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 Carolina Complete Health Clinical Policy Manual apply to Carolina Complete Health members. Policies in the Carolina Complete Health Clinical Policy Manual may have either a Carolina Complete Health or a “Centene” heading.  Carolina Complete Health utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Carolina Complete Health 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 Carolina Complete Health. In addition, Carolina Complete Health 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 Carolina Complete Health.   

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

Clinical Policies are effective July 1, 2021.

Navigate directory to a letter:

 A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | #

B

• Balloon Ostial Dilation (BOD), 1A-42 (PDF)
• Bariatric Surgery, CP.MP.37 (PDF)
• Blepharoplasty/Blepharoptosis, 1A-9 (PDF)
• Bone Mass Measurement, 1K-2 (PDF)
• Breast Imaging Procedures, 1K-1 (PDF)
  • MRI breast procedures do require prior authorization and should be obtained through NIA. Review “Utilization Review Matrix” on the NIA website for additional information.
• Breast Surgeries, 1A-12 (PDF)
• Bronchial Thermoplasty, CP.MP.110 (PDF)
• Burn Treatment, 1G-1 (PDF)

C

• CAR-T Cell Therapy, NC.CP.MP.500 (PDF)
• Cardio Biomarker Testing, CP.MP.156 (PDF) - latest revision effective date 11/21/23
• Caudal or Interlaminar Epidural Steroid Injections for Pain Management, CP.MP.164 (PDF)
• Childbirth Education, 1M-2 (PDF)
  
• Child Medical Evaluation and Medical Team Conference for Child Maltreatment, 1A-5 (PDF)
• Chiropractic Services, 1F (PDF)
• Cochlear and Auditory Brainstem Implants, 1A-4 (PDF)
• Cochlear and Auditory Brainstem Implant External Parts, Replacement, and Repair, 13A (PDF)
• Core Services Provided in FQHC and Rural Health Clinics, 1D-4 (PDF)
  
• Cosmetic and Reconstructive Procedures, NC.CP.MP.31 (PDF)
• Craniofacial Surgery, 1-O-2 (PDF)

D

• Deep Brain Stimulation, 1A-26 (PDF)
• Diabetes Outpatient Self-Management Education, 1A-24 (PDF)
• Diagnostic Assessment, 8A-5 (PDF)
• Dialysis Services (formerly ESRD), 1A-34 (PDF)
• Diaphragmatic/Phrenic Nerve Stimulation, CP.MP.203 (PDF) - latest revision effective date 10/17/23
• Dietary Evaluation and Counseling and Medical Lactation Services, 1-I (PDF)
• Digital EEG Spike, CP.MP.105 (PDF) - latest revision effective date 03/26/24
• Disc Compression Procedures, CP.MP.114 (PDF)
• Discography, CP.MP.115 (PDF)
• Drug Testing for Opioid Treatment and Controlled Substance Monitoring, 1S-8 (PDF)
  

E

• EEG in the Evaluation of Headache, CP.MP.155 (PDF) -  latest revision effective date 11/21/23
• Electrocardiography, Echocardiography, and Intravascular Ultrasound, 1R-4 (PDF)
  • For additional guidance related to 1R-4 Electrocardiography, Echocardiography, and Intravascular Ultrasound specific to Holter Monitors, please refer to policy titled Holter Monitor, CP.MP.113 (PDF).
  • The following procedures do require prior authorization and should be obtained through NIA: Transthoracic Echocardiography (TTE); Transesophageal Echocardiography (TEE); Stress Echocardiography.
    
• Electrodiagnostic Studies, 1A-27 (PDF)
• Electric Tumor Treating Fields (Optune), NC.CP.MP.145 (PDF)
• Endometrial Ablation, CP.MP.106 (PDF)
  
• Endovascular Repair of Aortic Aneurysm, 1A-21 (PDF)
• Enhanced Mental Health and Substance Abuse Services, 8A (PDF)
  • For guidance in reference to Enhanced Mental Health and Substance Abuse Services, please refer to the Behavioral Health UM Prior Authorization Guidelines.
• Evoked Potential Testing, NC.CP.MP.134 (PDF)
• Experimental Technologies, CP.MP.36 (PDF)
• External Ocular Photography, CP.VP.43 (PDF)
• Extended Opthalmoscopy, CP.VP.26 (PDF)
• Extracorporeal Shock Wave Lithotripsy, 1A-11 (PDF)

