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Policies & Criteria

Clinical Policies

Trillium Community Health Plan (Trillium) uses the following guidelines (listed in order of significance) to make OHP/Medicaid medical necessity decisions on a case-by-case basis, based on the information submitted with the request.

State/Federally Developed

  1. Oregon Administrative Rules, Oregon Health Authority Health Systems Division, Chapter 410
  2. Oregon Health Plan (OHP) Prioritized LIst and Guideline Notes
  3. Oregon Health Evidence Review Commission (HERC) Completed Guidances
  4. Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)

Non-State or Federally Developed

  1. InterQual Clinical Decision Support Criteria (Attachement 1 2017 Summary of Changes)
  2. American College of Radiology (ADR) Appropriateness Criteria: www.acr.org
  3. National Comprehensive Cancer Network (NCCN) Practice Guidelines in Oncology: www.nccn.org/professionals/physician_gls/f_guidelines

See OR.CP.MP.500 Requests for Authorization – Oregon Health Plan (OHP) for authorization hierarchy.

If you have any questions regarding these policies, please contact Provider Services at 877-600-5472.

Code Title Description Date Adopted
OR.CP.MP.500 (PDF) Requests for Authorization - Oregon Health Plan (OHP) Oregon Health Plan Prioritized List and subsequent policies/criteria/guidelines hierarchy to make medical necessity decisions. 9/12/2019

CP.MP.157 (PDF)

25-hydroxyvitamin D testing in children and adolescents

Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents

10/1/2019

CP.MP.92 (PDF)

Acupuncture

Medical necessity guidelines for acupuncture

10/1/2019

CP.MP.124 (PDF)

ADHD Assessment and Treatment

Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD)

10/1/2019

CP.MP.100 (PDF)

Allergy Testing and Therapy

Medical necessity guidelines for allergy testing and treatment

10/1/2019

CP.MP.108 (PDF)

Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia

Medical necessity guidelines for allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia

10/1/2019

CP.MP.96 (PDF)

Ambulatory EEG

Medical necessity guidelines for the use of ambulatory electroencephalogram (EEG) testing in the outpatient setting

10/1/2019

CP.MP.158 (PDF)

Ambulatory Surgery Center Optimization

Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services

10/1/2019

CP.MP.104 (PDF)

Applied Behavioral Analysis for Autism

Medical necessity guidelines for applied behavioral analysis for autism

10/1/2019

CP.MP.26 (PDF)

Articular Cartilage Defect Repairs

Medical necessity guidelines for articular cartilage defect repairs

10/1/2019

CP.MP.55 (PDF)

Assisted Reproductive Technology

Medical necessity guidelines for assisted reproductive technology

10/1/2019

CP.MP.119 (PDF)

Balloon sinus ostial dilation

Medical necessity guidelines for balloon sinus ostial dilation for chronic rhinosinusitus and recurrent acute rhinosinusitis

10/1/2019

CP.MP.37 (PDF)

Bariatric Surgery

Medical necessity guidelines for bariatric surgery for obesity in adolescents and adults

10/1/2019

CP.MP.168 (PDF)

Biofeedback

Medical necessity guidelines for biofeedback therapy

10/1/2019

CP.MP.93 (PDF)

Bone-anchored hearing aid

Medical necessity guidelines for bone-anchored hearing aid

10/1/2019

CP.MP.110 (PDF)

Bronchial Thermoplasty

Medical necessity guidelines for bronchial thermoplasty

10/1/2019

CP.MP.156 (PDF)

Cardiac biomarker testing

Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction

10/1/2019

CP.MP.83 (PDF)

Carrier Screening in Pregnancy

Medical necessity guidelines for carrier screening in pregnancy

10/1/2019

CP.MP.164 (PDF)

Caudal or Interlaminar Epidural Steroid Injections for Pain Management

Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management

10/1/2019

CP.MP.84 (PDF)

Cell-free Fetal DNA Testing

Medical necessity guidelines for cell-free fetal DNA testing

10/1/2019

CP.CPC.02 (PDF)

Clinical Policy Web Posting

Corporate and health plan responsibilities for initial posting and maintenance of clinical, payment, and specialty drug policies to public health plan websites

10/1/2019

CP.MP.94 (PDF)

Clinical Trials

Medical necessity guidelines for routine costs of clinical trials

10/1/2019

CP.MP.14 (PDF)

Cochlear Implant Replacements

Medical necessity guidelines for the replacement of cochlear implants and/or cochlear implant components. 

