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20-944 Medical Policies - 3rd Quarter 2020

Date: 11/24/20

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.

Summary Update

See highlights about the latest approved new and updated policies

The new and updated medical policies listed in the complete update were approved by Centene’s Corporate Clinical Policy Committee and/or Health Net’s Medical Advisory Council (MAC) in the third quarter of 2020.

The complete update with an overview of the medical policies is found in 20-944, Medical Policies – 3rd Quarter 2020. You can access this update below.

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.

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.

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center within 60 days, by telephone or through the Health Net provider website as listed below.

Complete Update

See highlights about the latest new and updated policies

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 third 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.

Purpose of medical policies

Medical policies vs member contract

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.

New Policies
Medical policy	Policy statement
Polymerase Chain Reaction Respiratory Viral Panel Testing	Split medical necessity statements to address panels of five pathogens or less and panels of six or more separately Added criteria for panels of five or less pathogens in the outpatient setting. Specified that the test will influence the plan of care, and added the following as indications: testing for other pathogens when COVID-19 suspected and COVID-19 testing is not available soon enough to influence the plan of care; when immunocompromised; or when ordered by an infectious disease specialist or when an infectious disease specialist is not available Moved codes 87632 and 87633 to a table of medically necessary codes when billed with Place of Service (POS) Codes in Table 3 Added codes 0098U, 0099U, 0100U, and 0115U as medically necessary when billed with Place of Service (POS) codes in Table 3
Thymus Transplantation	Policy provides medical necessity criteria for this procedure

