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21-790 Medical Policies - 3rd Quarter 2021

Date: 11/05/21

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 the latest changes to medical policies 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 third quarter of 2021. For a complete description of the background, criteria, references, and coding implications for the medical policies on the provider website.

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) and the Cal MediConnect Member Handbook define 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.

For Cal MediConnect plans, Medicare and Medicaid national and local policies must be applied first for primary coverage guidance.

Updated Policies

Updated Policy number and name	Updated Change
CP.MP.37 – Bariatric Surgery	Numerous changes include: Section II: Removed criteria for electrocardiography (ECG) during cardiac clearance except for high risk. Removed requirement of chest x-ray and specific criteria for polysomnography (PSG), noting that PSG is warranted if obstructive sleep apnea (OSA) screening is positive in II.C. Pulmonary Evaluation. Removed requirement of one year abstinence of drug and alcohol use and urine drug screen if history of abuse in II.F; added “current drug and alcohol abuse” to list of contraindications. Section V: Added one-anastomosis gastric bypass; endoscopic sleeve gastroplasty; transoral endoscopic surgery; vagus nerve blocking (e.g., Maestro) and gastric balloon (e.g., ReShape Duo, Orbera intagastic balloon, Obalon Balloon) to this list of procedures not supported by medical literature. Added the following CPT codes as not supporting medical necessity: 43648, 43882, 64595, 0312T, 0313T, 0314T, 0315T, 0316T and 0317T. Removed criteria options of fasting blood glucose levels.
CP.MP.93 – Bone Anchored Hearing Aids	Revised I.E from “threshold of 20dB” to “threshold of < 20dB” In I.F.4., added idiopathic causes to the list of causes of unilateral deafness.
CP.MP.164 – Caudal or Interlaminar Epidural Steroid Injections	In policy statement, changed “with or without radiographic guidance” to “with imaging, (except in rare instances, with documented justification).” Removed “Request is not for cervical interlaminar epidural steroid injections (ESI) above C7” to B.5, C.3 and D.5.
CP.MP.125 – DNA Analysis of Stool to Screen for Colorectal Cancer	Changed policy statement in I. to note DNA analysis of stool is allowed every 1–3 years.
CP.MP.107 – Durable Medical Equipment and Orthotics and Prosthetic Guidelines	Updated policy to remove neuromuscular stimulator, functional neuromuscular stimulator, and peroneal nerve stimulator, which was transferred to CP.MP.48 Neuromuscular Electrical Stimulation (NMES). Revised section on pneumatic compression devices to state that they are not proven safe and effective for lymphedema of the abdomen, trunk, chest, genitals, or neck; and for arterial insufficiency. Added criteria for Wheelchair-mounted Assistive Robotic Arm (JACO). Reorganized Standing Frame criteria and required that replacement requests also meet existing criteria for the initial request.
CP.MP.129 – Fetal Surgery In Utero for Prenatally Diagnosed Malformations	Added, “D. Placement of a thoraco-amniotic shunt for pleural effusion with or without secondary fetal hydrops,” to criteria set I. Added that repeat utero fetal surgery procedures require secondary review.
CP.MP.87 – Inhaled Nitric Oxide Therapy	Added indications for case-by-case review of inhaled nitric oxide (iNO) initiation for preterm infants <34 weeks at birth to Section II.
CP.MP.85 – Neonatal Sepsis Management	Removed “or level 1 nursery (rev code 171),” from II.D: “Asymptomatic infants with a positive blood culture and no other indications are appropriate for transitional care or level 1 nursery (rev code 171).” Added II.D. to say, “It is difficult to administer intravenous antibiotics in the home with home health care due to the challenge of keeping very small catheters in place and patent.”
CP.MP.170 – Nerve Blocks for Pain Management	Added refractory chronic pancreatitis as an indication for celiac plexus block to Section III. Added ICD -10 codes K86.0 and K86.1 to support coverage criteria. Added insufficient evidence to support peripheral nerve block for treatment of trigeminal neuralgia to VI.D.
