Clinical Coverage Policies

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For archived versions of clinical coverage policies, please contact Richard K. Davis

  • 1N-1, Allergy Testing
  • 1N-2, Allergy Immunotherapy

15, Ambulance Services

  • 1L-1, Anesthesia Services
  • 1L-2, Moderate (Conscious) Sedation, AKA Procedural Sedation and Analgesia (PSA)
  • 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
  • 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
  • 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 of 21
  • 8D-2, Residential Treatment Services
  • 8E, Intermediate Care Facilities for Individuals with Intellectual Disabilities
  • 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
  • 8O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders
  • 8P, North Carolina Innovations
  • 1G-1, Burn Treatment
  • 1G-2, Skin Substitutes
  • 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs
  • 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound

1F, Chiropractic Services
Chiropractic Services ICD-9 codes in effect through September 30, 2015

NC Health Choice Chiropractic Services

  • 3A, Home Health Services
  • 3B, PACE (Program of All-Inclusive Care for the Elderly)
  • 3D, Hospice Services
  • 3G, Private Duty Nursing
  • 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)
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