CP.MP.113 08/2016
Home Birth (PDF) CP.MP.136 12/2016
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 12/2017
Homocysteine Testing (PDF) CP.MP.121 08/2016
Hospice Services (PDF) CP.MP.54  07/2014
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 03/2009
Hyperhidrosis Treatments (PDF) CP.MP.62 05/2013
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 11/2019
Implantable Intrathecal Pain Pump (PDF) CP.MP.173 02/2019
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 04/2018
Inhaled Nitric Oxide (PDF) CP.MP.87 08/2013
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 03/2014
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 02/2014
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 08/2018
Laser Therapy for Skin Conditions (PDF) CP.MP.123 08/2016
Long Term Care Placement (PDF) CP.MP.71 05/2014
Low-Frequency Ultrasound Therapy for Wound Management (PDF) CP.MP.139 02/2017
Lung Transplantation (PDF) CP.MP.57 02/2014
Lysis of Epidural Lesions (PDF) CP.MP.116 07/2016
Measurement of Serum 1, 25-Dihydroxyvitamin D (PDF) CP.MP.152 12/2017
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.144 04/2017 - 07/23/2020
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.144 07/24/2020
Multiple Sleep Latency Testing (PDF) CP.MP.24 10/2008
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 10/2013
Neonatal Sepsis Management (PDF) CP.MP.85 08/2013
Nerve Blocks for Pain Management (PDF) CP.MP.170 08/2018
Neurofeedback for Behavioral Health Conditions (PDF) CP.BH.300 05/2020
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 06/2013
NICU Discharge Guidelines (PDF) CP.MP.81 06/2013
Non-Invasive Home Ventilators (PDF) CP.MP.184 05/31/2020
Non-Myeloablative Allogeneic Stem Cell Transplants (PDF) CP.MP.141 04/2017
Obstetrical Home Health Care Programs (PDF) CP.MP.91 01/2014
Optic Nerve Decompression Surgery (PDF) CP.MP.128 09/2016
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 05/2019
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 09/2012
Pancreas Transplant (PDF) CP.MP.102 04/2016
Panniculectomy (PDF) CP.MP.109 04/2016
Pediatric Heart Transplant (PDF) CP.MP.138 01/2017
Pediatric Liver Transplant (PDF) CP.MP.120 04/2018
Pediatric Oral Function Therapy (PDF) CP.MP.188 05/31/2020
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147  07/2017
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 04/2011
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 10/2016
Preventive Health and Clinical Practice Guidelines (PDF) CP.CPC.03 07/2015
Proton and Neutron Beam Therapy (PDF) CP.MP.70 03/2014
Radial Head Implant (PDF) CP.MP.148 08/2017
Radiofrequency Ablation for Uterine Fibroids (PDF) CP.MP.187 04/2020
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 08/2012
Sacroiliac Joint Fusion (PDF) CP.MP.126 09/2016
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 08/2018
Sclerotherapy for Vericose Veins (PDF) CP.MP.146 06/2017
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) CP.MP.174 03/2019
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 08/2018
Short Inpatient Hospital Stay (PDF) CP.MP.182 10/01/2020
Sickle Cell Disease Observation (PDF) CP.MP.88 09/2013
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 04/2020
Spinal Cord Stimulation (PDF) CP.MP.117 07/2016
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 03/2014