F

• Facet Joint Intervention, CP.MP.171 (PDF)
  
• Facility-Based Crisis Services for Children and Adolescents, 8A-2 (PDF)
  • For guidance in reference to Facility-Based Crisis Services for Children and Adolescents, please refer to the Behavioral Health UM Prior Authorization Guidelines.
• Facility-Based Sleep Studies for Obstructive Sleep Apnea, NC.CP.MP.248 (PDF) - Policy effective date 03/26/24
• Familiy Planning Services, 1E-7 (PDF)
  
• Fecal Microbiota Transplantation, 1A-40 (PDF)
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Ferriscan R2-MRI, CP.MP.53 (PDF) - latest revision effective date 12/19/23
  
• Fetal Surgery in Utero for Prenatally Diagnosed Malfunctions, NC.CP.MP.129 (PDF) - latest revision effective date 03/26/24
• Fetal Surveillance, 1E-4 (PDF)
  
• FIT Fecal Incontinence Treatments, NC.CP.MP.137 (PDF)
• Fluorescein Angiography, OC.UM.CP.0028 (PDF)
• Fundus Photography, OC.UM.CP.0029 (PDF)

G

• Gastric Electrical Stimulation, CP.MP.40 (PDF)
• General Ophthalmological Services, 1T-1 (PDF)
• Genetic Testing, 1S-4 (PDF)
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Oncology: Algorithmic Testing, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Oncology: Cancer Screening, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Oncology: Circulating Tumor DNA and Tumor Cells (Liquid Biopsy), V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Oncology: Cytogenetic Testing, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Aortopathies and Connective Tissue Disorders, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Cardiac Disorders, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Dermatologic Conditions, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Epilepsy,  Neurodegenerative, and Neuromuscular Conditions, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Exome and Genome Sequencing for Diagnosis of Genetic Disorders, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Eye Disorders, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Gastroenterologic Disorders (Non-Cancerous), V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Hearing Loss, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Hematologic Conditions (Non-Cancerous), V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Hereditary Cancer Susceptibility, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Immune, Autoimmune, and Rheumatoid Disorders, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Kidney Disorders, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Lung Disorders, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Metabolic, Endocrine, and Mitochondrial Disorders, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Non-Invasive Prenatal Screening (NIPS), V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Pharmacogenetics, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Prenatal and Preconception Carrier Screening, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Preimplantation Genetic Testing, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genetic Testing – Concert Genetics Testing: Skeletal Dysplasia & Rare Bone Disorders, V2.2023
  • Carolina Complete Health requires prior authorization for all genetic testing. 
• Genotyping and Phenotyping for HIV Resistance Testing, 1S-1 (PDF)
• Geropsychiatric Units in Nursing Facilities, 2B-2 (PDF)
• Gonioscopy, OC.UM.CP.0031 (PDF)
  

H

• Health and Behavior Intervention, 1M-3 (PDF)
  
• Hearing Aid, 7  (PDF)
• Heart/Lung Transplantation, NC.CP.MP.132 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Heart Transplantation, 11B-2 (PDF)
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Helicobacter Pylori Serology Testing, NC.CP.MP.153 (PDF) - latest revision effective date 11/21/23
• Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia, 11A-1 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Hematopoietic Stem-Cell Transplant for Acute Myeloid Leukemia, 11A-2 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Hematopoietic Stem-Cell Transplantation for Central Nervous System Embryonal Tumors & Ependymoma, 11A-10 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Hematopoietic Stem-Cell Transplantation for Chronic lymphocytic leukemia and Small lymphocytic lymphoma, 11A-16 (PDF)
  
• Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia, 11A-3 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors, 11A-6 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma, 11A-7 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Hematopoietic Stem-Cell Transplantation for Multiple Myeloma and Primary Amyloidosis, 11A-8 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Hematopoietic Stem-Cell Transplant for Non-Hodgkin’s Lymphoma, 11A-11 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood, 11A-15 (PDF)
  
