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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 (Attachment 1 2017 Summary of Changes)
  2. American College of Radiology (ACR) Appropriateness Criteria
  3. National Comprehensive Cancer Network (NCCN) Practice Guidelines in Oncology

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 1-877-600-5472.

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

February 15, 2022

CP.MP.92 (PDF)

Acupuncture

Medical necessity guidelines for acupuncture

September 21, 2021

CP.MP.124 (PDF)

ADHD Assessment and Treatment

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

May 17, 2022
CP.MP.175 (PDF) Air Ambulance Medical necessity guidelines for fixed wing air transportation. September 21, 2021

CP.MP.100 (PDF)

Allergy Testing and Therapy

Medical necessity guidelines for allergy testing and treatment

May 17, 2022

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

February 15, 2022

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

November 21, 2021
CP.MP.179 (PDF) Antithrombin III (Thrombate III, Atryn) Medical necessity criteria for Antithrombin III (Thrombate III, Atryn) February 15, 2022

CP.MP.26 (PDF)

Articular Cartilage Defect Repairs

Medical necessity guidelines for articular cartilage defect repairs

May 17, 2022

CP.MP.55 (PDF)

Assisted Reproductive Technology

Medical necessity guidelines for assisted reproductive technology

February 15, 2022

CP.MP.37 (PDF)

Bariatric Surgery

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

September 21, 2021

CP.MP.168 (PDF)

Biofeedback

Medical necessity guidelines for biofeedback therapyJuly 20, 2021

February 15, 2022

CP.MP.93 (PDF)

Bone-anchored hearing aid

Medical necessity guidelines for bone-anchored hearing aid

September 21, 2021

CP.MP.110 (PDF)

Bronchial Thermoplasty

Medical necessity guidelines for bronchial thermoplasty

July 20, 2021

CP.MP.186 (PDF)

Burn Surgery

Medical necessity guidelines for burn surgery, including debridement and application of skin substitutes for burns.

February 15, 2022

CP.MP.156 (PDF)

Cardiac biomarker testing

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

February 15, 2022

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

November 21, 2021

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

February 15, 2022

CP.MP.94 (PDF)

Clinical Trials

Medical necessity guidelines for routine costs of clinical trials

September 21, 2021

CP.MP.14 (PDF)

Cochlear Implant Replacements

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

September 21, 2021

CP.MP.31 (PDF)

Cosmetic and Reconstructive Surgery

Medical necessity guidelines for cosmetic and reconstructive surgery

February 15, 2022

CP.MP.61 (PDF)

Dental Anesthesia

Medical necessity guidelines for dental anesthesia

February 15, 2022
CP.MP.203 (PDF) Diaphragmatic/Phrenic Nerve Stimulation Medical necessity guidelines for diaphragmatic/phrenic nerve stimulation February 15, 2022

CP.MP.105 (PDF)

Digital electroencephalography spike analysis

Medical necessity guidelines for digital EEG spike analysis

February 15, 2022

CP.MP.114 (PDF)

Disc Decompression Procedures

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

July 20, 2021

CP.MP.115 (PDF)

Discography

Medical necessity guidelines for discography

September 21, 2021

CP.MP.101 (PDF)

Donor lymphocyte infusion

Medical necessity guidelines for donor lymphocyte infusion

February 15, 2022

CP.MP.50 (PDF)

Drugs of Abuse: Definitive Testing

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

May 17, 2022

CP.MP.107 (PDF)

Durable Medical Equipment (DME)

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

February 15, 2022

CP.MP.145 (PDF)

Electric Tumor Treating Fields

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

February 15, 2022

CP.MP.155 (PDF)

Electroencephalography in the evaluation of headache

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

February 15, 2022
CP.MP.211 (PDF) Electromyography and Nerve Conduction Studies Medical necessity criteria for EMG and NCS July 20, 2021

CP.MP.106 (PDF)

Endometrial ablation

Medical necessity guidelines for endometrial ablation

May 17, 2022

CP.MP.131 (PDF)

Essure Removal

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

February 15, 2022

CP.MP.134 (PDF)

Evoked Potential Testing

Medical necessity guidelines for evoked potential testing

August 31, 2021

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. 

