Clinical Coverage Policies
Sandhills Center utilizes all NC Medicaid clinical coverage policies as decision criteria for Utilization Management (UM) determinations. Below you will find links to the NC Medicaid policies page with direct links to each clinical coverage policy.
In some circumstances, NC Medicaid does not have a clinical coverage policy for a particular service or procedure or the NC Medicaid clinical coverage policy does not give specific review criteria. In those cases, Sandhills Center uses its own policy. Below you will find links to PDFs of those policies.
To ask questions about the clinical policies used by the Sandhills Center Tailored Plan, please contact the UM Director at 1-800-256-2452.
POLICIES
-A-
- Allergies
- 1N-1, Allergy Testing
- 1N-2, Allergy Immunotherapy
- Ambulance
- 15, Ambulance Services
- Anesthesia
- 1L-1, Anesthesia Services
- 1L-2, Moderate (Conscious) Sedation, AKA Procedural Sedation and Analgesia(PSA)
- Aqueous shunts for glaucoma - PDF
- Arthroscopic anterior cruciate ligament surgery — skeletally immature - PDF
- Auditory Implants External Parts
- 13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair
- 13B, Soft Band and Implantable Bone Conduction Hearing Aid External Parts Replacement and Repair
- Autonomic nervous system monitoring for neuropathy - PDF
-B-
- Behavioral Health
- 8A, Enhanced Mental Health and Substance Abuse Services
- 8A-1, Assertive Community Treatment (ACT) Program
- 8A-2, Facility-Based Crisis Service for Children and Adolescents
- 8A-5, Diagnostic Assessment 8A-6, Community Support Team (CST)
- 8B, Inpatient Behavioral Health Services
- 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers
- 8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of21
- 8D-2, Residential Treatment Services
- 8E, Intermediate Care Facilities for Individuals with Intellectual Disabilities
- 8F, Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD 8G, Peer Support Services
- 8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population
- 8J, Children's Developmental Service Agencies (CDSAs)
- 8L, Mental Health/Substance Abuse Targeted Case Management
- 8N, NC Health Choice Intellectual and Developmental Disabilities Targeted Case Management
- 8-O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders
- 8-P, North Carolina Innovations
- Blood lead screening and exposure - PDF
- Bone graft substitutes - PDF
- Bone marrow transplant for children with hyper IgM disorder - PDF
- Brainstem auditory evoked response - PDF
- Burn Treatments & Skin Substitutes
- 1G-1, Burn Treatment
- 1G-2, Skin Substitutes
-C-
- Canaloplasty and viscocanalostomy for glaucoma - PDF
- Cardiac Procedures
- 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs
- 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound
- Canaloplasty and viscocanalostomy for glaucoma - PDF
- Cecostomy for fecal incontinence - PDF
- Celiac disease - diagnostic testing - PDF
- Cervical cancer and human papillomavirus screening - PDF
- Chiropractic Services
- 1F, Chiropractic Services
- Chlamydia screening - PDF
- Colorectal cancer screening - PDF
- Community-Based Services
- 3A, Home Health Services
- 3B, PACE (Program of All-Inclusive Care for the Elderly)
- 3D, Hospice Services
- 3G-1, Private Duty Nursing for Beneficiaries Age 21 and Older
- 3G-2, Private Duty Nursing for Beneficiaries Under 21 years of Age
- 3H-1, Home Infusion Therapy
- 3K-1, Community Alternatives Program for Children (CAP/C)
- 3K-2, Community Alternatives Program for Disabled Adults (CAP/DA)
- 3L, State Plan Personal Care Services (PCS)