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Hemophilia Specialty Pharmacy Program, 9B (PDF)
• HIV Case Management (HIV CM), 12B (PDF)
• HIV Tropism Assay, 1S-2 (PDF)
• Holter Monitor, CP.MP.113 (PDF) - latest revision effective 11/21/23
• Home Health Services, 3A (PDF)
• Home Infusion Therapy (HIT), 3H-1 (PDF)
• Home Phototherapy for Neonatal Hyperbilirubinemia, CP.MP.150 (PDF)
• Home Visit for Newborn Care and Assessment, 1M-4 (PDF)
• Home Visit for Postnatal Assessment and Follow-Up Care, 1M-5 (PDF)
• Homocysteine Testing, CP.MP.121 (PDF)
  
• Hospice Services, 3D (PDF)
• Hyperbaric Oxgentation Therapy, 1A-8 (PDF)
• Hyperhidrosis Treatments, NC.CP.MP.62 (PDF) - latest revision effective date 03/26/24
• Hysterectomy, 1E-1 (PDF)
  

I

• Implantable Bone Conduction Hearing Aids (BAHA), 1A-36 (PDF)
• Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea, CP.MP.180 (PDF) - policy effective 01/23/24
• Implantable Intrathecal or Epidural Pain Pump, NC.CP.MP.173 (PDF) - latest revision effective date 04/10/24
• Implatable Loop Recorder, CP.MP.243 (PDF) -latest revision effective date 03/26/24
• Implantable Wireless Pulmonary Artery Pressure Monitoring, CP.MP.160 (PDF)
• Independent Practitioners (IP), 10B (PDF)
• Independent Practitioners Respiratory Therapy Services, 10D (PDF)
• Inhaled NO2, CP.MP.87 (PDF)
• Inpatient Behavioral Health Services, 8B (PDF)
  • Clinical Coverage Policy 8B notes that there is no authorization required for the first 72 hours of a member’s Inpatient admission. Authorization is required if a member’s stay is beyond 72 hours.  In order for CCH to assist with discharge planning as needed, CCH requests for providers to submit a notice of admission within 48 hours of a member’s admission via the usual Prior Authorization (PA) form submission process. The PA form can be found here in order to submit the notice of admission.
• Intestinal and Multivisceral Transplant, CP.MP.58 (PDF)
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Intradiscal Steroid Injections for Pain Management, CP.MP.167 (PDF) - latest revision effective date 10/17/23
• IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures, NC.CP.MP.61 (PDF)
  

J

K

• Keloid Excision and Scar Revision, 1-O-3 (PDF)
• Kidney (Renal) Transplantation, 11B-4 (PDF)
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
  • For guidance and reference to kidney transplantation in pediatrics, please refer to policy titled Pediatric Kidney Transplant, CP.MP.246 (PDF)

L

• Laboratory Services, 1S-3 (PDF)
  
• Laser Therapy for Skin Conditions, CP.MP.123 (PDF)
• Liver Transplantation, 11B-5 (PDF)
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
  • For guidance in reference to liver transplantation in pediatrics, please refer to policy titled Pediatric Liver Transplant, CP.MP.120 (PDF)
• Long Term Care Hospital Services, 2A-2 (PDF)
• Low-frequency Ultrasound and Non-contact Normothermic Wound Therapy, CP.MP.139 (PDF)
• Lung or Lobar Lung Transplantation, 11B-1 (PDF)
  
• Lysis of Epidural Adhesions, CP.MP.116 (PDF)

M

• Maternal Care Skilled Nurse Home Visit, 1M-6 (PDF)
• Mechanical Stretching Devices for Joint Stiffness and Contracture, NCP.MP.144 (PDF) - Policy effective 1/23/24
  
• Medically Necessary Circumcision, 1A-22 (PDF)
• Medically Necessary Criteria, NC.CP.MP.05 (PDF)
• Medically Necessary Routine Foot Care, 1C-2 (PDF)
  
• Moderate (Conscious) Sedation AKA Procedural Sedation and Analgesic (PSA), 1L-2 (PDF)
  

N

• Neonatal Abstinence Syndrome Guidelines, CP.MP.86 (PDF) - latest revision effective date 03/26/24
• Neonatal and Pediatric Critical and Intensive Care Services, 1A-7 (PDF)
• Neonatal Sepsis Management, CP.MP.85 (PDF) - latest revision effective date 03/26/24
• Nerve Blocks for Pain Management, CP.MP.170 (PDF) - latest revision effective date 10/17/23
  
