20-435 Medical Policies - 1st Quarter 2020
Date: 06/02/20
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 first quarter of 2020. A complete description of the updated medical policies is on the provider website. 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 |
|---|---|
| Diagnostic Testing Guidelines for 2019 Novel Coronavirus | The policy for novel coronavirus testing is based on CDC guidelines and subject to change based on Centers for Disease Control and Prevention (CDC) updates |
Updated Policies
| Medical policy | Change |
|---|---|
| Allergy Testing |
|
| Allogeneic Hematopoietic Cell Transplant for Sickle Cell Disease | Removed I.A.4. Requirement of a standard, myeloablative conditioning regimen |
| DME |
|
| Digital EEG Analysis | Removed Quantitative Electroencephalography (EEG) from criteria I |
| Evoked Potentials |
|
| Facet Joint Intervention | Under III, clarified that facet joint injections of the thoracic region are not medically necessary |
| Fractional Exhaled Nitric Oxide | Under Policy/Criteria, added that testing fractional exhaled nitric oxide (FeNO) is investigational for all other conditions, in addition to asthma, with supporting sources |
| Hyperemesis Gravidarum Treatment | Under Background, initial therapy section, noted that an extended release pyridoxine/doxylamine combination product is preferred |
| Hyperhidrosis Treatments | Section IV, added liposuction as the sole method of removing axillary sweat glands as investigational |
| Inhaled Nitric Oxide Therapy | In continuation criteria, clarified that member must have previously met initial approval criteria |
| Nerve Blocks for Pain Management | Added “neurolysis” as a not medically necessary procedure to Section V. on genicular nerve block |
| Nonmyeloablative Allogeneic Transplants |
|
| Obstetrical Home Health Programs |
|
| Pancreas Transplant |
|
| Pediatric Heart Transplantation | In I.D.15., replaced “Class II or III obesity (body mass index (BMI) ≥35.0 kg/m2) with BMI ≥120% of the 95th percentile and added a link to the CDC clinical growth charts |
| Pediatric Liver Transplant | I.C.13., added contraindication of substance use or dependence |
| Posterior Tibial Nerve Stimulation for Voiding Dysfunction |
|
| Proton & Neutron Beam Therapy | I.L., I.M., I.N, added indications for non-Hodgkin’s lymphoma, esophageal and esophagogastric junction cancers and non-small cell lung cancers |
| Sacroiliac Joint Interventions |
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| Selective Nerve Root Blocks |
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| Stereotactic Body Radiation Therapy |
|
| Guideline | New Guideline Links |
|---|---|
| Adult Preventive Health Guidelines | Note that the changes are based on updates from the United States Preventive Services Task Force (USPSTF) in 2019 that address: Breast cancer (BRCA) testing, screening for HIV infection in adults and prophylactic medications, risk reducing medications for women at increased risk for breast cancer |
Additional information
If you have questions about the information contained in this update, contact the Health Net Provider Services Center by email at provider_services@healthnet.com within 60 days, by telephone or through the Health Net provider website:
Line of Business | Telephone Number | Provider Portal | Email Address |
EnhancedCare PPO (IFP) | 1-844-463-8188 | provider_services@healthnet.com | |
EnhancedCare PPO (SBG) | 1-844-463-8188 | ||
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | ||
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | ||
Medicare (individual) | 1-800-929-9224 | ||
Medicare (employer group) | 1-800-929-9224 | ||
Medi-Cal | 1-800-675-6110 | N/A
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