10/1/2019

CP.MP.31 (PDF)

Cosmetic and Reconstructive Surgery

Medical necessity guidelines for cosmetic and reconstructive surgery

10/1/2019

CP.MP.61 (PDF)

Dental Anesthesia

Medical necessity guidelines for dental anesthesia

10/1/2019

CP.MP.105 (PDF)

Digital electroencephalography spike analysis

Medical necessity guidelines for digital EEG spike analysis

10/1/2019

CP.MP.114 (PDF)

Disc Decompression Procedures

Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression

10/1/2019

CP.MP.115 (PDF)

Discography

Medical necessity guidelines for discography

10/1/2019

CP.MP.125 (PDF)

DNA analysis of stool to screen for colorectal cancer

Medical necessity guidelines for DNA analysis of stool for colorectal cancer

10/1/2019

CP.MP.101 (PDF)

Donor lymphocyte infusion

Medical necessity guidelines for donor lymphocyte infusion

10/1/2019

CP.MP.107 (PDF)

Durable Medical Equipment (DME)

Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics

10/1/2019

CP.MP.145 (PDF)

Electric Tumor Treating Fields

Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM)

10/1/2019

CP.MP.155 (PDF)

Electroencephalography in the evaluation of headache

Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches

10/1/2019

CP.MP.106 (PDF)

Endometrial ablation

Medical necessity guidelines for endometrial ablation

10/1/2019

CP.MP.140 (PDF)

EpiFix Wound Treatment

Medical necessity guidelines for EpiFix® wound treatment

10/1/2019

CP.MP.131 (PDF)

Essure Removal

Medical necessity guidelines for removal of Essure®, a permanent birth control device

10/1/2019

CP.MP.134 (PDF)

Evoked Potential Testing

Medical necessity guidelines for evoked potential testing

10/1/2019

CP.MP.36 (PDF)

Experimental Technologies

General medical necessity guidelines to use in determining coverage of experimental or investigational or potentially experimental or investigational medical and behavioral health technologies.  These guidlines are to be used only when there is no other policy, criteria, or coverage statement available. 

10/1/2019

CP.MP.171 (PDF)

Facet Joint Interventions for pain management

Medical necessity guidelines for facet joint injections and facet joint radiofrequency neurotomy (ablation) for lumbar, thoracic, and cervical pain management

10/1/2019

CP.MP.137 (PDF)

Fecal incontinence treatments

Medical necessity guidelines for fecal incontinence treatments

10/1/2019

CP.MP.53 (PDF)

Ferriscan R2-MRI

Medical necessity guidelines for use of the FerriScan R2-MRI

10/1/2019

CP.MP.130 (PDF)

Fertility preservation

Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility

10/1/2019

CP.MP.129 (PDF)

Fetal surgery in utero for prenatally diagnosed malformations

Medical necessity guidelines for performing fetal surgery in utero

10/1/2019

CP.MP.175 (PDF)

Fixed Wing Air Transportation

Medical necessity guidelines for fixed wing air transportation

10/1/2019

CP.MP.103 (PDF)

Fractional exhaled nitric oxide

Medical necessity guidelines for use of fractional exhaled nitric oxide (FeNO) in asthma diagnosis and care

10/1/2019

CP.MP.43 (PDF)

Functional MRI

Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI).

10/1/2019

CP.MP.40 (PDF)

Gastric electrical stimulation

Medical necessity guidelines for gastric electrical stimulation

10/1/2019

CP.MP.95 (PDF)

Gender reassignment surgery

Medical necessity guidelines for surgery for the treatment of gender dysphoria

10/1/2019

CP.MP.89 (PDF)

Genetic Testing

Medical necessity criteria for genetic testing

10/1/2019

CP.MP.153 (PDF)

H. Pylori serology testing

Medical necessity guidelines for H. pylori serology testing

10/1/2019

CP.MP.132 (PDF)

Heart-Lung Transplant

Medical necessity guidelines for heart-lung transplantation

10/1/2019

CP.MP.113 (PDF)

Holter Monitors

Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring

10/1/2019

CP.MP.136 (PDF)

Home Birth

Medical necessity guidelines for planned home birth

10/1/2019

CP.MP.150 (PDF)

Home phototherapy for neonatal hyperbilirubinemia

Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia

10/1/2019

CP.MP.121 (PDF)

Homocysteine testing

Medical necessity guidelines for homocysteine testing

10/1/2019

CP.MP.54 (PDF)

Hospice Services

Medical necessity guidelines for hospice services

10/1/2019

CP.MP.27 (PDF)

Hyperbaric Oxygen Therapy

Medical necessity guidelines for hyperbaric oxygen therapy

10/1/2019

CP.MP.34 (PDF)

Hyperemesis gravidarum treatment

Medical necessity guidelines for the treatment of hyperemesis gravidarum, including intravenous and subcutaneous infusions of ondansetron and metoclopramide, enteral therapy, and total parenteral nutrition (TPN)

10/1/2019

CP.MP.62 (PDF)

Hyperhidrosis treatments

Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands

10/1/2019

CP.MP.173 (PDF)

Implantable Intrathecal Pain Pump

Medical necessity guidelines for preliminary trial and implantation of intrathecal pain pumps

10/1/2019

CP.MP.160 (PDF)

Implantable Wireless Pulmonary Artery Pressure Monitoring

Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring

10/1/2019

CP.MP.159 (PDF)

Infusion Therapy Site of Care Optimization

Medical necessity criteria for IV or injectable therapy services in an outpatient setting.

10/1/2019

CP.MP.87 (PDF)

Inhaled nitric oxide

Medical necessity guidelines for the use of inhaled nitric oxide (iNO)

10/1/2019

CP.MP.69 (PDF)

Intensity-Modulated Radiotherapy

Medical necessity guidelines for intensity-modulated radiotherapy (IMRT)

10/1/2019

CP.MP.58 (PDF)

Intestinal and multivisceral transplant

Medical necessity guidelines for the review of intestinal and multivisceral transplant requests.