Updated Policies
Medical policy	Change
Acupuncture	Section I.C., Added contraindications of severe neutropenia or malignancy or infection at the site of insertion
Air Ambulance	Renamed policy from Fixed Wing Air Transportation to Air Ambulance Removed criteria for fixed wing stating that transport distance exceeds that of rotary wing Applied other fixed wing criteria to both rotary and fixed wing Added example conditions Added indications for which air ambulance transport is not considered medically necessary
Applied Behavioral Analysis (ABA)	Replaced “Lovaas therapy” with Early Intensive Behavior Intervention (EIBI) Updated Section I.A. to include “ABA recommended by a qualified licensed professional” and added definition of “qualified licensed professional” Replaced “plan of care” with “treatment plan” in Section I.D. and added “the number of service hours necessary to effectively address the skill deficits and behavioral excesses is listed in the treatment plan and considers the member’s age, school attendance requirements and other daily activities when determining the number of hours of medically necessary direct service, group and supervision hours” to Section I.E Added “Assessments, evaluations, treatment plans, and documentation is expected to be current within each profession, licensure and state standards.” to Section II.J
Bone-Anchored Hearing Aid (BAHA)	Removed HCPCS code L8613. Added L8692 Added ICD-10 diagnosis codes H61.111–H61.119
Cell Free Fetal DNA Testing	Replaced I.B. “A cell-free fetal DNA test has not been performed in this pregnancy” with “No documentation that a chromosomal abnormality screening test has been performed in this pregnancy,” with examples noted Removed requirement and criteria for high risk for aneuploidy Added requirement of no documentation of a prior abnormal nuchal translucency screening in this pregnancy Removed restriction that fetus is < 23 weeks gestation at the time of the blood draw Added twin gestation as an option in addition to singleton Added CPT code 0168U as medically necessary
Diagnostic Testing Guidelines for 2019 Novel Coronavirus	Modified criteria to reflect Centers for Disease Control and Prevention (CDC) testing guidelines as of July 20, 2020 Added criteria for neonatal testing Added criteria for discontinuation of transmission-based precautions, home isolation and for return to work for healthcare providers Changed antibody/serology testing medical necessity statement to medically necessary for those presenting late in illness, in conjunction with viral testing, and when post-acute infection syndrome is suspected Added antibody testing code 86328 to the table supporting medical necessity, as well as codes 0202U, 0223U, 0224U
Facet Joint Interventions	Section I, Added that interventions should be performed under fluoroscopy or computed tomographic (CT) guidance Added criteria I.A.6 requiring that radiofrequency joint denervation/ablation procedure is being considered Added the following CPT codes as investigational: 0213T, 0214T, 0215T, 0216T, 0217T, and 0218T (diagnostic or therapeutic facet injections by U.S. ultrasound guidance) and noted in background that there is insufficient evidence to support U.S. guided interventions
Fecal Incontinence Treatments	Additional criteria added for sacral nerve stimulators from local coverage article (A53017) Clarified definition of chronic fecal incontinence as greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth Added additional criteria requiring a successful percutaneous test stimulation. Added sacral nerve stimulation for the treatment of chronic constipation or chronic pelvic pain to the not medically necessary Section II
Laser Therapy for Skin Conditions	Section I.A., Revised indication from “Mild, moderate, or severe psoriasis with < 10% body surface area (BSA) involvement” to “Localized plaque psoriasis < 10% body surface area (BSA) involvement, individual lesions, or with more extensive disease”
Mechanical Stretching Devices for Joint Stiffness and Contracture	Added a table of HCPCS codes not supporting medical necessity, including the following codes: E1399, E1801, E1806, E1811, E1815, E1816, E1818, E1830, E1831, E1840, E1841 (stretching devices)
Neonatal Sepsis Management Guidelines	Under Section III. Discharge criteria, added E. Follow-up planned with provider within 48 hours of discharge In background section I.G., changed ≥ 10⁵ colony forming units (CFU) to ≤ 10⁵ CFU
Nerve Blocks for Pain Management	Section I.A.3.b., For occipital nerve block, added “trigger point at the emergence of the greater occipital nerve or in the distribution of C2” as an alternative to tenderness at the affected nerve branch
Reduction Mammoplasty and Gynecomastia Surgery	Added note to reference CP.MP.95 Gender Affirming Procedures for breast surgeries that pertain to gender affirming procedures Section I.A.2., Added criteria for breast reduction for females that cup size has not changed in 6 months Section II.A.4., Added criteria for adolescent males requiring that adult testicular size has been attained
Sacroiliac Joint Fusion	Added clarification to Section II., “that sacroiliac joint fusion procedures, either open or minimally invasive (e.g., iFuse), are investigational for all other indications, including but not limited to, treatment of……”
Sacroiliac Joint Interventions	Added Patrick’s test/flexion, abduction and external rotation (FABER) test as an acceptable pain provocation test in I.A.3
Sclerotherapy for Varicose Veins	In I.A.2., added tributary and accessory vein treatment as indications when meeting the established criteria
Selective Nerve Root Blocks	Clarified criteria in II.B, C, and D.1 that a request for transforaminal epidural steroid injection (TFESI) is for one level bilaterally or up to two levels unilaterally
Skin Substitutes for Chronic Wounds	Section I.A., Added criteria of age ≥ 18 years, or type 1 diabetic Section I.E., Added to the requirement for documentation of effort to cease nicotine use that this does not include nicotine replacement therapy Added to Section II that all indications not noted in section I are not medically necessary Added CPT codes: 15271–15278; updated list of HCPCS codes of current products available, although not inclusive or guarantee of coverage
Tandem Transplant	Section I.B.2., Changed contraindication of significant systemic or multisystem disease to “significant, uncorrectable, life-limiting medical condition Removed substance abuse or dependence contraindication
Testing Select GU Conditions	Added ICD10 codes: O09.521–O09.529
Transcranial Magnetic Stimulation (TMS)	Clarified that Section I. refers to initial approval of TMS sessions Updated item I.B. to reflect “Oversight of treatment is provided by a licensed psychiatrist” Updated I.C. to include “Other standardized scale indicating moderately severe to severe depression” Added Section I.I., “The initial request can be reviewed for up to 20 TMS sessions” Added Section II., to include criteria for authorization of additional TMS sessions
Trigger Point Injections	Section I.B.4, Changed maximum of six injections per year to four
Vagus Nerve Stimulation	Added additional investigational indications for vagus nerve stimulation (VNS) to Section II Removed ICD-10 codes: G40.001, G40.009, G40.201, G40.209, G40.309, G40.A09, G40.409, G40.509, G40.802, G40.909, G40.911 and G40.919 Added ICD-10: G40.813, G40.814

Additional information

Line of Business	Telephone Number	Provider Portal	Email Address
EnhancedCare PPO (IFP)	1-844-463-8188	provider.healthnetcalifornia.com	provider_services@healthnet.com
EnhancedCare PPO (SBG)	1-844-463-8188	provider.healthnet.com	provider_services@healthnet.com
Health Net Employer Group HMO, POS, HSP, PPO, & EPO	1-800-641-7761	provider.healthnet.com	provider_services@healthnet.com
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO)	1-888-926-2164	provider.healthnetcalifornia.com	provider_services@healthnet.com
Medicare (individual)	1-800-929-9224	provider.healthnetcalifornia.com	provider_services@healthnet.com
Medicare (employer group)	1-800-929-9224	provider.healthnet.com	provider_services@healthnet.com
Medi-Cal	1-800-675-6110	provider.healthnet.com	N/A

Last Updated: 11/23/2020