May 17, 2022

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

September 21, 2021

CP.MP.137 (PDF)

Fecal incontinence treatments

Medical necessity guidelines for fecal incontinence treatments

September 21, 2021

CP.MP.53 (PDF)

Ferriscan R2-MRI

Medical necessity guidelines for use of the FerriScan R2-MRI

February 15, 2022

CP.MP.130 (PDF)

Fertility preservation

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

November 16, 2021

CP.MP.129 (PDF)

Fetal surgery in utero for prenatally diagnosed malformations

Medical necessity guidelines for performing fetal surgery in utero

September 21, 2021

CP.MP.43 (PDF)

Functional MRI

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

May 17, 2022

CP.MP.40 (PDF)

Gastric electrical stimulation

Medical necessity guidelines for gastric electrical stimulation

May 17, 2022

CP.MP.95 (PDF)

Gender Affirming Procedures

Medical necessity guidelines for surgery for the treatment of gender dysphoria

February 15, 2022
CP.MP.215 (PDF) Genetic Testing Aortopathies and Connective Tissue Disorders Hereditary connective tissue disorders are a group of disorders that affect the connective tissues that support the skin, bones, joints, heart, blood vessels, eyes, and other organs. May 17, 2022
CP.MP.216 (PDF) Genetic Testing Cardiac Disorders This document addresses genetic testing for cardiac disorders, focusing on cardiomyopathy, arrhythmia, congenital heart defects, and cholesterol disorders. May 17, 2022
CP.MP.217 (PDF) Genetic Testing Dermatologic Conditions This document addresses genetic testing for dermatologic conditions. May 17, 2022
CP.MP.218 (PDF) Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Disorders This document addresses genetic testing for neurodegenerative and neuromuscular genetic diseases. May 17, 2022
CP.MP.219 (PDF) Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders Rapid exome sequencing (rES) and rapid genome (rGS) sequencing involves sequencing of the exome or genome, respectively, in an accelerated time frame. May 17, 2022
CP.MP.220 (PDF) Genetic Testing Eye Disorders Age-related macular degeneration (AMD) is an eye condition that causes damage to the central portion of the retina (the macula), affecting the ability to see objects straight ahead. May 17, 2022
CP.MP.221 (PDF) Genetic Testing Gastroenterologic Disorders (non-cancerous) This document addresses genetic testing for common gastroenterologic (non-cancerous) conditions. May 17, 2022
CP.MP.222 (PDF) Genetic Testing General Approach to Genetic Testing Genetic testing refers to the use of technologies that identify genetic variation, which include genomic, transcriptional, proteomic, and epigenetic alterations, for the prevention, diagnosis, and treatment of disease.  May 17, 2022
CP.MP.223 (PDF) Genetic Testing Hearing Loss This policy primarily focuses on the use of genetic testing to identify a cause of suspected hereditary hearing loss. May 17, 2022
CP.MP.224 (PDF) Genetic Testing Hematologic Condition (non-cancerous) This document addresses genetic testing for common hematologic (non-cancerous) conditions May 17, 2022
CP.MP.225 (PDF) Genetic Testing Hereditary Cancer Susceptibility Genetic testing for hereditary cancer susceptibility is a germline test and can be performed on individual genes (e.g., BRCA1) or on many genes simultaneously (i.e., multi-gene panels). May 17, 2022
CP.MP.226 (PDF) Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders Immunodeficiency disorders impair the immune system’s ability to defend the body against foreign substances, such as bacteria, viruses, and cancer cells. May 17, 2022
CP.MP.227 (PDF) Genetic Testing Kidney Disorders Inherited kidney disorders and inherited disorders that indirectly affect the kidneys can be more common, such as autosomal dominant polycystic kidney disease, or more rare, such as Lowe syndrome and Fabry disease. May 17, 2022