10/1/2019

CP.MP.167 (PDF)

Intradiscal Steroid Injections for Pain Management

Medical necessity criteria for intradiscal steroid injections for pain management

10/1/2019

CP.MP.123 (PDF)

Laser therapy for skin conditions

Medical necessity guidelines for excimer laser based targeted phototherapy

10/1/2019

CP.MP.71 (PDF)

Long Term Care Placement Criteria

Medical necessity guidelines for long term care (LTC) placement

10/1/2019

CP.MP.139 (PDF)

Low-frequency ultrasound therapy for wound management

Medical necessity guidelines for low-frequency ultrasound therapy for wound management

10/1/2019

CP.MP.57 (PDF)

Lung Transplantation

Medical necessity guidelines for review of lung transplantation requests

10/1/2019

CP.MP.116 (PDF)

Lysis of Epidural Lesions

Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty

10/1/2019

CP.MP.152 (PDF)

Measurement of serum 1,25-dihydroxyvitamin D

Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D

10/1/2019

CP.MP.144 (PDF)

Mechanical Stretching Devices for Joint Stiffness and Contracture

Medical necessity guidelines for mechanical stretch devices, including low-load prolonged-duration stretch (LLPS) devices/dynamic stretch devices, static progressive (SP) stretch devices, and patient-actuated serial stretch devices.

10/1/2019

CP.CPC.05 (PDF)

Medical Necessity Criteria

This policy identifies the medical necessity guidelines used by the health plan and related definitions.

10/1/2019

CP.MP.24 (PDF)

Multiple Sleep Latency Testing

Medical necessity criteria for multiple sleep latency testing (MSLT)

10/1/2019

CP.MP.86 (PDF)

Neonatal abstinence syndrome guidelines

Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU)

10/1/2019

CP.MP.85 (PDF)

Neonatal sepsis management

Medical necessity guidelines for neonates requiring comprehensive assessment, treatment, and discharge planning for neonatal intensive care unit (NICU) stays related to sepsis management

10/1/2019

CP.MP.170 (PDF)

Nerve Blocks for Pain Management

Medical necessity criteria for nerve blocks for pain management

10/1/2019

CP.MP.82 (PDF)

NICU Apnea Bradycardia Guidelines

Medical necessity guidelines to assist with continuing care, discharge planning, and the transition to outpatient and home care of babies affected by ongoing neonatal apnea and bradycardia events

10/1/2019

CP.MP.81 (PDF)

NICU discharge guidelines

Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home.

10/1/2019

CP.MP.141 (PDF)

Non-myeloablative allogeneic stem cell transplants

Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants

10/1/2019

CP.MP.91 (PDF)

Obstetrical Home Health Care Programs

Medical necessity guidelines for OB home health programs

10/1/2019

CP.MP.128 (PDF)

Optic nerve decompression surgery

Medical necessity guidelines for optic nerve sheath decompression surgery

10/1/2019

CP.MP.176 (PDF)

Outpatient Cardiac Rehabilitation

Medical necessity criteria for conventional and intensive outpatient cardiac rehabiliation programs.

10/1/2019

CP.MP.50 (PDF)

Outpatient testing for drugs of abuse

Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. 

10/1/2019

CP.MP.102 (PDF)

Pancreas transplant

Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant.

10/1/2019

CP.MP.109 (PDF)

Panniculectomy

Medical necessity guidelines for panniculectomy

10/1/2019

CP.MP.138 (PDF)

Pediatric heart transplant

Medical necessity guidelines for pediatric heart transplant

10/1/2019

CP.MP.120 (PDF)

Pediatric Liver Transplant

Medical necessity guidelines for pediatric liver transplant for end-stage liver disease

10/1/2019

CP.MP.147 (PDF)

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention

Medical necessity guidelines for left atrial appendage closure devices for stroke prevention.

10/1/2019

CP.MP.133 (PDF)

Posterior tibial nerve stimulation for voiding dysfunction

Medical necessity guidelines for posterior tibial nerve stimulation for the treatment of voiding dysfunction, including urinary incontinence and overactive bladder

10/1/2019

CP.CPC.03 (PDF)

Preventive Health and Clinical Practice Guideline Policy

The process by which the Plan adopts/develops and distributes preventive health and clinical practice guidelines to assist practitioners and members in making decisions about appropriate health care for specific clinical circumstances.

10/1/2019

CP.MP.70 (PDF)

Proton and neutron beam therapy

Medical necessity guidelines for proton beam and neutron beam radiation therapy

10/1/2019

CP.MP.148 (PDF)

Radial Head Implant

Medical necessity guidelines for radial head implant, also known as arthroplasty

10/1/2019

CP.MP.51 (PDF)

Reduction mammoplasty and gynecomastia surgery

Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men

10/1/2019

CP.MP.126 (PDF)

Sacroiliac joint fusion

Medical necessity guidelines for sacroiliac joint fusion

10/1/2019

CP.MP.166 (PDF)

Sacroiliac Joint Interventions for Pain Management

Medical necessity criteria for sacroiliac joint interventions for pain management

10/1/2019

CP.MP.146 (PDF)

Sclerotherapy for Varicose Veins

Medical necessity guidelines for sclerotherapy for treatment of vericose veins

10/1/2019

CP.MP.174 (PDF)

Selective Dorsal Rhizotomy

Medical necessity criteria for Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy.

