Medical Policies

Please note the following changes will be implemented to the designated medical policies.

  • Effective 02/09/2022, MetroPlusHealth is implementing MPS 339 (Urinary Biomarkers) and MPS 340 (Unspecified Polymerase Chain Reaction Testing). We will not cover urinary biomarkers (88120, 88121) as a screening tool for bladder malignancy.  We will cover unspecified polymerase chain reaction testing (87798) up to 2 units per DOS prior to requiring additional information.
  • Effective 6/3/2021, MetroPlusHealth revised medical policy UM-MP231 Allergy Testing. We will only cover allergy testing when it is performed by board certified or residency trained Allergists/Immunologists or Dermatologists.
  • MetroPlusHealth covers treatment for Facial Lipoatrophy with FDA-approved fillers due to antiretroviral therapy in HIV infected persons. Effective 6/3/2021, MetroPlusHealth revised medical policy UM-MP240 Treatment for HIV-Associated Facial Lipoatrophy with FDA-Approved Fillers. Coverage is now limited to Medicaid, Special Needs Plan (SNP), Health and Recovery Plan (HARP) and Medicare members. Prior authorization is required. Providers should continue to request authorization for treatment of members in other lines of business who have previously received authorization from MetroPlusHealth and require continued treatment.

MetroPlus Health Plan utilizes clinical review criteria based upon a review of currently available clinical information(including Change Healthcare InterQual guidelines, clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).

MetroPlus Health Plan expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by MetroPlus Health Plan, as some programs exclude coverage for services or supplies that MetroPlus Health Plan considers medically necessary. If there is a discrepancy between our internal established guidelines and a member’s benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members.

last updated: November 9, 2022

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