- Computer-aided detection and diagnosis for chest imaging - PDF
- Core decompression for avascular necrosis of the hip - PDF
- Corneal implants - PDF
- D -
- Debridement of diabetic foot ulcers - PDF
- Dermabrasion and chemical peel - PDF
- Dietary Evaluation and Counseling
- 1-I, Dietary Evaluation and Counseling and Medical Lactation Services
- Donor human milk - PDF
- Drug testing - PDF
- Dynamic splinting - PDF
- E -
- Endovenous stents - PDF
- Enhanced cystoscopy for bladder cancer - PDF
- Epidermal nerve fiber density testing - PDF
- Erectile dysfunction treatments other than pharmaceuticals - PDF
- Esophageal pH monitoring - PDF
- Exhaled nitric oxide for diagnosis and management of lung disease - PDF
- External counterpulsation therapy - PDF
- F -
- Facility Services
- 2A-1, Acute Inpatient Hospital Services
- 2A-2, Long Term Care Hospital Services
- 2A-3, Out-of-State Services
- 2B-1, Nursing Facilities 2
- B-2, Geropsychiatric Units in Nursing Facilities
- Fetal surgeries in utero - PDF
- G -
- H -
- Hearing Aid Services
- 7, Hearing Aid Services
- Heart valve transplant - PDF
- Hidradenitis suppurativa surgery - PDF
- Home-use light box therapy for seasonal affective disorder - PDF
- Hydrogel spacer use during radiotherapy for prostate cancer - PDF
- Hyperthermia (therapy for cancer) - PDF
- Hypoglossal nerve stimulation - PDF
- I -
- IFuse implant system - PDF
- Implantable testosterone pellets - PDF
- Inhaled nitric oxide - PDF
- Injectable bulking agents — fecal incontinence - PDF
- Interferon gamma release assays for tuberculosis screening - PDF
- Intermittent pneumatic compression for peripheral artery disease - PDF
- Intracranial hypertension stent - PDF
- K -
- L -
- Laboratory Services
- 1S-1, Genotyping and Phenotyping for HIV Drug Resistance Testing
- 1S-2, HIV Tropism Assay
- 1S-3, Laboratory Services
- 1S-4, Genetic Testing
- 1S-5, Genetic Testing for Susceptibility to Breast and Ovarian Cancer (BRCA)
- 1S-7, Gene Expression Profiling for Breast Cancer
- 1S-8, Drug Testing for Opioid Treatment and Controlled Substance Monitoring
- Leiomyosarcoma and laparoscopic power morcellation - PDF
- Lipoprotein apheresis - PDF
- Lithotripsy treatment for salivary stones - PDF
- Liver elastography - PDF
- M -
- Manipulation under anesthesia (hip and elbow) - PDF
- Maternal Support Services (Baby Love)
- 1M-2, Childbirth Education
- 1M-3, Health and Behavior Intervention
- 1M-4, Home Visit for Newborn Care and Assessment
- 1M-5, Home Visit for Postnatal Assessment and Follow-up Care
- 1M-6, Maternal Care Skilled Nurse Home Visit
- Medical Equipment
- 5A-1, Physical Rehabilitation Equipment and Supplies
- 5A-2, Respiratory Equipment and Supplies
- 5A-3, Nursing Equipment and Supplies
- 5B, Orthotics & Prosthetics
- Medical three-dimensional printing - PDF
- Melody™ transcatheter pulmonary valve replacement - PDF
- N -
- Neuromuscular re-education - PDF
- Noninvasive testing for Helicobacter Pylori - PDF
- Noninvasive tests for rejection surveillance after heart transplant - PDF
- Nonpharmacologic treatments for chronic vertigo - PDF
- O -
- Obstetrics & Gynecology
- 1E-1, Hysterectomy
- 1E-2, Therapeutic and Non-therapeutic Abortions
- 1E-3, Sterilization Procedures
- 1E-4, Fetal Surveillance
- 1E-5, Obstetrics
- 1E-6, Pregnancy Management Program
- 1E-7, Family Planning Services
- Ophthalmological Services
- 1T-1, General Ophthalmological Services
- 1T-2, Special Ophthalmological Services
- P -
- Pediatric intensive feeding programs - PDF
- Pediatric turbinectomy and turbinoplasty - PDF
- Peptide receptor radionuclide therapy - PDF
- Percutaneous sacroplasty - PDF