10/1/2019

CP.MP.165 (PDF)

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management

Medical necessity criteria for selective nerve root blocks and transforaminal epidural injections for pain management

10/1/2019

CP.MP.88 (PDF)

Sickle cell disease observation

Medical necessity criteria for observation stay for sickle cell disease

10/1/2019

CP.MP.117 (PDF)

Spinal Cord Stimulation

Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation

10/1/2019

CP.CPC.04 (PDF)

State specific clinical policy process

This policy describes the process for creating, maintaining, and posting state-specific clinical policies

10/1/2019

CP.MP.22 (PDF)

Stereotactic Body Radiation Therapy

Medical necessity guidelines for stereotactic body radiation therapy

10/1/2019

CP.MP.162 (PDF)

Tandem Transplant

Medical necessity guidelines for tandem transplant

10/1/2019

CP.MP.149 (PDF)

Testing for rupture of fetal membranes

Medical necessity guidelines for testing for rupture of fetal membranes

10/1/2019

CP.MP.97 (PDF)

Testing for select genitourinary conditions

Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis

10/1/2019

CP.MP.49 (PDF)

Therapy Services (PT/OT/ST)

Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment.

10/1/2019

CP.MP.154 (PDF)

Thyroid hormones and insulin testing in pediatrics

Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics

10/1/2019

CP.MP.127 (PDF)

Total artificial heart

Medical necessity guidelines for a total artificial heart (TAH)

10/1/2019

CP.MP.163 (PDF)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN)

10/1/2019

CP.MP.151 (PDF)

Transcatheter closure of patent foramen ovale

Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder.

10/1/2019

CP.MP.172 (PDF)

Transcranial magnetic stimulation

This policy describes medical necessity guidelines for the use of transcranial magnetic stimulation

10/1/2019

CP.MP.169 (PDF)

Trigger Point Injections for Pain Management

Medical necessity criteria for trigger point injections for pain management

10/1/2019

CP.MP.38 (PDF)

Ultrasound in Pregnancy

Medical necessity guidelines for ultrasound use in pregnancy. 

10/1/2019

CP.MP.142 (PDF)

Urinary Incontinence Devices and Treatments

Medical necessity guidelines for treatments and devices for urinary incontinence including sacral neuromodulation (sacral nerve stimulation) and urethral bulking agents

10/1/2019

CP.MP.98 (PDF)

Urodynamic testing

Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction

10/1/2019

CP.MP.12 (PDF)

Vagus Nerve Stimulation

Medical necessity guidelines for vagus nerve stimulation.

10/1/2019

CP.MP.46 (PDF)

Ventricular Assist Devices

Medical necessity guidelines for ventricular assist devices.

10/1/2019

CP.MP.56 (PDF)

Ventriculectomy and cardiomyoplasty

Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures

10/1/2019

CP.MP.99 (PDF)

Wheelchair seating

Medical necessity guidelines for special wheelchair seating and cushions

10/1/2019

CP.MP.143 (PDF)

Wireless Motility Capsule

Medical necessity guidelines for wireless motility capsule

10/1/2019

CP.MP.111 (PDF)

Zika Virus Testing

Medical necessity guidelines for diagnostic testing for Zika Virus with the rRT-PCR and MAC-ELISA tests

10/1/2019
Code Title Description Date Adopted

CP.MP.157 (PDF)

25-hydroxyvitamin D testing in children and adolescents

Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents

10/1/2019

CP.MP.92 (PDF)

Acupuncture

Medical necessity guidelines for acupuncture

10/1/2019

CP.MP.124 (PDF)

ADHD Assessment and Treatment

Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD)

10/1/2019

CP.MP.100 (PDF)

Allergy Testing and Therapy

Medical necessity guidelines for allergy testing and treatment

10/1/2019

CP.MP.108 (PDF)

Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia

Medical necessity guidelines for allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia

10/1/2019

CP.MP.96 (PDF)

Ambulatory EEG

Medical necessity guidelines for the use of ambulatory electroencephalogram (EEG) testing in the outpatient setting

10/1/2019

CP.MP.158 (PDF)

Ambulatory Surgery Center Optimization

Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services

10/1/2019

CP.MP.104 (PDF)

Applied Behavioral Analysis for Autism

Medical necessity guidelines for applied behavioral analysis for autism

10/1/2019

CP.MP.26 (PDF)

Articular Cartilage Defect Repairs

Medical necessity guidelines for articular cartilage defect repairs

10/1/2019

CP.MP.55 (PDF)

Assisted Reproductive Technology

Medical necessity guidelines for assisted reproductive technology

10/1/2019

CP.MP.119 (PDF)

Balloon sinus ostial dilation

Medical necessity guidelines for balloon sinus ostial dilation for chronic rhinosinusitus and recurrent acute rhinosinusitis

10/1/2019

CP.MP.37 (PDF)

Bariatric Surgery

Medical necessity guidelines for bariatric surgery for obesity in adolescents and adults

10/1/2019

CP.MP.168 (PDF)