CP.MP.228 (PDF) Genetic Testing Lung Disorders One of the most common forms of inherited lung disorders is alpha-1 antitrypsin deficiency (AATD) is an autosomal recessive genetic disorder that results in decreased production of the alpha-1 antitrypsin (AAT) protein, or production of abnormal types of the protein that are functionally deficient. May 17, 2022
CP.MP.229 (PDF) Genetic Testing Metabolic Endocrine and Mitochondrial Disorders Genetic testing for metabolic, endocrine, and mitochondrial disorders aids in identifying the specific disorder that is present, so that proper treatment (if any) can be initiated, and at-risk family member/enrollee can be identified. May 17, 2022
CP.MP.230 (PDF) Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay This document addresses genetic testing for rare genetic conditions that impact multiple body systems. May 17, 2022
CP.MP.231 (PDF) Genetic Testing for Non-Invasive Prenatal Screening (NIPS) Non-invasive prenatal screening (NIPS) is a sequencing test performed on placental cell-free DNA found in maternal serum and is most commonly used to screen for fetal aneuploidy (trisomy 21, trisomy 13, and trisomy 18); sex chromosomes are also screened for fetal sex determination and sex chromosome aneuploidy. May 17, 2022
CP.MP.237 (PDF) Genetic Testing Oncology Algorithmic Testing Oncology prognostic and algorithmic tests are developed to aid in determining the likelihood that an individual has cancer, the prognosis for a patient diagnosed with cancer, and/or surveillance for recurrence. May 17, 2022
CP.MP.238 (PDF) Genetic Testing Oncology Cancer Screening This policy relates to genetic and biomarker tests that aim to screen for specific cancers in individuals who are at risk to develop them. May 17, 2022
CP.MP.240 (PDF) Genetic Testing Oncology Cytogenetic Testing Cytogenetic analysis of solid tumors and hematologic malignancies aims to both classify the type of tumor or cancer present and also to identify somatic oncogenic mutations in cancer. May 17, 2022
CP.MP.241 (PDF) Genetic Testing Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies The molecular analysis of solid tumors and hematologic malignancies aims to identify somatic oncogenic mutations in cancer.  May 17, 2022
CP.MP.232 (PDF) Genetic Testing Pharmacogenetics Pharmacogenetic tests are germline genetic tests that are developed to aid in assessing an individual's response to a drug treatment or to predict the risk of toxicity from a specific drug treatment. May 17, 2022
CP.MP.233 (PDF) Genetic Testing Preimplantation Genetic Testing Preimplantation genetic testing involves analysis of biopsied cells from an embryo as a part of an assisted reproductive procedure. May 17, 2022
CP.MP.234 (PDF) Genetic Testing Prenatal and Preconception Carrier Screening Carrier screening is performed to identify individuals at risk of having offspring with inherited recessive or X-linked single-gene disorders. May 17, 2022
CP.MP.235 (PDF) Genetic Testing Prenatal Diagnosis  Prenatal diagnostic testing for genetic disorders is performed on fetal cells derived from amniotic fluid, and/or percutaneous umbilical blood sampling (PUBS) (cordocentesis) or from placental cells via chorionic villus sampling (CVS). May 17, 2022
CP.MP.236 (PDF) Genetic Testing Skeletal Dysplasia and Rare Bone Disorders Genetic testing has allowed for gene identification in more than two thirds of the skeletal dysplasias. May 17, 2022
CP.MP.209 (PDF) GI Pathogen Nucleic Acid Detection Panel Testing Medical necessity guidelines for GI Pathogen Nucleic Acid Detection Panel Testing May 17, 2022

CP.MP.153 (PDF)

H. Pylori serology testing

Medical necessity guidelines for H. pylori

February 15, 2022

CP.MP.132 (PDF)

