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21-555 Medical Policies - 2nd Quarter 2021

Date: 07/30/21

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 second quarter of 2021. For a complete description of the background, criteria, references, and coding implications for the medical policies, go 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.

**New Policies**
Medical policy	Policy statement
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder	Behavioral health policy addresses the medical necessity criteria for transcranial magnetic stimulation (TMS) for obsessive compulsive disorder (OCD).
Electromyography and Nerve Conduction Studies	This policy addresses the medical necessity criteria for electromyography (EMG) and nerve conduction studies (NCS).
Repair of Nasal Valve Compromise	Repair of nasal valve compromise is medically necessary when meeting all of the criteria.

**Updated Policies**
Medical policy	Change
ADHD Assessment and Testing	Revised language in I.A.5.d to specify electrocardiogram (ECG) can be performed only if clinically indicated. Added CPT codes 93000, 93005 and 93010 to the not medically necessary table when billed with a sole diagnosis of attention deficit hyperactivity disorder (ADHD). Added assessment of serum lipid profiles to II.A, as well as applicable codes 80061, 83718, 83719, 82721, 83722 and 84475 to not medically necessary table when billed with a sole diagnosis of ADHD. Removed CPT codes 92585 and 92586 deleted in 2021. Replaced with codes 92650, 92651, 92652, and 92653.
Disc Decompression Procedures	Changed policy statement in II regarding minimally invasive procedures from “investigational” to stating that the listed procedures are not superior to other technologies.
Durable Medical Equipment and Orthotics and Prosthetics Guidelines	Added criteria for enclosed beds to “Other Equipment” section of policy. Added references and codes E0316, E1399 and E0328 or E0329 (when combined with E0316 or E1399) for enclosed beds.
Early Elective Deliveries Before 39 Weeks Gestation	Added link to updated American College of Obstetrics and Gynecology (ACOG) Committee Opinion 818 with revisions to delivery timing recommendations, fetal growth restriction and intrahepatic cholestasis of pregnancy.
Evoked Potential Testing	Added replacement CPT codes 92652 and 92653 to the table under Coding Implications.
Gender Affirming Procedures	Replaced “psychiatrist/psychologist” with “qualified behavioral health practitioner.” Revised letter requirement, removed requirement for 12 months in associated gender for chest surgery. Reformatted surgical procedure requirements by type of surgery and added criteria to those sections rather than having a general criteria section. Replaced ‘electrolysis’ with “hair removal” to indicate other acceptable methods.
Hospice Care	Updated “creatinine clearance < 10 (or < 15 with diabetes), or creatinine clearance < 15 with CHF (or < 20 with diabetes and CHF)” to “creatinine clearance <15 ml/min” per LCD L34538 update.
Nerve Block for Pain Management	Added the following note to VI. Peripheral/ganglion nerve blocks: Peripheral/ganglion nerve blocks may be approved without prior authorization when used during another medically necessary procedure (i.e., as anesthesia during surgery).
Non-Emergency Ambulance Transportation	Added codes to ICD-10 section and noted that the list is not inclusive and dependent on member benefit: Z74.01 Bed confinement status. Z74.3 Need for continuous supervision. Z78.1 Physical restraint status. Z99.89 Dependence on other enabling machines and devices.
Panniculectomy	Expanded criteria for complications related to pannus to include non-healing ulceration under panniculus, chronic maceration or necrosis of overhanging skin folds, recurrent or persistent skin infection under panniculus, intertriginous dermatitis or cellulitis or panniculitis. Added the following ICD 10 codes: L03.319, L03.818, L98.499. Separated “D” into separate criteria points, D and E, adding that bariatric surgery weight loss must be stable for six months.
Percutaneous Left Atrial Appendage (Watchman)	Verbiage edits to I.B, adding contraindications of 1–11 in addition to the note regarding warfarin. Replaced “investigational” in II with “there is a paucity of evidence regarding the long-term safety and efficacy of all other percutaneous devices for occlusion of the LAA …”
Skilled Nursing Facility Leveling	Added note to refer to CP.MP.213 Post-Acute Care if InterQual^®criteria is not available. Specified that criteria I applies to facilities contracted for levels 1–4 and added criteria II, which applies to facilities contracted for levels 1–5. Condensed criteria that was the same between levels. Changed hourly requirements for nursing and therapy for each level of care Updated background.
Skin Substitutes for Chronic Wounds	HCPCS codes removed as they are not included in Medicare Article A56696: Q4150, Q4183, Q4190, Q4208–Q4226. Q4210, Q4217, Q4219, and Q4220 also removed. New codes added (from Article A56696): Q4176, Q4237, Q4238, and Q4239.
Spinal Cord Stimulation	Revised I.A.6–7, B.6–7, C.4–5, D.5–6, and E.8–9 to strengthen criteria for psychological evaluation and drug abuse.
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition	Added indications for radiation enteritis, liver failure in children, liver failure in adults, and acute necrotizing pancreatitis in adults, in I.A.2.j–I.A.2.m, along with relevant ICD-10 codes (i.e., K52.0, K72.00–K72.91, K85.01, K85.02, K85.11, K85.12, K85.31, K85.32, K85.81, K85.82, K85.91, K85.92 and Z76.82). In I.B.2, changed “end-stage renal disease” to “stage 5 chronic kidney disease.” Replaced “experimental/investigational” with “not proven safe and effective” in section II.
Vagus Nerve Stimulation	Added new HCPCs code K1020 to a new table of HCPCS codes that do not support coverage criteria.

**Clinical Practice Guidelines**
Clinical Practice Guidelines Grid	Updated grid to include behavioral health guidelines sources.

Additional information

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

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: 07/29/2021