Biofeedback

Medical necessity guidelines for biofeedback therapy

10/1/2019

CP.MP.93 (PDF)

Bone-anchored hearing aid

Medical necessity guidelines for bone-anchored hearing aid

10/1/2019

CP.MP.110 (PDF)

Bronchial Thermoplasty

Medical necessity guidelines for bronchial thermoplasty

10/1/2019

CP.MP.156 (PDF)

Cardiac biomarker testing

Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction

10/1/2019

CP.MP.83 (PDF)

Carrier Screening in Pregnancy

Medical necessity guidelines for carrier screening in pregnancy

10/1/2019

CP.MP.164 (PDF)

Caudal or Interlaminar Epidural Steroid Injections for Pain Management

Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management

10/1/2019

CP.MP.84 (PDF)

Cell-free Fetal DNA Testing

Medical necessity guidelines for cell-free fetal DNA testing

10/1/2019

CP.CPC.02 (PDF)

Clinical Policy Web Posting

Corporate and health plan responsibilities for initial posting and maintenance of clinical, payment, and specialty drug policies to public health plan websites

10/1/2019

CP.MP.94 (PDF)

Clinical Trials

Medical necessity guidelines for routine costs of clinical trials

10/1/2019

CP.MP.14 (PDF)

Cochlear Implant Replacements

Medical necessity guidelines for the replacement of cochlear implants and/or cochlear implant components. 

10/1/2019

CP.MP.31 (PDF)

Cosmetic and Reconstructive Surgery

Medical necessity guidelines for cosmetic and reconstructive surgery

10/1/2019

CP.MP.61 (PDF)

Dental Anesthesia

Medical necessity guidelines for dental anesthesia

10/1/2019

CP.MP.105 (PDF)

Digital electroencephalography spike analysis

Medical necessity guidelines for digital EEG spike analysis

10/1/2019

CP.MP.114 (PDF)

Disc Decompression Procedures

Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression

10/1/2019

CP.MP.115 (PDF)

Discography

Medical necessity guidelines for discography

10/1/2019

CP.MP.125 (PDF)

DNA analysis of stool to screen for colorectal cancer

Medical necessity guidelines for DNA analysis of stool for colorectal cancer

10/1/2019

CP.MP.101 (PDF)

Donor lymphocyte infusion

Medical necessity guidelines for donor lymphocyte infusion

10/1/2019

CP.MP.107 (PDF)

Durable Medical Equipment (DME)

Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics

10/1/2019

CP.MP.145 (PDF)

Electric Tumor Treating Fields

Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM)

10/1/2019

CP.MP.155 (PDF)

Electroencephalography in the evaluation of headache

Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches

10/1/2019

CP.MP.106 (PDF)

Endometrial ablation

Medical necessity guidelines for endometrial ablation

10/1/2019

CP.MP.140 (PDF)

EpiFix Wound Treatment

Medical necessity guidelines for EpiFix® wound treatment

10/1/2019

CP.MP.131 (PDF)

Essure Removal

Medical necessity guidelines for removal of Essure®, a permanent birth control device

10/1/2019

CP.MP.134 (PDF)

Evoked Potential Testing

Medical necessity guidelines for evoked potential testing

10/1/2019

CP.MP.36 (PDF)

Experimental Technologies

General medical necessity guidelines to use in determining coverage of experimental or investigational or potentially experimental or investigational medical and behavioral health technologies.  These guidlines are to be used only when there is no other policy, criteria, or coverage statement available. 

10/1/2019

CP.MP.171 (PDF)

Facet Joint Interventions for pain management

Medical necessity guidelines for facet joint injections and facet joint radiofrequency neurotomy (ablation) for lumbar, thoracic, and cervical pain management

10/1/2019

CP.MP.137 (PDF)

Fecal incontinence treatments

Medical necessity guidelines for fecal incontinence treatments

10/1/2019

CP.MP.53 (PDF)

Ferriscan R2-MRI

Medical necessity guidelines for use of the FerriScan R2-MRI

10/1/2019

CP.MP.130 (PDF)

Fertility preservation

Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility

10/1/2019

CP.MP.129 (PDF)

Fetal surgery in utero for prenatally diagnosed malformations

Medical necessity guidelines for performing fetal surgery in utero

10/1/2019

CP.MP.175 (PDF)

Fixed Wing Air Transportation

Medical necessity guidelines for fixed wing air transportation

10/1/2019

CP.MP.103 (PDF)

Fractional exhaled nitric oxide

Medical necessity guidelines for use of fractional exhaled nitric oxide (FeNO) in asthma diagnosis and care

10/1/2019

CP.MP.43 (PDF)

Functional MRI

Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI).