Tandem Transplant (PDF) CP.MP.162  07/2018
Testing for Rupture of Fetal Membranes (PDF) CP.MP.149 08/2017
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 06/2016
Therapy Services (PT/OT/ST) (PDF) CP.MP.49 04/2011
Thymus Transplantation (PDF) CP.MP.189 06/30/2020
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) CP.MP.154 12/2017
Total Artificial Heart (PDF) CP.MP.127 12/2016
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 05/2016
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 12/2017
Transcranial Magnetic Stimulation (PDF) CP.BH.200  12/2018
Trigger Point Injections for Pain Management (PDF) CP.MP.169 08/2018
Ultrasound in Pregnancy (PDF) CP.MP.38 01/2011
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 04/2017
Urodynamic Testing (PDF) CP.MP.98 10/2015
Vagus Nerve Stimulation (PDF) CP.MP.12 10/2013
Ventricular Assist Devices (PDF) CP.MP.46 12/2009
Ventriculectomy and Cardiomyoplasty (PDF) CP.MP.56 05/2013
Video Electroencephalographic (VEEG) Monitoring (PDF)
CP.MP.177 10/31/2019
Wheelchair Seating (PDF) CP.MP.99 10/2015
Wireless Motility Capsule (PDF) CP.MP.143 04/2017
Pharmacy Policies A-E
Rx Policy Title Policy Number Effective Date
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 5/16/2019
ACEI ARB Duplicate Therapy (PDF) CP.PMN.61 5/17/2019
Acitretin (Soriatane) (PDF) CP.PMN.40 5/6/2020
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 8/13/2019
aflibercept (Eylea) (PDF) CP.PHAR.184 2/13/2019
agalsidase beta (Fabrazyme) (PDF) CP.PHAR.158 5/16/2019
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 5/14/2019
alglucosidase alfa (Lumizyme) (PDF) CP.PHAR.160 5/16/2019
Alpha-1 Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) CP.PHAR.94 6/26/2019
Amifampridine (Firdapse) (PDF) CP.PHAR.411 9/13/2019
Amisulpride (Barhemsys) (PDF) CP.PMN.236 5/6/2020
Apomorphine (Apokyn) (PDF) CP.PHAR.488 5/6/2020
asenapine (Saphris) (PDF) CP.PMN.15 2/15/2019
asfotase alfa (Strensiq) (PDF) CP.PHAR.328 11/20/2018
atezolizumab (Tecentriq) (PDF) CP.PHAR.235 5/20/2019
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 3/19/2019
avelumab (Bacencio) (PDF) CP.PHAR.333 6/26/2019
axicabtagene ciloleucel (Yescarta) (PDF) CP.PHAR.362 8/16/2019
azacitidine (Vidaza) (PDF) CP.PHAR.387 11/20/2018
becaplermin (Regranex) (PDF) CP.PMN.21 2/15/2019
Bedaquiline (Sirturo) (PDF) CP.PMN.212 5/6/2020
belatacept (Nulojix) (PDF) CP.PHAR.201 11/14/2018
belimumab (Benlysta) (PDF) CP.PHAR.88 8/10/2019
belinostat (Beleodaq) (PDF) CP.PHAR.311 11/17/2018
bendamustine (Bendeka, Treanda) (PDF) CP.PHAR.307 11/14/2018
benralizumab (Fasenra) (PDF) CP.PHAR.373 5/30/2019
Benznidazole (PDF) CP.PMN.90 2/18/2019
Benzyl alcohol (Ulesfia) (PDF) CP.PMN.202 8/17/2019
betaine (Cystadane) (PDF) CP.PHAR.143 11/20/2018
bevacizumab (Avastin, Mvasi) (PDF) CP.PHAR.93 6/26/2019
Bexarotene (Targretin) (PDF) CP.PHAR.75 5/16/2019
bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 2/15/2019
blinatumomab (Blincyto) (PDF) CP.PHAR.312 8/13/2019
Bortezomib (Velcade) (PDF) CP.PHAR.410 2/19/2019
Brand Name Override (PDF) CP.PMN.22 2/19/2019
Bremelanotide (Vyleesi) (PDF) CP.PHAR.434 5/6/2020
brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 8/13/2019
Brexanolone (Zulresso) (PDF) CP.PHAR.417 5/13/2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 5/6/2020
Brimonidine (Mirvaso) (PDF) CP.PMN.192 5/13/2019
buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 2/15/2019
Burosumab-twza (Crysvita) (PDF) CP.PHAR.11 8/10/2019
cabazitaxel (Jevtana) (PDF) CP.PHAR.316 9/13/2019
calcifediol (Rayaldee) (PDF) CP.PMN.76 8/16/2019
canakinumab (Ilaris) (PDF) CP.PHAR.246 5/16/2019
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 8/17/2019
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 5/13/2019
Carbamazepine ER (Equetro) (PDF) CP.PMN.137 5/17/2019
carfilzomib (Kyprolis) (PDF) CP.PHAR.309 11/14/2018
carglumic acid (Carbaglu) (PDF) CP.PHAR.206 2/14/2019
Cariprazine (Vraylar) (PDF) CP.PMN.91 6/26/2019
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 11/26/2018
Cenegermin-bkbj (Oxervate (PDF) CP.PMN.186 8/14/2019
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 8/15/2019
cetuximab (Erbitux) (PDF) CP.PHAR.317 11/17/2018
Chloramphenicol (PDF) CP.PHAR.388 2/15/2019
cinacalcet (Sensipar) (PDF) CP.PHAR.61 8/10/2019
clobazam (Onfi) (PDF) CP.PMN.54 6/26/2019
collagenase clostridium histolyticum (Xiaflex) (PDF) CP.PHAR.82 8/15/2019
Continuous Glucose Monitors (PDF) CP.PMN.214 5/6/2020
copanlisib (Aliqopa) (PDF) CP.PHAR.357 11/20/2018
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) CP.PHAR.385 9/13/2019
corticotropin (H.P. Acthar Gel) (PDF) CP.PHAR.168 4/2/2019
cosyntropin (Cortrosyn) (PDF) CP.PHAR.203 2/13/2019
cysteamine (Cystagon, Procysbi) (PDF) CP.PHAR.155 5/16/2019
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 5/17/2019
Cytomegalovirus Immune Globulin (CytoGam) (PDF) CP.PHAR.277 8/15/2019
daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 8/15/2019
daratumumab (Darzalex) (PDF) CP.PHAR.310 8/13/2019
Darbepoetin alfa (Aranesp) (PDF) CP.PHAR.236 5/14/2019
daunorubicin/cytarabine (Vyxeos) (PDF) CP.PHAR.352 11/20/2018
deferasirox (Jadenu) (PDF) CP.PHAR.145 8/10/2019
deferiprone (Ferriprox) (PDF) CP.PHAR.147 8/17/2019
deferoxamine (Desferal) (PDF) CP.PHAR.146 8/15/2019
degarelix acetate (Firmagon) (PDF) CP.PHAR.170 11/17/2018
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 5/16/2019
Desmopressin acetate (DDAVP Injection, Stimate, Noctiva) (PDF) CP.PHAR.214 2/13/2019
Dexrazoxane (Zinecard Totect) (PDF) CP.PHAR.418 5/13/2019
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 2/18/2019
droxidopa (Northera) (PDF) CP.PMN.17 11/13/2018
Duplicate SSRI/SNRI Therapy (PDF) CP.PMN.60 8/15/2019
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 7/19/2019
eculizumab (Soliris) (PDF) CP.PHAR.97 5/14/2019
Edaravone (Radicava) (PDF) CP.PHAR.343 5/16/2019
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 5/13/2019
elosulfase alfa (Vimizim) (PDF) CP.PHAR.162 5/16/2019
elotuzumab (Empliciti) (PDF) CP.PHAR.308 5/14/2019
eltrombopag (Promacta) (PDF) CP.PHAR.180 5/30/2019
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 5/30/2019
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 8/16/2019
epoprostenol (Flolan), Veletri) (PDF) CP.PHAR.192 4/2/2019
Eptinezumab (Vyepti) (PDF) CP.PHAR.489 5/6/2020
eribulin Mesylate (Halaven) (PDF) CP.PHAR.318 11/17/2018
erwina asparaginase (Erwinaze) (PDF) CP.PHAR.301 2/15/2019
Esketamine (Spravato) (PDF) CP.PMN.199 9/13/2019
etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 8/13/2019
eteplirsen (Exondys 51) (PDF) CP.PHAR.288 2/15/2019
Pharmacy Policies F-N
Rx Policy Title Policy Number Effective Date
