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Clinical & Payment Policies

Clinical policies are one set of guidelines used to assist in administering Iowa Total Care benefits, either by prior authorization or payment rules. These 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 listed here apply to Iowa Total Care members. These policies may have either an Iowa Total Care or a Centene heading. Iowa Total Care utilizes InterQual® criteria for those medical technologies, procedures, or services for which an Iowa 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 and durable medical equipment by logging into the secure provider portal or by calling Iowa Total Care. In addition, Iowa 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 Iowa Total Care.     

If you have any questions regarding these policies, please contact Provider Services.

Policy Title (Listed Alphabetically) Policy Number Effective Date
25-hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157
Acupuncture (PDF) CP.MP.92 9/30/2018
ADHD Assessment and Treatment (PDF) CP.MP.124 5/29/2022
Allergy Testing and Therapy (PDF) CP.MP.100 5/29/2022
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF) CP.MP.108 1/31/2019
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 1/31/2019
Antithrombin III (PDF) CP.MP.179  
Applied Behavioral Analysis for Autism (PDF) CP.MP.104 3/21/2019
Articular Cartilage Defect Repairs (PDF) CP.MP.26 4/30/2022
Assisted Reproductive Technology (PDF) CP.MP.55 2/1/2022
Balloon Sinus Ostial Dilation (PDF) CP.MP.119 9/30/2018
Bariatric Surgery (PDF) CP.MP.37 6/30/2018
Biofeedback (PDF) CP.MP.168 2/1/2022
Bone-Anchored Hearing Aid (PDF) CP.MP.93 10/31/2018
Bronchial Thermoplasty (PDF) CP.MP.110 3/31/2019
Burn Surgery (PDF) CP.MP.186 2/1/2022
Cardiac Biomarker Testing (PDF) CP.MP.156 1/22/2022
Carrier Screening in Pregnancy (PDF) CP.MP.83 5/31/2019
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) CP.MP.164 8/31/2018
Clinical Practice & Preventive Health Guidelines CPG GRID 3/30/2022
Clinical Trials (PDF) CP.MP.94 10/31/2018
Cochlear Implant Replacements (PDF) CP.MP.14 10/31/2018
Cosmetic and Reconstructive Surgery (PDF) CP.MP.31 3/31/2019
Dental Anesthesia (PDF) CP.MP.61 4/30/2019
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 2/1/2022
Digital Electroencephalography Spike Aanalysis (PDF) CP.MP.105 1/31/2019
Disc Decompression Procedures (PDF) CP.MP.114 5/31/2019
Discography (PDF) CP.MP.115 6/30/2018
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) CP.MP.125 7/31/2018
Donor Lymphocyte Infusion (PDF) CP.MP.101 10/31/2018
Drugs of Abuse: Presumptive Testing (PDF) CP.MP.208 5/29/2022
Durable Medical Equipment & Orthotics and Prosthetics Guidelines (PDF) CP.MP.107 2/1/2022
Electric Tumor Treating Fields (PDF) CP.MP.145 2/1/2022
Electroencephalography in the Evaluation of Headache (PDF) CP.MP.155 2/21/2022
Endometrial Ablation (PDF) CP.MP.106 5/29/2022
EpiFix Wound Treatment (PDF) CP.MP.140 3/31/2019
Essure Removal (PDF) CP.MP.131 10/31/2018
Evoked Potential Testing (PDF) CP.MP.134 6/6/2021
Experimental Technologies (PDF) CP.MP.36 4/30/2022
Facet Joint Interventions for Pain Management (PDF) CP.MP.171 9/14/2018
Fecal Incontinence Treatments (PDF) CP.MP.137 11/30/2018
Ferriscan R2-MRI (PDF) CP.MP.53 12/11/2018
Fertility Preservation (PDF) CP.MP.130 9/30/2018
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 10/31/2018