10/1/2019

CP.MP.40 (PDF)

Gastric electrical stimulation

Medical necessity guidelines for gastric electrical stimulation

10/1/2019

CP.MP.95 (PDF)

Gender reassignment surgery

Medical necessity guidelines for surgery for the treatment of gender dysphoria

10/1/2019

CP.MP.89 (PDF)

Genetic Testing

Medical necessity criteria for genetic testing

10/1/2019

CP.MP.153 (PDF)

H. Pylori serology testing

Medical necessity guidelines for H. pylori serology testing

10/1/2019

CP.MP.132 (PDF)

Heart-Lung Transplant

Medical necessity guidelines for heart-lung transplantation

10/1/2019

CP.MP.113 (PDF)

Holter Monitors

Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring

10/1/2019

CP.MP.136 (PDF)

Home Birth

Medical necessity guidelines for planned home birth

10/1/2019

CP.MP.150 (PDF)

Home phototherapy for neonatal hyperbilirubinemia

Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia

10/1/2019

CP.MP.121 (PDF)

Homocysteine testing

Medical necessity guidelines for homocysteine testing

10/1/2019

CP.MP.54 (PDF)

Hospice Services

Medical necessity guidelines for hospice services

10/1/2019

CP.MP.27 (PDF)

Hyperbaric Oxygen Therapy

Medical necessity guidelines for hyperbaric oxygen therapy

10/1/2019

CP.MP.34 (PDF)

Hyperemesis gravidarum treatment

Medical necessity guidelines for the treatment of hyperemesis gravidarum, including intravenous and subcutaneous infusions of ondansetron and metoclopramide, enteral therapy, and total parenteral nutrition (TPN)

10/1/2019

CP.MP.62 (PDF)

Hyperhidrosis treatments

Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands

10/1/2019

CP.MP.173 (PDF)

Implantable Intrathecal Pain Pump

Medical necessity guidelines for preliminary trial and implantation of intrathecal pain pumps

10/1/2019

CP.MP.160 (PDF)

Implantable Wireless Pulmonary Artery Pressure Monitoring

Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring

10/1/2019

CP.MP.159 (PDF)

Infusion Therapy Site of Care Optimization

Medical necessity criteria for IV or injectable therapy services in an outpatient setting.

10/1/2019

CP.MP.87 (PDF)

Inhaled nitric oxide

Medical necessity guidelines for the use of inhaled nitric oxide (iNO)

10/1/2019

CP.MP.69 (PDF)

Intensity-Modulated Radiotherapy

Medical necessity guidelines for intensity-modulated radiotherapy (IMRT)

10/1/2019

CP.MP.58 (PDF)

Intestinal and multivisceral transplant

Medical necessity guidelines for the review of intestinal and multivisceral transplant requests.

10/1/2019

CP.MP.167 (PDF)

Intradiscal Steroid Injections for Pain Management

Medical necessity criteria for intradiscal steroid injections for pain management

10/1/2019

CP.MP.123 (PDF)

Laser therapy for skin conditions

Medical necessity guidelines for excimer laser based targeted phototherapy

10/1/2019

CP.MP.71 (PDF)

Long Term Care Placement Criteria

Medical necessity guidelines for long term care (LTC) placement

10/1/2019

CP.MP.139 (PDF)

Low-frequency ultrasound therapy for wound management

Medical necessity guidelines for low-frequency ultrasound therapy for wound management

10/1/2019

CP.MP.57 (PDF)

Lung Transplantation

Medical necessity guidelines for review of lung transplantation requests

10/1/2019

CP.MP.116 (PDF)

Lysis of Epidural Lesions

Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty

10/1/2019

CP.MP.152 (PDF)

Measurement of serum 1,25-dihydroxyvitamin D

Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D

10/1/2019

CP.MP.144 (PDF)

Mechanical Stretching Devices for Joint Stiffness and Contracture

Medical necessity guidelines for mechanical stretch devices, including low-load prolonged-duration stretch (LLPS) devices/dynamic stretch devices, static progressive (SP) stretch devices, and patient-actuated serial stretch devices.

10/1/2019

CP.CPC.05 (PDF)

Medical Necessity Criteria

This policy identifies the medical necessity guidelines used by the health plan and related definitions.

10/1/2019

CP.MP.24 (PDF)

Multiple Sleep Latency Testing

Medical necessity criteria for multiple sleep latency testing (MSLT)

10/1/2019

CP.MP.86 (PDF)

Neonatal abstinence syndrome guidelines

Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU)

10/1/2019

CP.MP.85 (PDF)

Neonatal sepsis management

Medical necessity guidelines for neonates requiring comprehensive assessment, treatment, and discharge planning for neonatal intensive care unit (NICU) stays related to sepsis management

10/1/2019

CP.MP.170 (PDF)

Nerve Blocks for Pain Management

Medical necessity criteria for nerve blocks for pain management

10/1/2019

CP.MP.82 (PDF)

NICU Apnea Bradycardia Guidelines

Medical necessity guidelines to assist with continuing care, discharge planning, and the transition to outpatient and home care of babies affected by ongoing neonatal apnea and bradycardia events

10/1/2019

CP.MP.81 (PDF)

NICU discharge guidelines

Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home.

10/1/2019

CP.MP.141 (PDF)

Non-myeloablative allogeneic stem cell transplants

Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants

10/1/2019

CP.MP.91 (PDF)

Obstetrical Home Health Care Programs

Medical necessity guidelines for OB home health programs

10/1/2019

CP.MP.128 (PDF)

Optic nerve decompression surgery

Medical necessity guidelines for optic nerve sheath decompression surgery

10/1/2019

CP.MP.176 (PDF)

Outpatient Cardiac Rehabilitation

Medical necessity criteria for conventional and intensive outpatient cardiac rehabiliation programs.