Factor XIII A-Subunit, Recombinant (Tretten) (PDF) CP.PHAR.222 2/13/2019
ferric carboxymaltose (Injectafer) (PDF) CP.PHAR.234 2/14/2019
ferric gluconate (Ferrlecit) (PDF) CP.PHAR.166 2/14/2019
Ferric maltol (Accrufer) (PDF) CP.PMN.213 5/6/2020
ferumoxytol (Feraheme) (PDF) CP.PHAR.165 2/14/2019
Fluorouracil Cream (Tolak) (PDF) CP.PMN.165 11/21/2018
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 3/13/2019
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 8/12/2019
Gabapentin ER (Gralise, Horizant) (PDF) CP.PMN.240 5/6/2020
galsulfase (Naglazyme) (PDF) CP.PHAR.161 5/16/2019
gemtuzumab ozogamicin (Mylotarg) (PDF) CP.PHAR.358 11/14/2018
glycerol phenylbutyrate (Ravicti) (PDF) CP.PHAR.207 3/13/2019
Glycopyrronium (Qbrexza) (PDF) CP.PMN.177 11/21/2018
goserelin acetate (Zoladex) (PDF) CP.PHAR.171 11/17/2018
hemin (Panhematin) (PDF) CP.PHAR.181 2/13/2019
histrelin acetate (Vantas, Supprelin LA) (PDF) CP.PHAR.172 11/17/2018
House dust mite allergen extract (Odactra) (PDF) CP.PMN.111 8/16/2019
Hyaluronate Derivatives (PDF) CP.PHAR.05 9/27/2019
Hydroxyurea (Siklos) (PDF) CP.PMN.193 5/13/2019
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 5/17/2019
idursulfase (Elaprase) (PDF) CP.PHAR.156 5/17/2019
iloperidone (Fanapt) (PDF) CP.PMN.32 2/15/2019
imiglucerase (Cerezyme) (PDF) CP.PHAR.154 5/16/2019
Immune Globulin Injections (PDF) CP.PHAR.103 8/10/2019
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 5/16/2019
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 9/13/2019
Infusion Therapy Site of Care Optimization (PDF) CP.PHAR.493 5/6/2020
Inotersen (Tegsedi) (PDF) CP.PHAR.405 5/30/2019
inotuzumab ozogamicin (Besponsa) (PDF) CP.PHAR.359 11/20/2018
Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF) CP.PHAR.420 5/13/2019
interferon gamma- 1b (Actimmune) (PDF) CP.PHAR.52 2/13/2019
intra baclofen (Gablofen) (PDF) CP.PHAR.149 11/14/2018
ipilimumab (Yervoy) (PDF) CP.PHAR.319 5/14/2019
irinotecan Liposome (Onivyde) (PDF) CP.PHAR.304 11/14/2018
iron sucrose (Venofer) (PDF) CP.PHAR.167 2/14/2019
isotretinoin (PDF) CP.PMN.143 11/14/2018
Itraconazole (Sporanox ,Onmel, Tolsura) (PDF) CP.PMN.124 5/6/2020
lacosamide (Vimpat) (PDF) CP.PMN.155 8/17/2019
Lactitol (Pizensy) (PDF) CP.PMN.241 5/6/2020
Lanadelumab-fylo (Takhzyro) (PDF) CP.PHAR.396 4/30/2019
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 11/20/2018
laronidase (Aldurazyme) (PDF) CP.PHAR.152 5/16/2019
lesinurad (Zurampic), lesinurad-allopurinol (Duzallo) (PDF) CP.PMN.150 8/14/2019
letermovir (Prevymis) (PDF) CP.PHAR.367 2/15/2019
Leucovorin Injection (PDF) CP.PHAR.393 11/20/2018
leuprolide acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF) CP.PHAR.173 8/16/2019
levoleucovorin (Fusilev) (PDF) CP.PHAR.151 11/14/2018
l-glutamine (Endari) (PDF) CP.PMN.116 11/14/2018
lurasidone (Latuda) (PDF) CP.PMN.50 2/15/2019
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 5/6/2020
Lusutrombopag (Mulpleta) (PDF) CP.PHAR.407 3/19/2019
lutetium Lu 177 dotatate (Lutathera) (PDF) CP.PHAR.384 8/16/2019
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 5/17/2019
mecasermin (Increlex) (PDF) CP.PHAR.150 8/15/2019
mechlorethamine (Valchlor) (PDF) CP.PHAR.381 8/13/2019
megestrol Acetate Oral Suspension (Megace ES) (PDF) CP.PMN.179 11/21/2018
mepolizumab (Nucala) (PDF) CP.PHAR.200 9/13/2019
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 5/16/2019