Heart-Lung Transplant

Medical necessity guidelines for heart-lung transplantation

May 17, 2022

CP.MP.113 (PDF)

Holter Monitors

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

February 15, 2022

CP.MP.136 (PDF)

Home Birth

Medical necessity guidelines for planned home birth

May 17, 2022

CP.MP.150 (PDF)

Home phototherapy for neonatal hyperbilirubinemia

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

February 15, 2022

CP.MP.121 (PDF)

Homocysteine testing

Medical necessity guidelines for homocysteine testing

May 17, 2022

CP.MP.54 (PDF)

Hospice Services

Medical necessity guidelines for hospice services

February 15, 2022

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)

May 17, 2022

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

May 17, 2022
CP.MP.180 (PDF) Implantable Hypoglossal Nerve Stimulation Medical necessity criteria for Implantable Hypoglossal Nerve Stimulation (Inspire) for Obstructive Sleep Apnea February 15, 2022

CP.MP.173 (PDF)

Implantable Intrathecal Pain Pump

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

May 17, 2022

CP.MP.160 (PDF)

Implantable Wireless Pulmonary Artery Pressure Monitoring

Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring

May 17, 2022

CP.MP.87 (PDF)

Inhaled nitric oxide

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

September 21, 2021

CP.MP.69 (PDF)

Intensity-Modulated Radiotherapy

Medical necessity guidelines for intensity-modulated radiotherapy (IMRT)

February 15, 2022

CP.MP.58 (PDF)

Intestinal and multivisceral transplant

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

May 17, 2022

CP.MP.167 (PDF)

Intradiscal Steroid Injections for Pain Management

Medical necessity criteria for intradiscal steroid injections for pain management

September 21, 2021

CP.MP.123 (PDF)

Laser therapy for skin conditions

Medical necessity guidelines for excimer laser based targeted phototherapy

May 17, 2022

CP.MP.71 (PDF)

Long Term Care Placement Criteria

Medical necessity guidelines for long term care (LTC) placement

July 20, 2021

CP.MP.139 (PDF)

Low-frequency ultrasound and noncontact normothermic wound therapy

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

May 17, 2022
CP.MP.57 (PDF) Lung Transplantation Medical necessity guidelines for review of lung transplantation requests May 17, 2022

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

July 20, 2021

CP.MP.152 (PDF)

Measurement of serum 1,25-dihydroxyvitamin D

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

October 31, 2021

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.

February 15, 2022

CP.CPC.05 (PDF)

Medical Necessity Criteria

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

September 21, 2021

CP.MP.24 (PDF)

Multiple Sleep Latency Testing

Medical necessity criteria for multiple sleep latency testing (MSLT)

July 20, 2021

CP.MP.86 (PDF)

Neonatal abstinence syndrome guidelines

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

May 17, 2022

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

September 21, 2021

CP.MP.170 (PDF)

Nerve Blocks for Pain Management

Medical necessity criteria for nerve blocks for pain management

February 15, 2022
CP.MP.48 (PDF) Neuromuscular Electrical Stimulation (NMES) Medical necessity requirements for the use of neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES) September 21, 2021

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

July 20, 2021

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.

September 21, 2021
CP.MP.184 (PDF) Non-Invasive Home Ventilators Medical necessity guidelines for non-invasive home ventilators July 20, 2021

CP.MP.141 (PDF)

Non-myeloablative allogeneic stem cell transplants

Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants

May 17, 2022

CP.MP.91 (PDF)

Obstetrical Home Health Care Programs

Medical necessity guidelines for OB home health programs

February 15, 2022
CP.MP.239 (PDF) Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) Genetic tests performed on cell-free circulating tumor DNA (ctDNA), also referred to as a liquid biopsy, potentially offer a noninvasive alternative to tissue biopsy for detection of “driver mutations”, or acquired genetic mutations that may guide targeted therapy, and may also be used to track progression of disease. May 17, 2022

CP.MP.128 (PDF)

Optic nerve decompression surgery

Medical necessity guidelines for optic nerve sheath decompression surgery

September 21, 2021
CP.MP.202 (PDF) Orthognathic Surgery Medical necessity guidelines for Orthognathic Surgery February 15, 2022

CP.MP.176 (PDF)

Outpatient Cardiac Rehabilitation

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

July 20, 2021
CP.MP.190 (PDF) Oxygen Use and Concentrators Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxemia. May 17, 2022

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.