• NICU Apnea Bradycardia Guidelines, CP.MP.82 (PDF) - latest revision effective date 03/26/24
• NICU Discharge Guidelines, CP.MP.81 (PDF) - latest revision effective date 03/26/24
• Noninvasive Pulse Oximetry, 1A-3 (PDF)
• Nursing Equipment and Supplies, 5A-3 (PDF)
• Nursing Facilities, 2B-1 (PDF)

O

• Obstetrical Services, 1E-5 (PDF)
• Ocular Photodynamic Therapy, 1A-13 (PDF)
• Off Label Antipsychotic Safety Montoring in Beneficiaries 18 and older, 9E (PDF)
• Off Label Antipsychotic Safety Monitoring in Beneficiaries through age 17, 9D (PDF)
• Opioid Treatment Program Service, 8A-9 (PDF)
• Orthognthic Surgery, CP.MP.202 (PDF) - latest revision effective date 12/19/23
• Orthotics and Prosthetics, 5B (PDF)
• Osteogenic Stimulation, NC.CP.MP.194 (PDF)
• Out-of-State Services, 2A-3 (PDF)
• Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers, 8C (PDF)
  • For guidance in reference to Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers, please refer to the Behavioral Health UM Prior Authorization Guidelines.
• Outpatient Pharmacy Program, 9 (PDF)
  
• Outpatient Specialized Therapies, 10A (PDF)
• Over-the-Counter Products, 9A (PDF)

P

• Pancreas Transplantation, NC.CP.MP.102 (PDF)
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Panniculectomy, NC.CP.MP.109 (PDF) - policy effective 01/23/24
• Parenteral Nutrition and Intradialtic Parenteral Nutririon Carrier Screening, CP.MP.163 (PDF)
• Pediatric Kidney Transplant, CP.MP.246 (PDF) - latest revision effective date 10/17/23
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Pediatric Liver Transplant, CP.MP.120 (PDF)
  • Carolina Complete Health requires prior authorization for all transplant procedures.  
• Peer Support Services (PSS), 8G (PDF)
  • For guidance in reference to Peer Support Services, please refer to the Behavioral Health UM Prior Authorization Guidelines.
• Transcatheter Closure of Patent Foramen Ovale, CP.MP.151 (PDF)
• Phase II Outpatient Cardiac Rehabilitation Programs, 1R-1 (PDF)
• Phototherapy for Neonatal Hyperbilirubinemia, CP.MP.150 (PDF) - latest revision effective date 12/19/23
• Physical Rehabilitation Equipment and Supplies, 5A-1 (PDF)
  
  • For guidance in reference non-invasive osteogenic stimulation, please refer to policy titled Osteogenic Stimulation, NC.CP.MP.194 (PDF)
• Physician's Drug Program (PDP), 1B (PDF)
• Physician Fluoride Varnish Services, 1A-23 (PDF)
• Placental and Umbilical Cord Blood as Source of Stem Cells, 11A-14 (PDF)
• Podiatry Services, 1C-1 (PDF)
  
• Polymerase Chain Reaction Respiratory Viral Panel Testing, CP.MP.181 (PDF)  - latest revision effective date 01/23/24
• Posterior Tibial Nerve Stimulation for Voiding Dysfunction, CP.MP.133 (PDF) - latest revision effective date 10/17/23
• Pregnancy Management Program, 1E-6 (PDF)
• Preventative Medicine Annual Health Assessment, 1A-2 (PDF)
• Private Duty Nursing for Beneficiaries Age 21 and Older, 3G-1 (PDF)
• Private Duty Nursing for Beneficiaries Under 21 Years of Age, 3G-2 (PDF)
• Proton and Neutron Beam Therapies, CP.MP.70 (PDF) - latest revision effective date 01/23/24
• Psychological Services in Health Departments and School-based Health Centers Sponsored by Health Departments to the Under-21 Population, 8I (PDF)

