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20-217 Medical Policies - 4th Quarter 2019

Date: 03/06/20

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.

Review new and updated policies to stay current on clinical criteria for procedures and services

The medical policies listed in this update were approved by Centene’s Corporate Clinical Policy Committee and/or Health Net’s Medical Advisory Council (MAC) in the fourth quarter of 2019. A complete description of the updated medical policies is on the provider website at provider.healthnet.com. Then, select Working with Health Net > Clinical > Medical Policies. Policies will have either the Centene or Health Net logo.

Purpose of medical policies

Medical policies offer guidelines to help decide medical necessity for certain procedures, equipment and services. They are not intended to give medical advice or tell providers how to practice. If required, providers must get prior authorization before services are given.

Medical policies vs member contract

All services must be medically needed, unless the member’s individual benefits contract states otherwise. The Evidence of Coverage (EOC) or Certificate of Insurance (COI) defines member benefits in addition to eligibility requirements, and coverage exclusions and limits.

If legal or regulatory mandates apply, they may override medical policy.
If there are any conflicts between medical policy guidelines and related member benefits contract language, the benefits contract will apply.

For Medicare Advantage plans, apply the Medicare national and local policies for primary coverage guidance. For Medi-Cal plans, appropriate coverage guidelines take precedence over these plan policies and must be applied first.

New Policies
Medical policy		Policy statement
Antithrombin III		Medically necessary for the diagnosis of hereditary antithrombin deficiency and either treatment or prevention of thromboembolism and human-derived antithrombin III (Thrombate III^®), or for prevention of peri-operative and peri-partum thromboembolism and recombinant antithrombin III (Atryn^®) or Thrombate III
Implantable Hypoglossal Nerve Stimulation		Medical necessary for the treatment of moderate to severe obstructive sleep apnea when criteria in the policy are met
Video EEG		Policy provides medical necessity criteria for performance in a monitored setting (ambulatory or inpatient, including observation) and describes specific indications when there is a known seizure disorder; suspected epileptic seizures, when single event EEG or ambulatory EEG monitoring is inconclusive; describes specific indications in suspected non-epileptic seizure; and for preoperative evaluation of patient undergoing epilepsy surgery or implantation of intracranial electrodes. Outpatient video encephalography (EEG) monitoring in the home is not medically necessary
Updated Policies
Medical policy		Change
Balloon Sinuplasty for Treatment of Chronic Sinusitis		Added ≥ 2 years in the pediatric section
Bariatric Surgery		II.B., Noted that glycemic control requirement does not apply to those who qualify for surgery based on BMI between 30 and 35 with type 2 diabetes mellitus (DM) II.B.1., Changed HbA1C requirement to < 7% instead of 6.5-7%
Cardiac Risk Assessment-Laboratory Tests		Removed homocysteine since there is a separate corporate policy I.B., Added under medically necessary: Apolipoprotein B in high-risk individuals to assess if additional intense interventions are necessary when low density lipoprotein (LDL) cholesterol goals are reached but investigational for general population screening (II.E.)
Clinical Trials		Added link to California Senate Bill No. 583 effective in January 2020
Cosmetic and Reconstructive Surgery		Removed from medically necessary section procedures that are found in Interqual^® (nasal surgery, Nuss procedure)
DNA Analysis of Stool to Screen for Colorectal Cancer		I.A., Changed age supporting medical necessity from 50–85 to 45–85
Endometrial Ablation		I.A.2., Added “abnormal uterine bleeding” as an indication and combined this with the residual menstrual bleeding after androgen therapy in a female to male transgender person indication Removed reference to criteria in CP.MP.95 Gender Affirming Procedures Added the following codes as medically necessary: N92.5, N92.6, N93.8, N93.9 to the ICD-10-CM Code table
Evoked Potentials		Removed age limit in I.B.6 and replaced with “infants and preverbal children or children with developmental delay or intellectual disability”
Facet Joint Interventions		Moved A.1 to A.5 and clarified that injections must be two weeks apart if a second injection is required due to a lack of positive response
Fecal Incontinence Treatments		Revised I.C.3.b. to state, "Failure of, or not a candidate for, medical interventions or surgical sphincter repair" Added CPT code 64566 and HPCPS code L8605 as codes that do not support medical necessity
Ferriscan		Replaced codes D61.89 and D61.9 with expanded range of D61.01–D61.9 in the ICD-10-CM Code table that supports coverage
Gastric Electrical Stimulation		Removed contraindications of alcohol dependency, dialysis, and cancer w/limited life span

	Gender Affirming Procedures	Previously entitled “Gender Reassignment“ Procedures Replaced term “gender reassignment” with “gender affirmation” throughout the policy and changed title to “Gender Affirming Procedures” Codes reviewed (14040 corrected and added14001 and 15101)
	Genetic Testing	Under I.E., Added that technical and clinical performance of the genetic test is supported by published peer-reviewed medical literature
	Hyperhidrosis Treatments	Removed informational codes for chemical denervation of sweat glands: 64560, 64563. Added codes 11450 and 11451 in the CPT Codes table
	Infusion Therapy Site of Care Optimization	I.D., Added an indication for homelessness or an unsafe environment with no ambulatory infusion center available
	Neovascular (Wet) Macular Degeneration Treatment	II., Clarified that thermal laser photocoagulation may be considered medically necessary in select cases for the treatment of neovascular age-related macular degeneration (AMD) for well-demarcated extrafoveal classic choroidal revascularization (CNV) and for small lesions outside the central macula
	Nerve Blocks for Pain Management	Corrected V. on Genicular Nerve Blocks and Neurotomy to state that they are experimental vs not medically necessary VI. Peripheral/Ganglion Nerve Blocks: Section A indication added for peripheral nerve blocks for malignant pain Section B.1. and 2., Added indication for diagnosis or treatment of post-herniorrhaphy pain and therapeutic post-herniorrhaphy pain Section C, Added peripheral nerve blocks for prevention or treatment of headaches, including migraines, refractory migraines in pregnancy, and short-lasting unilateral neuralgiform headaches as not medically necessary
	Sclerotherapy for Varicose Veins	Added VenaSeal^™ as an example of cyanoacrylate in the investigational statement in section III. Added codes for cyanoacrylate (36482, 36483) to a new table of CPT codes that do not support medical necessity I.A.2., Added perforating veins under a current or healed ulcer as an indication; edited previous criteria for saphenous veins to apply to saphenous veins or perforating veins
	Transcatheter Closure of Patent Foramen Ovale	I., Added Gore^® Cardioform as an FDA-approved device appropriate for medically necessary closure of PFO
	Urinary Incontinence Devices and Treatments	I. and II., Separated out criteria for trial and placement of sacral neuromodulation (SNM), with trial criteria being the same as permanent placement, excluding the permanent placement requirement for a positive response to the trial
	Urodynamic Testing	I.D.8., Added indication of complex anorectal malformation, along with accompanying diagnosis codes of Q42.0–Q42.3 under ICD-10-CM that support medical necessity II.B., Noted in investigational statement regarding asymptomatic patients, that evaluation of suspected urological abnormalities is appropriate in the presence of complex anorectal malformation Added ICD-10-CM code R39.14 to support medical necessity of all procedure codes Added ICD-10-CM code R35.1 to support medical necessity for CPT 51798
	Wheelchair Seating	Added G61.0, G71.00, G71.01, G71.02, and G71.09 as medically necessary per revised local coverage determination (LCD) Added ICD-10 codes M62.3, M62.89, Q67.8, Q68.1, and Q74.3 as codes that support E2609 which were inadvertently omitted from this section of the policy

Last Updated: 03/05/2020