Fixed Wing Air Transportation (PDF) CP.MP.175 4/30/2019
Fractional Exhaled Nitric Oxide (PDF) CP.MP.103 12/30/2018
Functional MRI (PDF) CP.MP.43 4/30/2022
Gastric Electrical Stimulation (PDF) CP.MP.40 4/30/2022
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) CP.MP.209 5/29/2022
Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF) CP.MP.215 5/6/2022
Genetic Testing: Cardiac Disorders (PDF) CP.MP.216 5/6/2022
Genetic Testing: Dermatologic Conditions (PDF) CP.MP.217 5/6/2022
Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders (PDF) CP.MP.218 5/6/2022
Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF) CP.MP.219 5/6/2022
Genetic Testing: Eye Disorders (PDF) CP.MP.220 5/6/2022
Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) (PDF) CP.MP.221 5/6/2022
Genetic Testing: General Approach to Genetic Testing (PDF) CP.MP.222 5/6/2022
Genetic Testing: Hearing Loss (PDF) CP.MP.223 5/6/2022
Genetic Testing: Hematologic Condition (Non-Cancerous) (PDF) CP.MP.224 5/6/2022
Genetic Testing: Hereditary Cancer Susceptibility (PDF) CP.MP.225 5/6/2022
Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF) CP.MP.226 5/6/2022
Genetic Testing: Kidney Disorders (PDF) CP.MP.227 5/6/2022
Genetic Testing: Lung Disorders (PDF) CP.MP.228 5/6/2022
Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF) CP.MP.229 5/6/2022
Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF) CP.MP.230 5/6/2022
Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF) CP.MP.231 5/6/2022
Genetic Testing: Pharmacogenetics (PDF) CP.MP.232 5/6/2022
Genetic Testing: Preimplantation (PDF) CP.MP.233 5/6/2022
Genetic Testing: Prenatal and Preconception Carrier Screening (PDF) CP.MP.234 5/6/2022
Genetic Testing: Prenatal Diagnosis (Via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF) CP.MP.235 5/6/2022
Genetic Testing: Skeletal Dyspasia and Rare Bone Disorders (PDF) CP.MP.236 5/6/2022
H. Pylori Serology Testing (PDF) CP.MP.153 11/30/2018
Heart-Lung Transplant (PDF) CP.MP.132 4/30/2022
Holter Monitors (PDF) CP.MP.113 2/1/2022
Home Births (PDF) CP.MP.136 3/30/2022
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 10/31/2018
Homocysteine Testing (PDF) CP.MP.121 5/29/2022
Hospice (PDF) CP.MP.54 2/1/2022
Hyperbaric Oxygen Therapy (PDF) CP.MP.27 1/31/2019
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 4/30/2022
Hyperhidrosis Treatments (PDF) CP.MP.62 3/30/2022
Implantable Intrathecal or Epidural Pain Pump (PDF) CP.MP.173 3/30/2022
Implantable Hypoglossal Nerve Stimulation (PDF) CP.MP.180  
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 4/30/2022
Infusion Therapy Site of Care Optimization (PDF)  CP.MP.159 10/31/2018
Inhaled Nitric Oxide (PDF) CP.MP.87 5/31/2019
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 2/1/2022
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 4/30/2022
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 8/31/2018
Laser Therapy for Skin Conditions (PDF) CP.MP.123 5/29/2022
Long Term Care Placement Criteria (PDF) CP.MP.71 4/30/2019
Low-Frequency Ultrasound Therapy for Wound Management (PDF) CP.MP.139 5/29/2022
Lung Transplantation (PDF) CP.MP.57 4/30/2022
Lysis of Epidural Lesions (PDF) CP.MP.116 5/31/2019
Measurement of Serum 1,25-Dihydroxyvitamin D (PDF) CP.MP.152 11/30/2018
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) CP.MP.144 2/1/2022
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) CP.MP.161 5/31/2019
Multiple Sleep Latency Testing (PDF) CP.MP.24 4/30/2019