May 17, 2022

CP.MP.109 (PDF)

Panniculectomy

Medical necessity guidelines for panniculectomy

February 15, 2022

CP.MP.138 (PDF)

Pediatric heart transplant

Medical necessity guidelines for pediatric heart transplant

May 17, 2022

CP.MP.120 (PDF)

Pediatric Liver Transplant

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

May 17, 2022

CP.MP.188 (PDF)

Pediatric Oral Function Therapy

Medical necessity guidelines for pediatric oral function therapy.

July 20, 2021

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.

July 20, 2021
CP.MP.181 (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing. May 17, 2022

CP.MP.213 (PDF)

Post-Acute Care

Medical necessity criteria for Post-Acute Care

May 17, 2022

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

September 21, 2021

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.

February 15, 2022

CP.MP.70 (PDF)

Proton and neutron beam therapy

Medical necessity guidelines for proton beam and neutron beam radiation therapy

February 15, 2022

CP.MP.148 (PDF)

Radial Head Implant

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

July 20, 2021

CP.MP.187 (PDF)

Radiofrequency Ablation of Uterine Fibroids

Medical necessity criteria for radiofrequency ablation of uterine fibroids.

May 17, 2022

CP.MP.51 (PDF)

Reduction mammoplasty and gynecomastia surgery

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

November 21, 2021

CP.MP.210 (PDF)

Repair of Nasal Valve Compromise

Medical necessity guidelines for the treatment of Repair of Nasal Valve Compromise

July 20, 2021

CP.MP.126 (PDF)

Sacroiliac joint fusion

Medical necessity guidelines for sacroiliac joint fusion

September 21, 2021

CP.MP.166 (PDF)

Sacroiliac Joint Interventions for Pain Management

Medical necessity criteria for sacroiliac joint interventions for pain management

September 21, 2021

CP.MP.146 (PDF)

Sclerotherapy for Varicose Veins

Medical necessity guidelines for sclerotherapy for treatment of vericose veins

September 21, 2021

CP.MP.174 (PDF)

Selective Dorsal Rhizotomy

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

February 15, 2022

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

September 21, 2021
CP.MP.182 (PDF) Short Inpatient Hospital Stay Medical necessity criteria for inpatient hospital stay of 2 days or less February 15, 2022

CP.MP.206 (PDF)

Skilled Nursing Facility Leveling

Medical necessity criteria for skilled nursing facility levels of care 

May 17, 2022

CP.MP.185 (PDF)

Skin Substitutes for Chronic Wounds

Medical necessity criteria for skin substitutes in the treatment of chronic wounds.

July 20, 2021

CP.MP.117 (PDF)

Spinal Cord Stimulation

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

May 17, 2022

CP.CPC.04 (PDF)

State specific clinical policy process

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

February 15, 2022

CP.MP.22 (PDF)

Stereotactic Body Radiation Therapy

Medical necessity guidelines for stereotactic body radiation therapy

May 17, 2022

CP.MP.162 (PDF)

Tandem Transplant

Medical necessity guidelines for tandem transplant

May 17, 2022

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

May 17, 2022

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.

February 16, 2021

CP.MP.154 (PDF)

Thyroid hormones and insulin testing in pediatrics

Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics

February 15, 2022

CP.MP.127 (PDF)

Total artificial heart

Medical necessity guidelines for a total artificial heart (TAH)

February 15, 2022

CP.MP.163 (PDF)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

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

July 20, 2021

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.

