20-709 Medical Policies - 2nd Quarter 2020
Date: 09/17/20
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.
Read the new and updated policies about 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 second quarter of 2020. For a complete description of the background, criteria, references, and coding implications for the medical policies, log on to the provider website and select Medical Policies under Resources for you. Or, go directly to the Provider Library. Policies will have either the Centene or Health Net logo.
Purpose of medical policies
Medical policies offer guidelines to help determine 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 |
Burn Surgery | Policy provides medical necessity criteria for burn debridement and/or excision and the use of skin substitutes for burns during the acute phase of treatment |
Pediatric Oral Function Therapy | Policy includes medically necessary indications for this therapy |
Radiofrequency Ablation of Uterine Fibroids | Considered investigational/experimental
|
| Skin Substitutes for Chronic Wounds | Policy provides medical necessity criteria for skin substitutes in the treatment of chronic wounds and lists various products |
Updated Policies | |
Medical policy | Change |
ADHD Assessment and Testing
| Attention Deficit Hyperactivity Disorder (ADHD):
|
Ambulatory EEG | Ambulatory electroencephalography (EEG): Added the following 2020 CPT codes: 95700, 95705, 95708, 95717, 95719, 95721, 95723, and 95725 |
Biofeedback |
|
Bronchial Thermoplasty | Revised to consider investigational instead of not medically necessary |
Cardiac Rehabilitation, Outpatient | Removed uncontrolled diabetes from the list of contraindications |
Diagnostic Testing Guidelines for 2019 Novel Coronavirus | Note that this policy is subject to change as new guidelines and recommendations are published.
|
Electric Tumor Treating Fields | Added age restriction of ≥ 22 years |
Facet Joint Intervention | In III, Clarified that facet joint injections of the thoracic region are not medically necessary |
Genetic and Pharmacogenetic Testing | Added general criteria and background for pharmacogenetic testing |
| Heart-Lung Transplant | Removed various contraindications related to pulmonary and cardiovascular diseases and edited various malignancy contraindications |
| Homocysteine Testing | Changed borderline B12 deficiency and idiopathic venous thromboembolism (VTE) indications from medically necessary to investigational and revised codes ICD-10 to reflect this change |
| Hospice Care | Replaced “glomerular filtration rate” with “creatinine clearance” in H.3.b and H.3.c |
| Implantable Wireless Pulmonary Artery Pressure Monitoring | Revised to consider investigational instead of not medically necessary |
| Inhaled Nitric Oxide Therapy |
|
| Intestinal and Multivisceral Transplant | Edited malignancy contraindications |
| Lung Transplantation | Edited malignancy contraindications |
| Mechanical Stretching Devices for Joint Stiffness and Contracture |
|
| Non-Invasive Home Ventilator | Added criteria for second/back up noninvasive ventilator from CP.MP.107 DME |
| Pancreas Transplant |
|
| Pediatric Liver Transplant | Edited malignancy contraindication |
| Sclerotherapy for Varicose Veins |
|
| Total Parenteral Nutrition and Intradialytic Parenteral Nutrition | Revised I.A.1. “documentation of failure of enteral (i.e., oral or tube feeding) nutrition” to “Documentation of nutritional insufficiency, in the absence of total parenteral nutrition (TPN)” |
| Trigger Point Injections | CPT 20560 and 20561 added as not supporting coverage criteria |
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
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 |