- Peristeen® anal irrigation system - PDF
- Peroral endoscopic myotomy - PDF
- Pet therapy - PDF
- Pharmacy Services
- 9, Outpatient Pharmacy Program
- 9A, Over-The-Counter Products
- 9B, Hemophilia Specialty Pharmacy Program
- 9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17
- 9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older
- Aduhelm Injection
- Agents for Duchenne Muscular Dystrophy
- Antifungal Agents - Vusion
- Antinarcolepsy/Antihyperkinesis Agents
- Cialis
- Crinone
- Cystic Fibrosis
- Emend
- Emflaza
- Entresto
- Epidiolex Initial PA Criteria
- Epinephrine Auto-Injections
- Evrysdi
- Gattex
- Gocovri and Osmolex ER
- Growth Hormones
- Hematinics (Procrit, Epogen, Aranesp, Mircera, Retacrit)
- Hepatitis C Medications
- Hetlioz
- Immunomodulators
- Ivermectin
- Juxtapid
- Lupus Medications
- Migraine Therapy - Calcitonin Gene-Related Inhibitors
- Monoclonal Antibodies
- Movement Disorders
- Neuromuscular Blocking Agents (Botox, Myobloc, Dysport, Xeomin)
- Opioid Analgesics
- Opioid Dependence Therapy Agents
- PCSK9 Inhibitors
- Mu-Opioid Receptor Antagonists, Peripherally-Acting (Relistor)
- Sedative Hypnotics Synagis Therapeutic Continuous Glucose Monitoring Systems (CGM) and Related Supplies
- Topical Antihistamines
- Topical Anti-Inflammatories
- Topical Local Anesthetics
- Triptans
- Zolgensma
- Phrenic (diaphragmatic) nerve stimulation - PDF
- Physician Administered Drug Program
- Physician Clinical Coverage Policies
- 1A-2, Preventive Medicine Annual Health Assessment
- 1A-3, Noninvasive Pulse Oximetry
- 1A-4, Cochlear and Auditory Brainstem Implants
- 1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment
- 1A-6, Invasive Electrical Bone Growth Stimulation
- 1A-7, Neonatal and Pediatric Critical and Intensive Care Services
- 1A-8, Hyperbaric Oxygenation Therapy
- 1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)
- 1A-11, Extracorporeal Shock Wave Lithotripsy
- 1A-12, Breast Surgeries
- 1A-13, Ocular Photodynamic Therapy
- 1A-14, Surgery for Ambiguous Genitalia
- 1A-15, Surgery for Clinically Severe or Morbid Obesity
- 1A-16, Surgery of the Lingual Frenulum
- 1A-17, Stereotactic Pallidotomy
- 1A-19, Transcranial Doppler Studies
- 1A-20, Sleep Studies and Polysomnography Services
- 1A-21, Endovascular Repair of Aortic Aneurysm
- 1A-22, Medically Necessary Circumcision
- 1A-23, Physician Fluoride Varnish Services
- 1A-24, Diabetes Outpatient Self-Management Education
- 1A-25, Spinal Cord Stimulation
- 1A-26, Deep Brain Stimulation
- 1A-27, Electrodiagnostic Studies
- 1A-28, Visual Evoked Potential (VEP)
- 1A-30 Spinal Surgeries
- 1A-31, Wireless Capsule Endoscopy
- 1A-32, Tympanometry and Acoustic Reflex Testing
- 1A-33, Vagus Nerve Stimulation for the Treatment of Seizures
- 1A-34, Dialysis Services
- 1A-36, Implantable Bone Conduction Hearing Aids (BAHA)
- 1A-38, Special Services: After Hours
- 1A-39, Routine Costs in Clinical Trial Services for Life-Threatening Conditions
- 1A-40, Fecal Microbiota Transplantation
- 1A-41- Office Based Opioid Treatment: Use of Buprenorphine and Buprenorphine-Naloxone
- 1A-42, Balloon Ostial Dilation
- Planned home births - PDF
- Plasmapheresis and plasma exchange - PDF
- Platelet-rich plasma for nonhealing diabetic wounds - PDF
- Podiatry
- 1C-1, Podiatry Services
- 1C-2, Medically Necessary Routine Foot Care
- Port-wine stain and infantile hemangioma treatment - PDF
- Posterior tibial neurostimulation treatment - PDF
- Postural orthostatic tachycardia syndrome treatment with physical therapy - PDF
- R -
- Radiology
- 1K-1 Breast Imaging Procedures
- 1K-2, Bone Mass Measurement
- 1K-6, Radiation Oncology
