No Longer Active Clinical Coverage Policies
and Provider Manuals
The North Carolina Division of Medical Assistance has archived the following because they are no longer active.
No Longer Active Clinical Coverage Policies and Manuals
- Biventricular Pacemaker for the Treatment of Congestive Heart Failure, 11D (Date of Termination 4/30/12)
- Bone Morphogenic Protein-2, 11H (Date of Termination 3/1/12)
- Child Service Coordination, 1M-1 (Terminated eff. 3/1/11)
- Compression Garments, 1A-1 (8/1/05)
- Donor Leukocyte, Donor Lymphocyte or Buffy Coat Infusion for Hematologic Malignancies that Relapse or at a High Risk for Relapse after Allogeneic Stem Cell Transplantation, 11A-4 (Date of Termination 12/31/2011)
- Extracorporeal Membrane Oxygenation/Extracorporeal Life Support, 11F (Date of Termination 4/30/12)
- High Dose Chemotherapy, Bone Marrow or Peripheral Stem Cell Transplant for Ovarian Cancer and Germ Cell Tumors Arising in the Ovaries, 11A-13 (Date of Termination 3/1/12)
- Home Tocolytic Infusion Therapy, 3H-2 (Date of Termination 8/31/2011)
- Implantable Cardioverter Defibrillator, 11E (Date of Termination 4/30/12)
- In-Home Care for Adults, 3E (Date of Termination 12/31/12)
- In-Home Care for Children, 3F (Date of Termination 12/31/12)
- Maternity Care Coordination, 1M-8 (Terminated eff. 3/1/11)
- Non-Myeloablative Allogeneic Stem Cell Transplant (Mini-Transplant, Mini-Allograft Reduced Intensity Conditioning) for Treatment of Malignancies, 11A-12 (Date of Termination 4/30/12)
- Personal Care Services and PCS-Plus, 3C (Date of Termination 5/31/11)
- Photophoresis for Solid Organ Rejection Autoimmune Disease and GVHD, 11G (Date of Termination 3/1/12)
- Prior Authorization for Outpatient Pharmacy Point-of-Sale Medications, A3 (Date of Termination 9/30/12)
- Laboratory Services - Provider Seminar Handout (Replaced by 1S-3, Laboratory Services 4/1/12)
- Panniculectomy, 1A-10 (End Date 10/1/10)
- Section 12 - Community Alternatives Program for Disabled Adults (CAP/DA)
Coverage provided under
3K-2, Community Alternatives Program for Disabled Adults and Choice Option (CAP/DA-Choice) (3/12/12)