Metreleptin (Myalept) (PDF) CP.PHAR.425 8/12/2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 8/16/2019
mifepristone (Korlym) (PDF) CP.PHAR.101 2/13/2019
Migalastat (Galafold) (PDF) CP.PHAR.394 2/1/2019
Milnacipran (Savella) (PDF) CP.PMN.125 5/17/2019
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 5/14/2019
Mixed pollens allergen extract (Oralair) (PDF) CP.PMN.85 8/16/2019
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 11/20/2018
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 11/26/2018
Moxidectin (PDF) CP.PMN.162 11/20/2018
nafarelin acetate (Synarel) (PDF) CP.PHAR.174 11/17/2018
naloxone (Evzio) (PDF) CP.PMN.139 8/16/2019
naltrexone (Vivitrol) (PDF) CP.PHAR.96 2/13/2019
Natalizumab (Tysabri) (PDF) CP.PHAR.259 5/14/2019
necitumumab (Portrazza) (PDF) CP.PHAR.320 11/17/2018
Neomycin-fluocinolone cream (Neo-Synalar) (PDF) CP.PMN.167 11/21/2018
nitisinone (Orfadin, Nityr) (PDF) CP.PHAR.132 11/20/2018
nivolumab (Opdivo) (PDF) CP.PHAR.121 2/14/2019
No Coverage Criteria/Off Label Use Policy (PDF) CP.PMN.53 5/17/2019
Non-Calcium Contining Phosphate Binders (PDF) CP.PMN.04 2/15/2019
Non-preferred blood glucose monitors and test strips (PDF) CP.PMN.215 5/6/2020
nusinersen (Spinraza) (PDF) CP.PHAR.327 8/13/2019
Pharmacy Policies O-Z
Rx Policy Title Policy Number Effective Date
obinutuzumab (Gazyva) (PDF) CP.PHAR.305 11/14/2018
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 5/16/2019
octreotide acetate (Sandostatin, Sandostatin LAR) (PDF) CP.PHAR.40 2/14/2019
ofatumumab (Arzerra) (PDF) CP.PHAR.306 11/17/2018
olaratumab (Lartruvo) (PDF) CP.PHAR.326 11/20/2018
omacetaxine (Synribo) (PDF) CP.PHAR.108 5/14/2019
omalizumab (Xolair) (PDF) CP.PHAR.01 2/14/2019
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 9/13/2019
Onasemnogene abeparvovec (Zolgensma) (PDF) CP.PHAR.421 8/12/2019
Osilodrostat (Isturisa) (PDF) CP.PHAR.487 5/6/2020
Ospemifene (Osphena) (PDF) CP.PMN.168 5/15/2019
oxymetazoline (Rhofade) (PDF) CP.PMN.86 5/15/2019
Ozanimod (Zeposia) (PDF) CP.PHAR.462 5/6/2020
Paclitaxel, Protein Bound (Abraxane) (PDF) CP.PHAR.176 07/18/2020
paliperidone ER (Invega) (PDF) CP.PMN.30 2/15/2019
panitumumab (Vectibix) (PDF) CP.PHAR.321 11/17/2018
Parathyroid hormone (Natpara) (PDF) CP.PHAR.282 8/15/2019
Paricalcitol (Zemplar) (PDF) CP.PHAR.270 8/10/2019
pasireotide (Signifor LAR) (PDF) CP.PHAR.332 11/14/2018
Patiromer (Veltassa) (PDF) CP.PMN.205 8/12/2019
Patisiran (Onpattro) (PDF) CP.PHAR.395 11/26/2018
pegademase Bovine (Adagen) (PDF) CP.PHAR.392 11/20/2018
pegaptanib (Macugen) (PDF) CP.PHAR.185 2/13/2019
pegaspargase (Oncaspar) (PDF) CP.PHAR.353 11/14/2018
pegfilgrastim (Neulasta) (PDF) CP.PHAR.296 8/13/2019
peginterferon alfa-2b (Sylatron) (PDF) CP.PHAR.89 8/17/2019
pegloticase (Krystexxa) (PDF) CP.PHAR.115 2/14/2019
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 2/1/2019
pegvisomant (Somavert) (PDF) CP.PHAR.389 11/20/2018
pembrolizumab (Keytruda) (PDF) CP.PHAR.322 8/16/2019
pemetrexed (Alimta) (PDF) CP.PHAR.368 4/2/2019
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 5/17/2019
plerixafor (Mozobil) (PDF) CP.PHAR.323 8/13/2019
Polatuzuman vedotin – piiq (Polivy) (PDF) CP.PHAR.433 8/16/2019
pralatrexate (Folotyn) (PDF) CP.PHAR.313 11/17/2018
Prasterone (Intrarosa) (PDF) CP.PMN.99 2/18/2019
pregabalin (Lyrica) (PDF) CP.PMN.33 9/13/2019