- 1K-7, Prior Approval for Imaging Services
- Radiation therapy following surgical excision of keloids - PDF
- Radiofrequency ablation of genicular nerves for knee pain - PDF
- Reconstructive Surgery
- 1-O-1, Reconstructive and Cosmetic Surgery
- 1-O-2, Craniofacial Surgery
- 1-O-3, Keloid Excision and Scar Revision
- 1-O-5, Rhinoplasty and/or Septorhinoplasty
- Retinal telescreening for diabetic retinopathy - PDF
- Rib fixation - PDF
- Rural Health Clinics, FQHC, and Health Departments
- 1D-1, Refugee Health Assessments Provided in Health Departments
- 1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments
- 1D-3, Tuberculosis Control and Treatment Provided in Health Departments
- 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
- S -
- Seasonal influenza testing - PDF
- Smell and taste dysfunction testing - PDF
- Solid Organ Transplants
- 11B-1, Lung Transplantation
- 11B-2, Heart Transplantation
- 11B-3, Islet Cell Transplantation
- 11B-4, Kidney (Renal) Transplantation
- 11B-5, Liver Transplantation
- 11B-6, Heart/Lung Transplantation
- 11B-7, Pancreas Transplant
- 11B-8, Small Bowel and Small Bowel/Liver and Multivisceral Transplants
- Somatosensory evoked potentials test - PDF
- Specialized infant formula - PDF
- Specialized Therapies
- 10A, Outpatient Specialized Therapies
- 10B, Independent Practitioners (IP)
- 10C, Local Education Agencies (LEAs)
- 10D, Independent Practitioners Respiratory Therapy Services
- Speech evaluation recording (CPT 70371) - PDF
- Sphenopalatine ganglion block injections for headache - PDF
- Stem Cell Transplants
- 11A-1, Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)
- 11A-2, Hematopoietic Stem-Cell Transplant for Acute Myeloid Leukemia
- 11A-3, Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia
- 11A-5, Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemias
- 11A-6, Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors
- 11A-7, Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma
- 11A-8, Hematopoietic Stem-Cell Transplantation For Multiple Myeloma and Primary Amyloidosis
- 11A-9, Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms
- 11A-10, Hematopoietic Stem-Cell Transplantation (HSCT) for Central Nervous System (CNS) Embryonal Tumors & Ependymoma
- 11A-11, Hematopoietic Stem-Cell Transplant for Non-Hodgkin’s Lymphoma
- 11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells
- 11A-15, Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
- 11A-16, Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
- 11A-17, CAR-T Cell Therapy
- Stereotactic navigation in sinus surgery - PDF
- Streptococcal testing - PDF
- Supraglottoplasty and laryngoplasty - PDF
- T -
- Targeted Case Management
- 12B, Human Immunodeficiency Virus (HIV) Case Management
- Telehealth
- Testing for coronavirus (COVID-19) - PDF
- Tilt table testing - PDF
- Transvaginal and transabdominal ultrasound - PDF
- Treatment of leg length discrepancy - PDF
- Tumor treatment fields for glioblastoma - PDF
- V -
- Vaginitis diagnostic testing - PDF
- Ventricular Assist Device
- 11C, Ventricular Assist Device
- Video head impulse testing - PDF
- Viral load and CD4 testing in human immunodeficiency virus infection - PDF
- Vision Services
- 6A, Routine Eye Exam and Visual Aids for Recipients Under Age 21
- 6B, Routine Eye Examination and Visual Aids for Beneficiaries 21 Years of Age and Older
- Vision therapy for visual system disorders - PDF
- Vitamin D screening - PDF
- Vitiligo dermatology treatment - PDF
- Volatile organic compounds for urinary tract infection - PDF
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