10/1/2019

CP.MP.50 (PDF)

Outpatient testing for drugs of abuse

Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. 

10/1/2019

CP.MP.102 (PDF)

Pancreas transplant

Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant.

10/1/2019

CP.MP.109 (PDF)

Panniculectomy

Medical necessity guidelines for panniculectomy

10/1/2019

CP.MP.138 (PDF)

Pediatric heart transplant

Medical necessity guidelines for pediatric heart transplant

10/1/2019

CP.MP.120 (PDF)

Pediatric Liver Transplant

Medical necessity guidelines for pediatric liver transplant for end-stage liver disease

10/1/2019

CP.MP.147 (PDF)

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention

Medical necessity guidelines for left atrial appendage closure devices for stroke prevention.

10/1/2019

CP.MP.133 (PDF)

Posterior tibial nerve stimulation for voiding dysfunction

Medical necessity guidelines for posterior tibial nerve stimulation for the treatment of voiding dysfunction, including urinary incontinence and overactive bladder

10/1/2019

CP.CPC.03 (PDF)

Preventive Health and Clinical Practice Guideline Policy

The process by which the Plan adopts/develops and distributes preventive health and clinical practice guidelines to assist practitioners and members in making decisions about appropriate health care for specific clinical circumstances.

10/1/2019

CP.MP.70 (PDF)

Proton and neutron beam therapy

Medical necessity guidelines for proton beam and neutron beam radiation therapy

10/1/2019

CP.MP.148 (PDF)

Radial Head Implant

Medical necessity guidelines for radial head implant, also known as arthroplasty

10/1/2019

CP.MP.51 (PDF)

Reduction mammoplasty and gynecomastia surgery

Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men

10/1/2019

CP.MP.126 (PDF)

Sacroiliac joint fusion

Medical necessity guidelines for sacroiliac joint fusion

10/1/2019

CP.MP.166 (PDF)

Sacroiliac Joint Interventions for Pain Management

Medical necessity criteria for sacroiliac joint interventions for pain management

10/1/2019

CP.MP.146 (PDF)

Sclerotherapy for Varicose Veins

Medical necessity guidelines for sclerotherapy for treatment of vericose veins

10/1/2019

CP.MP.174 (PDF)

Selective Dorsal Rhizotomy

Medical necessity criteria for Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy.

10/1/2019

CP.MP.165 (PDF)

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management

Medical necessity criteria for selective nerve root blocks and transforaminal epidural injections for pain management

10/1/2019

CP.MP.88 (PDF)

Sickle cell disease observation

Medical necessity criteria for observation stay for sickle cell disease

10/1/2019

CP.MP.117 (PDF)

Spinal Cord Stimulation

Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation

10/1/2019

CP.CPC.04 (PDF)

State specific clinical policy process

This policy describes the process for creating, maintaining, and posting state-specific clinical policies

10/1/2019

CP.MP.22 (PDF)

Stereotactic Body Radiation Therapy

Medical necessity guidelines for stereotactic body radiation therapy

10/1/2019

CP.MP.162 (PDF)

Tandem Transplant

Medical necessity guidelines for tandem transplant

10/1/2019

CP.MP.149 (PDF)

Testing for rupture of fetal membranes

Medical necessity guidelines for testing for rupture of fetal membranes

10/1/2019

CP.MP.97 (PDF)

Testing for select genitourinary conditions

Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis

10/1/2019

CP.MP.49 (PDF)

Therapy Services (PT/OT/ST)

Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment.

10/1/2019

CP.MP.154 (PDF)

Thyroid hormones and insulin testing in pediatrics

Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics

10/1/2019

CP.MP.127 (PDF)

Total artificial heart

Medical necessity guidelines for a total artificial heart (TAH)

10/1/2019

CP.MP.163 (PDF)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN)

10/1/2019

CP.MP.151 (PDF)

Transcatheter closure of patent foramen ovale

Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder.

10/1/2019

CP.MP.172 (PDF)

Transcranial magnetic stimulation

This policy describes medical necessity guidelines for the use of transcranial magnetic stimulation

10/1/2019

CP.MP.169 (PDF)

Trigger Point Injections for Pain Management

Medical necessity criteria for trigger point injections for pain management

10/1/2019

CP.MP.38 (PDF)

Ultrasound in Pregnancy

Medical necessity guidelines for ultrasound use in pregnancy. 

10/1/2019

CP.MP.142 (PDF)

Urinary Incontinence Devices and Treatments

Medical necessity guidelines for treatments and devices for urinary incontinence including sacral neuromodulation (sacral nerve stimulation) and urethral bulking agents

10/1/2019

CP.MP.98 (PDF)

Urodynamic testing

Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction

10/1/2019

CP.MP.12 (PDF)

Vagus Nerve Stimulation

Medical necessity guidelines for vagus nerve stimulation.

10/1/2019

CP.MP.46 (PDF)

Ventricular Assist Devices

Medical necessity guidelines for ventricular assist devices.