Progesterone (Crinone, Endometrin, Milprosa) (PDF) CP.PMN.243 5/6/2020
protein c concentrate, human (Ceprotin) (PDF) CP.PHAR.330 2/15/2019
Pyrimethamine (Daraprim) (PDF) CP.PMN.44 5/6/2020
QL of Diabetic Test Strips not receiving insulin (PDF) CP.PMN.151 2/14/2019
Quantity Limit Overrides (PDF) CP.PMN.59 2/1/2019
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 5/6/2020
ramucirumab (Cyramza) (PDF) CP.PHAR.119 9/13/2019
ranibizumab (Lucentis) (PDF) CP.PHAR.186 6/26/2019
ranolazine (Ranexa) (PDF) CP.PMN.34 2/15/2019
Ravulizumab-cwvz (Ultomiris) (PDF) CP.PHAR.415 5/13/2019
Request for Medically Necessary Drug not on the PDL (PDF) CP.PMN.16 11/14/2018
reslizumab (Cinqair) (PDF) CP.PHAR.223 2/14/2019
Rifamycin (Aemcolo) (PDF) CP.PMN.196 5/13/2019
rifapentine (Priftin) (PDF) CP.PMN.05 2/15/2019
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 5/16/2019
Rituximab (Rituxan), Rituximab and hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 6/26/2019
romidepsin (Istodax) (PDF) CP.PHAR.314 3/6/2019
romiplostim (Nplate) (PDF) CP.PHAR.179 3/6/2019
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 8/12/2019
rufinamide (Banzel) (PDF) CP.PMN.157 8/17/2019
sapropterin (Kuvan) (PDF) CP.PHAR.43 5/16/2019
Sarecycline (Seysara) (PDF) CP.PMN.189 5/30/2019
sargramostim (Leukine) (PDF) CP.PHAR.295 8/15/2019
sebelipase alfa (Kanuma) (PDF) CP.PHAR.159 5/17/2019
Segesterone-Ethinyl Estradiol (Annovera) (PDF) CP.PMN.190 2/19/2019
Selpercatinib (Retevmo) (PDF) CP.PHAR.478 5/6/2020
Short ragweed pollen allergen extract (Ragwitek) (PDF) CP.PMN.83 8/16/2019
siltuximab (Sylvant) (PDF) CP.PHAR.329 2/15/2019
simeprevir (Olysio) (PDF) CP.PHAR.280 8/15/2019
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 5/16/2019
sodium oxybate (Xyrem) (PDF) CP.PMN.42 5/17/2019
sodium phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 2/14/2019
Sodium zirconium cyclosilicate (Lokelma) (PDF) CP.PMN.163 8/17/2019
Stiripentol (Diacomit) (PDF) CP.PMN.184 11/26/2018
Tadalafil (Cialis) (PDF) CP.PMN.132 8/16/2019
Tadalafil BPH - ED (Cialis) (PDF) CP.PMN.132 5/6/2020
Tafamidis meglumine, Tafamidis (Vyndaquel, Vyndamax) (PDF) CP.PHAR.432 8/16/2019
Tafenoquine (Krintafel) (PDF) CP.PMN.178 5/30/2019
taliglucerase alfa (Elelyso) (PDF) CP.PHAR.157 5/17/2019
Tavaborole (Kerydin) (PDF) CP.PMN.105 2/15/2019
teduglutide (Gattex) (PDF) CP.PHAR.114 9/13/2019
Tegaserod (Zelnorm) (PDF) CP.PMN.206 8/12/2019
Telotristat ethyl (Xermelo) (PDF) CP.PHAR.337 5/16/2019
temasmorelin (Egrifta) (PDF) CP.PHAR.109 8/15/2019
temsirolimus (Torisel) (PDF) CP.PHAR.324 11/20/2018
Teplizumab CP.PHAR.492 5/6/2020
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 5/6/2020
testosterone pellet (Testopel) (PDF) CP.PHAR.354 9/13/2019
thyrotropin alfa (Thyrogen) (PDF) CP.PHAR.95 8/15/2019
Timothy grass pollen allergen extract (Grastek) (PDF) CP.PMN.84 8/16/2019
tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 8/16/2019
Tolvaptan (Jynarque, Samsca) (PDF) CP.PHAR.27 8/15/2019
trabectedin (Yondelis) (PDF) CP.PHAR.204 2/14/2019
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 9/13/2019
Triamcinolone ER Injection  (Zilretta) (PDF) CP.PHAR.371 2/15/2019
Triclabendazole (Egaten) (PDF) CP.PMN.207 8/12/2019
Trientine (Syprine) (PDF) CP.PHAR.438 5/6/2020
triptorelin pamoate (Trelstar, Triptodur) (PDF) CP.PHAR.175 8/16/2019
Ustekinumab (Stelara) (PDF) CP.PHAR.264 5/14/2019