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 4/30/2022
Neonatal Sepsis Management (PDF) CP.MP.85 7/31/2018
Nerve Blocks and Neurolysis for Pain Management (PDF) CP.MP.170 2/1/2022
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 5/31/2019
NICU Discharge Guidelines (PDF) CP.MP.81 8/31/2018
Non-Invasive Home Ventilator (PDF) CP.MP.184  
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF) CP.MP.141 4/30/2022
Obstetrical Home Health Care Programs (PDF) CP.MP.91 2/1/2022
Omalizumab (Xolair) (PDF) CP.PHAR.01 2/01/2019
Oncology Algorithmic Testing (PDF) CP.MP.237 5/6/2022
Oncology Cancer Screening (PDF) CP.MP.238 5/6/2022
Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) CP.MP.239 5/6/2022
Oncology Cytogenetic Testing (PDF) CP.MP.240 5/6/2022
Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) CP.MP.241 5/6/2022
Optic Nerve Decompression Surgery (PDF) CP.MP.128 8/31/2018
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 5/31/2019
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 10/1/2020
Oxygen Use & Concentrators (PDF) CP.MP.190 3/30/2022
Pancreas Transplant (PDF) CP.MP.102 4/30/2022
Panniculectomy (PDF) CP.MP.109 3/31/2019
Pediatric Heart Transplant (PDF) CP.MP.138 4/30/2022
Pediatric Liver Transplant (PDF) CP.MP.120 4/30/2022
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 5/31/2019
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 5/29/2022
Post-Acute Care (PDF) CP.MP.213 3/30/2022
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 8/31/2018
Proton and Neutron Beam Therapy (PDF) CP.MP.70 2/4/2019
Radial Head Implant (PDF) CP.MP.148 5/31/2019
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 4/30/2022
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 7/31/2018
Sacroiliac Joint Fusion (PDF) CP.MP.126 6/30/2018
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 8/31/2018
Sclerotherapy for Varicose Veins (PDF) CP.MP.146 4/30/2019
Selective Dorsal Rhizotomy (PDF) CP.MP.174 3/31/2019
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) CP.MP.165 8/31/2018
Skilled Nursing Facility Leveling (PDF) CP.MP.206 3/30/2022
Sickle Cell Disease Observation (PDF) CP.MP.88 7/31/2018
Spinal Cord, Peripheral Nerve and Percutaneous Electrical Nerve Stimulation (PDF) CP.MP.117 4/30/2022
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 3/30/2022
Tandem Transplant (PDF) CP.MP.162 4/30/2022
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 5/29/2022
Therapy Services (PT/OT/ST) (PDF) CP.MP.49 4/30/2019
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)  CP.MP.154 11/30/2018
Total Artificial Heart (PDF) CP.MP.127 12/30/2018
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 4/30/2019
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 11/30/2018
Transcranial Magnetic Stimulation (PDF) CP.MP.172 3/8/2019
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF) CP.BH.200 4/30/2022
Trigger Point Injections for Pain Management (PDF) CP.MP.169 8/31/2018
Ultrasound in Pregnancy (PDF) CP.MP.38 5/29/2022
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 3/31/2019
Urodynamic Testing (PDF) CP.MP.98 5/29/2022
Vagus Nerve Stimulation (PDF) CP.MP.12 2/27/2019
Ventricular Assist Devices (PDF) CP.MP.46 4/30/2022
Ventriculectomy and Cardiomyoplasty (PDF) CP.MP.56 2/28/2019
Wheelchair Seating (PDF) CP.MP.99 5/29/2022
Wireless Motility Capsule (PDF) CP.MP.143 3/31/2019
Zika Virus Testing (PDF) CP.MP.111 5/31/2019