Q

R

• Radiation Oncology, 1K-6 (PDF)
• Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD), 8F (PDF)
  • For guidance in reference to RB-BHT for Autsim Spectrum Disease, please refer to checklist titled Applied Behavioral Analysis Outpatient Treatment Request Checklist and the Behavioral Health UM Prior Authorization Guidelines.
• Respiratory Equipment and Supplies, 5A-2 (PDF)
  • Prior approval is required prior to the initiation of oxygen therapy and for continuation of active oxygen therapy on at least an annual basis.
• Rhinoplasty and/or Septorhinoplasty, 1-O-5 (PDF)
• Routine Cost in Clinical Trial Services for Life Threatening Conditions, 1A-39 (PDF)
• Routine Eye Examination and Visual Aids - Under 21, 6A (PDF)
• Routine Eye Examination and Visual Aids - 21 and up, 6B (PDF)

S

• Sacroiliac Joint Fusion, CP.MP.126 (PDF)
  
• Sacroiliac Joint Interventions for Pain Management, CP.MP.166 (PDF) - latest revision effective date 10/17/23
• Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), OC.UM.CP.0014 (PDF)
  
• Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders, CP.MP.146 (PDF) - latest revision effective date 11/21/23
• Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy, CP.MP.174 (PDF) - latest revision effective date 01/23/24
• Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections, CP.MP.165 (PDF) - latest revision effective date 10/17/23
• Sexually Transmitted Disease Treatment Provided in Health Departments, 1D-2
• Skin Substitutes, 1G-2 (PDF)
• Sleep Studies and Polysomnography Services, 1A-20 (PDF)
  • For specifics related to Facility-Based Sleep Studies for Sleep Apnea, please refer to policy titled Facility-Based Sleep Studies for Obstructive Sleep Apnea, NC.CP.MP.248 (PDF)
• Soft Band and Implantable Bone Conduction Hearing Aids External Parts, Replacement, and Repair, 13B (PDF)
• Special Ophthalmological Services, 1T-2 (PDF)
  
• Special Services: After Hours, 1A-38 (PDF)
• Spinal Cord, Peripheral Nerve and Percutaneous Electrical Nerve Stimulation, NC.CP.MP.117 (PDF) - latest revision effective date 03/26/24
• Spinal Surgeries, 1A-30 (PDF)
• State Plan Personal Care Services (PCS), 3L (PDF)
• Stereotactic Pallidotomy, 1A-17 (PDF)
• Sterilization Procedures, 1E-3 (PDF)
  
• Surgery for Ambiguous Genitalia, 1A-14 (PDF)
  
• Surgery of the Lingual Frenulum, 1A-16 (PDF)

T

• Telehealth, Virtual Communications and Remote Patient Monitoring, 1-H (PDF)
• Testing for Select Genitourinary Conditions (previously Diagnosis of Vaginitis), CP.MP.97 (PDF) - latest revision effective 11/21/23
• Therapeutic and Non-therapeutic Abortions, 1E-2 (PDF)
  
• Therapeutic Utilization of Inhaled Nitric Oxide, CP.MP.87 (PDF)
  
• Thymus Tissue Implantation, 11B-9 (PDF)
  
• Thyroid Hormones and Insulin Testing in Pediatrics, CP.MP.154 (PDF) - policy effective 11/21/23
• Transcatheter Closure of Patent Foramen Ovale, CP.MP.151 (PDF) - latest revision effective date 01/23/24
• Trigger Point injections for Pain Management, CP.MP.169 (PDF) - latest revision effective date 10/17/23
• Tuberculosis Control and Treatment Provided in Health Departments, 1D-3 (PDF)
• Tympanometry and Acoustic Reflex Testing, 1A-32 (PDF)

U

• Urinary Incontinence Devices and Treatments, NC.CP.MP.142 (PDF) - latest revision effective date 01/23/24
• Urodynamic Testing, CP.MP.98 (PDF)

V

• Vagus Nerve Stimulation for the Treatment of Seizures, CP.MP.12 (PDF) - latest revision effective date 10/17/23
• Ventricular Assist Device, NC.CP.MP.46 (PDF)
• Visual Field Testing, OC.UM.CP.0063 (PDF)
• Vitamin D, CP.MP.152 (PDF) - latest revision effective date 11/21/23
  

W

• Wireless Motility Capsule, CP.MP.143 (PDF) - latest revision effective date 11/21/23

X

Y

Z

#

• 25-hydroxyvitamin D Testing in Children and Adolescents, CP.MP.157 (PDF) - latest revision effective 11/21/23