Valproate (Depacon) (PDF) CP.PHAR.429 8/12/2019
Valrubicin (Valstar) (PDF) CP.PHAR.439 5/6/2020
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 5/16/2019
velaglucerase alfa (VPRIV) (PDF) CP.PHAR.163 5/16/2019
verteporfin (Visudyne) (PDF) CP.PHAR.187 2/13/2019
vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 5/17/2019
vigabatrin (Sabril) (PDF) CP.PHAR.169 8/10/2019
vilazodone (Viibryd) (PDF) CP.PMN.145 8/17/2019
vincristine sulfate liposome injection (Marqibo) (PDF) CP.PHAR.315 11/17/2018
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 2/15/2019
vortioxetine HBr (Trintellix) (PDF) CP.PMN.65 8/16/2019
ziv-aflibercept (Zaltrap) (PDF) CP.PHAR.325 11/20/2018
zoledronic acid (Reclast, Zometa) (PDF) CP.PHAR.59 2/14/2019

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

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

Payment Policies
Policy Title Policy Number Effective Date
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 12/2017
3-Day Payment Window (PDF) CC.PP.500 07/01/2014
30-Day Readmission (PDF) CC.PP.501 01/01/2015
Add on Code Billed Without Primary Code (PDF) CC.PP.030 01/01/2013
Allergy Testing and Therapy (PDF) CP.MP.100 02/2016
Ambulatory Electroencephalography EEG (PDF) CP.MP.96 09/2015 - 09/14/2020
Ambulatory Electroencephalography EEG (PDF) CP.MP.96 09/15/2020
Antithrombin III (Thrombate III, Atryn) (PDF)
CP.MP.179 10/31/2019
Assistant Surgeon (PDF) CC.PP.029 01/01/2014
Bilateral Procedures (PDF) CC.PP.037 01/01/2014
Bronchial Thermoplasty (PDF) CP.MP.110 05/2016
Burn Surgery (PDF) CP.MP.186 05/31/2020
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 12/2017
Cerumen Removal (PDF) CC.PP.008 01/01/2014
Clean Claims (PDF) CC.PP.021 01/01/2013
Clinic Facility Charge (PDF) CC.PP.059 01/29/2018
Coding Editing Overview (PDF) CC.PP.011 01/01/2013
Cosmetic and Reconstructive Surgery (PDF) CP.MP.31 05/31/2020
Cosmetic Procedures (PDF) CC.PP.024 01/01/2014
Diagnosis of Vaginitis (PDF) CP.MP.97 06/2016
Digital EEG Spike Analysis (PDF) CP.MP.105 01/2016
Distinct Procedural Modifiers (PDF) CC.PP.020 01/01/2013
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) CP.MP.125 09/2016 - 09/14/2020
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) CP.MP.125 09/15/2020
Duplicate Primary Code Billing (PDF) CC.PP.044 01/01/2014
E&M Medical Decision-Making (PDF) CC.PP.051 06/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 12/2017
EM Bundling Edits (PDF) CC.PP.010 01/01/2013
Endometrial Ablation (EA) (PDF) CP.MP.106 01/2016
EpiFix Wound Treatment (PDF)
CP.MP.140 01/01/2019 - 07/23/2020
Evoked Potential Testing (PDF) CP.MP.134 11/2016
Extended Ophthalmoscopy (PDF) OC.UM.CP.0026 01/01/2018
External Ocular Photography (PDF) OC.UM.CP.0043 10/01/2016
Fractional Exhaled Nitric Oxide FeNo (PDF) CP.MP.103 01/2016
Fluorescein Angiography (PDF) OC.UM.CP.0028 01/01/2018
Fundus Photography (PDF) OC.UM.CP.0029 01/01/2018
Global Maternity Billing (PDF) CC.PP.016 01/01/2013
Gonioscopy (PDF) OC.UM.CP.0031 10/01/2016
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 12/2017
Holter Monitors (PDF) CP.MP.113 08/2016
Homocysteine Testing (PDF)
CP.MP.121 08/2016
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 01/01/2013
Inpatient Consultation (PDF) CC.PP.038 01/01/2014
Incidental Diagnostic and Laboratory Tests Billed with Evaluation and Management Services (PDF) CC.PP.010 01/01/2013