February 15, 2022

CP.MP.169 (PDF)

Trigger Point Injections for Pain Management

Medical necessity criteria for trigger point injections for pain management

September 21, 2021

CP.MP.38 (PDF)

Ultrasound in Pregnancy

Medical necessity guidelines for ultrasound use in pregnancy. 

May 17, 2022

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

February 15, 2022

CP.MP.98 (PDF)

Urodynamic testing

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

May 17, 2022

CP.MP.12 (PDF)

Vagus Nerve Stimulation

Medical necessity guidelines for vagus nerve stimulation.

September 21, 2021

CP.MP.46 (PDF)

Ventricular Assist Devices

Medical necessity guidelines for ventricular assist devices.

May 17, 2022

CP.MP.99 (PDF)

Wheelchair seating

Medical necessity guidelines for special wheelchair seating and cushions

May 17, 2022

CP.MP.143 (PDF)

Wireless Motility Capsule

Medical necessity guidelines for wireless motility capsule

February 15, 2022
CP.MP.194 (PDF) Osteogenic Stimulation Electrical osteogenic stimulation can be performed invasively or non-invasively. November 16, 2021

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 – Kinase Inhibitor

Antineoplastic Antibiotics

Antineoplastic Combinations

Antineoplastic Enzyme Inhibitors

Antineoplastic Enzymes

Antineoplastic Radiopharmaceuticals

Antineoplastics Misc.

Chemotherapy Rescue/Antidote Agents

Antineoplastic XPO1 Inhibitors

Mitotic Inhibitors

Topoisomerase I Inhibitors

Antianginal Agents

Antihyperlipidemics

Antihypertensives

Beta Blockers

Cardiovascular Agents - Misc.

Vasopressors

 

Adrenal Steroid Inhibitors

Aldosterone Receptor Antagonists

Androgen

Antidiabetics

Bone Density Regulators

Corticosteroids

Corticotropin

Estrogen Combinations

Gender Dysphoria Treatment Agents

GNRH/LHRH Antagonists

Growth Hormone Receptor Antagonists

Growth Hormone Releasing Hormones

Growth Hormones

Insulin-Like Growth Factors

LHRH/GNRH Agonist Analog Pituitary Suppressants

Metabolic Modifiers

Miscellaneous Endocrine agents

Natriuretic Peptides

Posterior Pituitary Hormones

Progesterone Receptor Antagonists

Progestins and Combined Contraceptives

Somatostatic Agents

Vasopressin Receptor Antagonists

Antiemetics

Digestive Aids

Diuretics

Gastrointestinal Agents - Misc.

Genitourinary Agents - Misc.

Gout Agents

Ulcer Drugs

Urinary Antispasmodics

Vaginal Products

 

Anticoagulants

Hematological Agents - Misc.

Hematopoietic Agents

 

Allergenic Extracts/Biologicals Misc.

Alternative Medicines

Antidotes and Specific Antagonists

Chelating Agents

Diabetic Supplies

Diagnostic Products

Endocrine-Metabolic Agent

Enzymes

Immunological Agent

Immunomodulators

Immunosuppressive Agents

Nutrients

Potassium Removing Agents

Other Misc. Drugs

Systemic Lupus Erythematosus Agents

Tissue Products

Wound Care Products

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.

 

Antiasthmatic and Bronchodilator Agents

Respiratory 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.
OR.CP.MP.500 (PDF) Requests for Authorization - Oregon Health Plan (OHP) To ensure that Trillium staff and any delegated entities making Utilization Management decisions for Oregon Health Plan (OHP) members follow the Oregon Health Plan Prioritized List and subsequent policies/criteria/guidelines to make medical necessity decisions. 
OR.CP.MP.501 (PDF) Applying National Comprehensive Cancer Network Guidelines To provide Trillium staff and any delegated entities making Utilizaton Management decisions for Oregon Health Plan (OHP) members the use of the most up to date NCCN guidelines when the Health Evidence Review Commission's HERC is behind in posting.