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Clinical Payment Policies

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
    (does not apply to HSP)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

The following chart lists the policy number, policy name, a description of the policy, and applicable lines of business.

Policy Number

Policy Name

Description of policy

Line of Business

CP.MP.38, effective as of July 5, 2019

Ultrasound in Pregnancy (PDF)

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented.

The following ultrasounds during pregnancy are considered medically necessary: one standard first trimester ultrasound (76801); one standard second or third trimester ultrasound (76805); one detailed anatomic ultrasound (76811) to evaluate for suspected anomaly based on history, laboratory abnormalities or clinical evaluation; or where there are suspicious results from a limited or standard ultrasound. Transvaginal ultrasound (76817) is considered medically necessary when conducted in the first trimester for the same indication as a standard first trimester ultrasound, and later in pregnancy to assess cervical length, location of the placenta in women with placenta previa, or after an inconclusive transabdominal ultrasound. Indications for additional ultrasounds are described in the policy.

Commercial,* Medicare, Cal MediConnect

CA.CP.MP.38, effective as of July 5, 2019

Ultrasound in Pregnancy (PDF)

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented.

The following ultrasounds during pregnancy are considered medically necessary: one standard first trimester ultrasound (76801); one standard second or third trimester ultrasound (76805); one detailed anatomic ultrasound (76811) to evaluate for suspected anomaly based on history, laboratory abnormalities or clinical evaluation; or where there are suspicious results from a limited or standard ultrasound. Transvaginal ultrasound (76817) is considered medically necessary when conducted in the first trimester for the same indication as a standard first trimester ultrasound, and later in pregnancy to assess cervical length or location of the placenta in women with placenta previa. Indications for additional ultrasounds are described in the policy.

Medi-Cal

CP.MP.152, effective as of September 14, 2018

Measurement of Serum 1,25-dihydroxyvitamin D (PDF)

This policy addresses when measurement of 1,25(OH)2D is appropriate and medically necessary

Medicare, Medi-Cal, Cal MediConnect, Commercial*

CP.MP.153, effective as of September 14, 2018

Helicobacter Pylori Serology Testing (PDF)

This policy outlines why serologic antibody testing cannot distinguish between an active infection and a past infection, and why alternative, non-invasive testing methods (for example, the urea breath test and stool antigen test) exist for detecting the presence of H. pylori

Medicare, Medi-Cal, Cal MediConnect, Commercial*

CP.MP.154, effective as of September 14, 2018

Thyroid Hormones and Insulin Testing in Pediatrics (PDF)

This policy discusses the medical necessity requirements for the testing of thyroid stimulating hormone (TSH), thyroxine (T4) as well as by insulin

Medi-Cal, Commercial*

CP.MP.155, effective as of September 14, 2018

EEG in the Evaluation of Headache (PDF)

This policy addresses the use of electroencephalography (EEG) in the diagnostic evaluation of headache

Medicare, Medi-Cal, Cal MediConnect, Commercial*

CP.MP.156, effective as of September 14, 2018

Cardiac Biomarker Testing for Acute Myocardial Infarction (PDF)

This policy discusses the medical necessity requirements for testing of cardiac biomarkers

Medicare, Medi-Cal, Cal MediConnect, Commercial*

CP.MP.157, effective as of September 14, 2018

25-hydroxyvitamin D Testing in Children and Adolescents (PDF)

This policy outlines the recommendations against universal screening for vitamin D deficiency in healthy children

Medi-Cal, Commercial*

*Commercial includes HMO, POS, HSP, PPO, EPO and products offered through Covered California.

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Last Updated: 08/05/2021