Inpatient Only Procedures (PDF) CC.PP.018 01/01/2013
IV Hydration (PDF) CC.PP.012 01/01/2013
Laser Therapy for Skin Conditions (PDF) CP.MP.123 08/2016
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 11/01/2020
Leveling of ER Services (PDF) CC.PP.053 10/01/2017
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 02/2017
Maximum Units of Service (PDF) CC.PP.007 01/01/2013
Measurement of Serum 1,25-dihydroxyvitamin D (PDF) CP.MP.152 12/2017
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.144 04/2017 - 07/23/2020
Moderate Conscious Sedation (PDF) CC.PP.015 01/01/2013
Modifier -25 clinical validation (PDF) CC.PP.013 01/01/2013
Modifier -59 clinical validation (PDF) CC.PP.014 01/01/2013
Modifier DOS Validation (PDF) CC.PP.034 01/01/2013
Modifier to Procedure Code Validation (PDF) CC.PP.028 01/01/2013
Multiple CPT Code Replacements (PDF) CC.PP.033 01/01/2014
NCCI Unbundling (PDF) CC.PP.031 01/01/2013
Never Paid Events (PDF) CC.PP.017 01/01/2013
New Patient (PDF) CC.PP.036 01/01/2014
Non-Invasive Home Ventilators (PDF) CP.MP.184 05/31/2020
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) CC.PP.061 05/30/18
Not Medically Necessary IP Services (PDF) CC.PP.060 06/01/2018
Outpatient Consultation (PDF) CC.PP.039 01/01/2014
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 09/2012
Pediatric Oral Function Therapy (PDF) CP.MP.188 05/31/2020
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 01/01/2013
Physician's Consultation Services (PDF) CC.PP.054 11/01/2017
Place of Service Mismatch (PDF) CC.PP.063 09/01/2018
Post-Operative Visits (PDF) CC.PP.042 01/01/2014
Pre-Operative Visits (PDF) CC.PP.041 01/01/2014
Problem Oriented Visits with Preventive Visits (PDF) CC.PP.057 11/1/2017
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/1/2017
Professional Component Modifier -26 (PDF) CC.PP.027 01/01/2013
PROM Testing (PDF) CP.MP.149 08/2017
Pulse Oximetry (PDF) CC.PP.025 01/01/2014
Robotic Surgery (PDF) CC.PP.050 8/2017
Same Day Visits (PDF) CC.PP.040 11/01/2019
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF) OC.UM.CP.0014 01/01/2018
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) CP.MP.174 03/2019
Short Inpatient Hospital Stay (PDF) CP.MP.182 10/01/2020
Sleep Studies Place of Services (PDF) CC.PP.035 05/01/2017 
Status "B" Bundled Services (PDF) CC.PP.046 01/01/2014
Status "P" Bundled Services (PDF) CC.PP.049 03/15/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 01/01/2013
Testing for Rupture of Fetal Membranes (PDF) CP.MP.149 08/2017
Testing for Select Genitourinary Conditions (PDF) CP.MP.97  06/2016
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) CP.MP.154 12/2017
Transgender Related Services (PDF) CC.PP.047 01/01/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 01/2011
Unbundled Professional Services (PDF) CC.PP.043 01/01/2014
Unbundled Surgical Procedures (PDF) CC.PP.045 01/01/2014
Unlisted Procedure Codes (PDF) CC.PP.009 01/01/2013
Urine Specimen Validity Testing (PDF) CC.PP.056 11/01/2017 
Urodynamic Testing (PDF) CP.MP.98 10/2015
Visual Field Test (PDF) OC.UM.CP.0063 01/01/2018
Vitamin D Testing in Children (PDF) CP.MP.157 12/2017
Wheelchair Accessories (PDF) CC.PP.502 07/01/2016
Wheelchair Seating (PDF) CP.MP.99  10/2015
Wireless Motility Capsule (PDF) CP.MP.143  04/2017