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.

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

CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections (PDF)
CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
CP.MP.166 Sacroiliac Joint Interventions (PDF)
CP.MP.167 Intradiscal Steroid Injections (PDF)
CP.MP.169 Trigger Point Injections (PDF)
CP.MP.170 Nerve Blocks (PDF)
CP.MP.171 Facet Joint Interventions (PDF)

NE.PMN.12 Clozapine ODT (Fazado®) PDF)
NE.PHAR.15 Botulinum Toxins (PDF)
NE.PHAR.67 HER2 Breast Cancer Treatment (PDF)
NE.PMN.15 Asenapine (Saphris®) PDF)
NE.PMN.27 Linezolid (Zyvox) PFD)
NE.PMN.30 paliperidone ER (Invega®) (PDF)
NE.PMN.32 Iloperidone (Fanapt®) PDF)
NE.PMN.42 sodium oxybate (Xyrem®) PDF)
NE.PMN.50 lurasidone (Latuda®) (PDF)
NE.PMN.54 clobazam (Onfi®) (PDF)
NE.PMN.62 tedizolid (Sivextro®) (PDF)
NE.PMN.68 Brexpiprazole (Rexulti) (PDF)

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the 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.

Clinical & Payment Policies

Clinical Policies

Clinical Policies

Pharmacy Policies

Payment Policies

Payment Policies