10/1/2019

CP.MP.56 (PDF)

Ventriculectomy and cardiomyoplasty

Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures

10/1/2019

CP.MP.99 (PDF)

Wheelchair seating

Medical necessity guidelines for special wheelchair seating and cushions

10/1/2019

CP.MP.143 (PDF)

Wireless Motility Capsule

Medical necessity guidelines for wireless motility capsule

10/1/2019

CP.MP.111 (PDF)

Zika Virus Testing

Medical necessity guidelines for diagnostic testing for Zika Virus with the rRT-PCR and MAC-ELISA tests

10/1/2019

Pharmacy Criteria

Trillium Community Health Plan’s goal is to offer the right drug coverage to our members. Trillium Oregon Health Plan (OHP) covers prescription and some over the counter drugs when they are ordered by a licensed prescriber registered with the state of Oregon to provide services to OHP members. The pharmacy program does not cover all drugs. Some drugs need prior approval and some have a limit on the amount of drug that can be given.

Clinical policies are one set of guidelines used to assist in administering health plan benefits. 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. 

The Trillium Pharmacy and Therapeutics (P&T) Committee is comprised of community doctors and pharmacists. Together we work to offer drugs used to treat many conditions and illnesses. All clinical policies are reviewed annually by the Trillium P&T Committee, which meets quarterly. Approved criteria and revisions made by the P&T Committee go into effect the first day of the month the start of the following quarter. All medications newly approved by the FDA (Food and Drug Administration) require prior approval until reviewed by our P&T Committee.

All policies found in the Trillium Community Health Plan Clinical Policy Manual apply to Trillium Community Health Plan members. Policies in the Trillium Community Health Plan Clinical Policy Manual may have either a Trillium Community Health Plan or a “Centene” heading. Polices listed as being approved for the Medicaid and/or Oregon Health Plan lines of business apply to prior authorization requests for Trillium OHP members.

All prior authorization requests are subject to the Oregon Health Plan’s Prioritized List and Guideline Notes in addition to applicable clinical policy coverage guidelines. Requests for non-preferred medications not listed on Trillium OHP’s Preferred Drug List (PDL) require trial and failure of preferred options prior to approval unless submitted documentation can support the medical necessity of the non-preferred medication.

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

Anti-Inflammatory Agents

Musculoskeletal Therapy Agents

Opioid Agents

 

Amebicides

Amnoglycosides

Antifungals

Antihelmintics

Anti-Infective Agents - Misc.

Antimalarials

Antimycobacterial Agents

Antivirals

Fluoroqunolones

Passive Immunizing and Treatment Agents

Tetracyclines

Alkylating Agents

Antimetabolites

Antineoplastic - Angiogenesis Inhibitors

Antineoplastic - Antibodies

Antineoplastic - BCL-2 Inhibitors

Antineoplastic - Cellular Immunotherapy

Antineoplastic - Hedgehog Pathway Inhibitors

Antineoplastic - Hormonal and Related Agents

Antineoplastic - Immunomodulators

Antineoplastic Antibiotics

Antineoplastic Combinations

Antineoplastic Enzyme Inhibitors

Antineoplastic Enzymes

Antineoplastic Radiopharmaceuticals

Antineoplastics Misc.

Chemotherapy Rescue/Antidote Agents

Mitotic Inhibitors

Topoisomerase I Inhibitors

 

Androgen

Antidiabetics

Bone Density Regulators

Corticosteroids

Corticotropin

GNRH/LHRH Antagonists

Growth Hormone Receptor Antagonists

Growth Hormones

Hormone Receptor Modulators

Insulin-Like Growth Factors (Somatomedins)

LHRH/GNRH Agonist Analog Pituitary Suppressants

Metabolic Modifiers

Posterior Pituitary Hormones

Progesterone Receptor Antagonists

Progestins and Combined Contraceptives

Somatostatic Agents

Vasopressin Receptor Antagonists

Antiemetics

Gastrointestinal Agents - Misc.

Genitourinary Agents - Misc.

Gout Agents

Urinary Antispasmodics

Vaginal Products

Anticoagulants

Hematological Agents - Misc.

Hematopoietic Agents

ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants

Anticonvulsants

AntiMyasthenic/Cholinergic Agents

Antiparkinson and Related Therapy Agents

Hypnotics/Sedatives/Sleep Disorder Agents

Migraine Products

Psychotherapeutic and Neurological Agents - Misc.

 

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 Trillium Community Health Plan Payment Policy Manual apply with respect to Trillium Community Health Plan members. Policies in the Trillium Community Health Plan Payment Policy Manual may have either a Trillium Community Health Plan or a “Centene” heading.  In addition, Trillium Community 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 Trillium Community Health Plan.     

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

Behavioral Health Policies

Policy Reference Number Policy Name Description
OR.MM.BH.112 (PDF) Involuntary Psychiatric Care Trillium provides psychiatric care as outlined in our contract with Oregon Health Authority (OHA) and Oregon Administrative Rules (OAR). Trillium makes reasonable effort to provide covered services on a voluntary basis consistent with current Declaration for Mental Health Treatment in lieu of involuntary treatment.

Other Policies

Policy Reference Number Policy Name Description
OR.MM.117 (PDF) Advance Directives To provide opportunity for and educate members about their right to be involved in decisions regarding their care including documentation of advance directives and allowance of the member’s representative to facilitate care or make treatment decisions when the member is unable to do so.