Payment policies are guidelines used to administer payment rules that are generally based on accepted principles of correct coding. These policies are used to determine whether health care services are correctly coded for reimbursement. Many payment policies are implemented through pre-payment claims editing. Each payment rule is sourced to a generally accepted coding principle including, but not limited to, claims processing guidelines published by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04 Claims Processing Manual, the CMS National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits, Medically Unlikely Edits (MUE), and policy manual, Current Procedural Terminology (CPT) guidance published by the American Medical Association (AMA), health plan clinical policies based on medical necessity, and at times state-specific claims reimbursement guidance.

All policies published on the Iowa Total Care website apply to Iowa Total Care members. Policies may have either an Iowa Total Care or a Centene heading. In addition, Iowa 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 a payment policy is payable by Iowa Total Care.     

The Payment Policies may be accessed through the links below.  

If you have any questions regarding these policies, please contact Provider Services.

Policy Title (Listed Alphabetically) Policy Number Effective
3-Day Payment Window (PDF) CC.PP.500 7/1/2019
30-Day Readmission (PDF) CC.PP.501 12/1/2021
Add on Code Billed Without Primary Code (PDF) CC.PP.030 7/1/2019
Assistant Surgeon (PDF) CC.PP.029 7/1/2019
Bilateral Procedures (PDF) CC.PP.037 7/1/2019
Cerumen Removal (PDF) CC.PP.008 7/1/2019
Clean Claims (PDF) CC.PP.021 7/1/2019
Coding Overview (PDF) CC.PP.011 7/1/2019
Cosmetic Procedures (PDF) CC.PP.024 7/1/2019
Distinct Procedural Modifiers (PDF) CC.PP.020 7/1/2019
Duplicate Primary Code Billing (PDF) CC.PP.044 7/1/2019
E&M Medical Decision-Making (PDF) CC.PP.051 7/1/2019
E&M Services Billed with Treatment Room Revenue Codes (PDF) CC.PP.071 3/30/2022
EM Bundling Edits (PDF) CC.PP.010 7/1/2019
Global Maternity Billing (PDF) CC.PP.016 7/1/2019
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 7/1/2019
Inpatient Consultation (PDF) CC.PP.038 7/1/2019
Inpatient Only Procedures (PDF) CC.PP.018 7/1/2019
IV Hydration (PDF) CC.PP.012 7/1/2019
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 3/3/2021
Maximum Units (PDF) CC.PP.007 7/1/2019
Moderate Conscious Sedation (PDF) CC.PP.015 7/1/2019
Modifier -25 clinical validation (PDF) CC.PP.013 7/1/2019
Modifier -59 clinical validation (PDF) CC.PP.014 7/1/2019
Modifier DOS Validation (PDF) CC.PP.034 7/1/2019
Modifier to Procedure Code Validation (PDF) CC.PP.028 7/1/2019
Multiple CPT Code Replacement (PDF) CC.PP.033 7/1/2019
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) CC.PP.065 10/1/2020
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF) CC.PP.068 5/2/2022
Multiple Procedure Reduction: Ophthalmology (PDF) CC.PP.069 5/2/2022
NCCI Unbundling (PDF) CC.PP.031 7/1/2019
Never Paid Events (PDF) CC.PP.017 7/1/2019
New Patient (PDF) CC.PP.036 7/1/2019
Non-Obstetrical and Obstetrical Transabdominal & Transvaginal Ultrasounds (PDF) CC.PP.061 5/2/2022
Outpatient Consultation (PDF) CC.PP.039 7/1/2019
Pelvic and Transabdominal US (PDF) CC.PP.061 7/1/2019
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 7/1/2019
Physician's Consultation Services (PDF) CC.PP.054 7/1/2019
Physician's Office Lab Testing (PDF) CC.PP.055 12/22/2021
Place of Service Mismatch (PDF) CC.PP.063 7/1/2019
Post-Operative Visits (PDF) CC.PP.042 7/1/2019
Pre-Operative Visits (PDF) CC.PP.041 7/1/2019
Problem Oriented Visits with Preventative Visits (PDF) CC.PP.057 7/1/2019
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 7/1/2019
Professional Component (PDF) CC.PP.027 7/1/2019
Pulse Oximetry (PDF) CC.PP.025 7/1/2019
Renal Hemodialysis (PDF) CC.PP.067 5/2/2022
Robotic Surgery (PDF) CC.PP.050 7/1/2019
Same Day Visits (PDF) CC.PP.040 7/1/2019
Sleep Studies Place of Services (PDF) CC.PP.035 7/1/2019
Status "B" Bundled Services (PDF) CC.PP.046 7/1/2019
Status "P" Bundled Services (PDF) CC.PP.049 7/1/2019
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 7/1/2019
Unbundled Professional Services (PDF) CC.PP.043 7/1/2019
Unbundled Surgical Procedures (PDF) CC.PP.045 7/1/2019
Unlisted Procedure Codes (PDF) CC.PP.009 7/1/2019
Urine Specimen Validity Testing (PDF) CC.PP.056 7/1/2019
Wheelchair Accessories (PDF) CC.PP.502 7/1/2019

New Technology

Health technology is always changing and we want to grow with it. If we think a new medical advancement can benefit our members, we evaluate it for coverage.

These advancements include:

  • New technology
  • New medical procedures
  • New drugs
  • New devices
  • New application of existing technology

Sometimes, our medical director and/or medical management staff will identify technological advances that could benefit our members. The Clinical Policy Committee (CPC) reviews requests for coverage and decides whether we should change any of our benefits to include the new technology. If the CPC doesn’t review a request for coverage of new technology, our Medical Director will review the request and make a one-time determination. The CPC may then review the new technology request at a future meeting.