CP.BH.300 – Neurofeedback	Annual review by the Behavioral Health Subcommittee. Revision to Description Section: The U.S. Food and Drug Administration (FDA) has not approved this treatment as safe and effective for any condition. The Centers for Medicare & Medicaid Services (CMS) has not approved this treatment as Reasonable and Necessary for any condition. It currently remains Experimental and Investigational. Revision to Policy and Criteria Section I. B, and F, G and H There are significant symptoms that interfere with the individual’s ability to function in at least one life area as measured by a widely recognized validated standardized severity scale focused on the symptom profile. There is evidence that standard evidence-based outpatient treatments (including psychotherapy and medication management) are considered insufficient to safely and effectively treat the patient’s condition. There is a readily identifiable response measurable by a symptom specific validated standardized scale. Neurofeedback training is performed by a physician or qualified non-physician practitioner who has undergone neurofeedback training and certification. This can include nurse practitioners, physician assistants, qualified mental health professionals, psychologists and, where applicable, biofeedback technicians.
CP.MP.48 – Neuromuscular Electrical Stimulation	Added code E0744 to “HCPCS codes that do not support coverage criteria.”
CP.MP.82 – NICU Apnea Bradycardia Guidelines	Neonatal Intensive Care Unit (NICU): In I.A.1 and I.B., changed requirement for no clinically significant events before discharge from “5” to “5–7” days.
CP.MP.81 – NICU Discharge Guidelines	Added I.A.3 regarding weight lost in preterm infants less than a week old. Added a note regarding gastrostomy tube placement recovery/education to I.B.2.d.ii. Updated II.A with temperature range. Added “Chronic Lung Disease (CLD)/” to “Bronchopulmonary dysplasia (BPD)” for condition in III.B.3.a. Added new Section VI regarding caregiver competency. Added A.5 regarding caffeine for apnea. In Discharge Recommended Practices: Added “immunoglobulin” to C.2, updated C.3 with influenza injection.
CP.MP.49 – Physical, Occupational and Speech Therapy	This corporate policy replaces the Health Net Specific policy (HNCA.CP.MP.103).
CP.MP.213 – Post-Acute Care	Updated therapy requirement verbiage for Skilled Nursing Facility (SNF) Level 1 from “skilled therapy for up to 2 hours per day” to “skilled therapy 1–2 hours per day.” For SNF Levels 1 and 2, changed requirement from skilled nursing hours and therapy hours to skilled nursing hours or therapy hours.
CP.MP.51 – Reduction Mammoplasty & Gynecomastia Surgery	Deleted “for non-cosmetic reasons” from the policy statement in I. Replaced "and/or" with "or" in I.A.1. Requirements for both reduction mammoplasty and gynecomastia, and changed requirement of photographic documentation to “photographic documentation may be requested to support written documentation.”
CP.MP.126 – Sacroiliac Joint Fusion	Section I updated to indicate criteria specific to open sacroiliac joint (SIJ) fusion. New criteria added for Section II, specific to minimally invasive SIJ fusion.
CP.MP.166 – Sacroiliac Joint Interventions	Updated I.A. to specify that the criteria apply to therapeutic injections as well as diagnostic. Updated I.B. to state “A second diagnostic or confirmatory sacroiliac joint injection when pain was improved by at least 75% after the first diagnostic SIJ injection”, rather than that pain did not improve. I.C. was updated to specify “therapeutic” SIJ injection. II was changed from 50% to 75%.
CP.MP.146 – Sclerotherapy for Varicose Veins	Clarified in III to cyanoacrylate is used in endovenous ablation and not sclerotherapy.
CP.MP.88, CP.MP.83 – Sickle Cell Observation Carrier Screening for Pregnancy	These policies have been retired because there is Interqual® criteria.
CP.MP.206 – Skilled Nursing Facility Leveling	Updated therapy requirement verbiage for SNF Level 1 from “skilled therapy for up to 2 hours per day” to “skilled therapy 1–2 hours per day.” For SNF Levels 1 and 2, changed requirement from skilled nursing hours and therapy hours to skilled nursing hours or therapy hours.
CP.MP.38 – Ultrasound in Pregnancy	Revised several sections with regard to number of transvaginal ultrasounds for prior preterm births and total number allowed. Note this is subject to Medicaid and Medicare coverage guidelines.

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 portal	provider_services@healthnet.com
EnhancedCare PPO (SBG)	1-844-463-8188	provider portal	provider_services@healthnet.com
Health Net Employer Group HMO, POS, HSP, PPO, & EPO	1-800-641-7761	provider portal	provider_services@healthnet.com
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO)	1-888-926-2164	provider portal	provider_services@healthnet.com
Medicare (individual)	1-800-929-9224	provider portal	provider_services@healthnet.com
Medicare (employer group)	1-800-929-9224	provider portal	provider_services@healthnet.com
Medi-Cal	1-800-675-6110	provider portal	N/A
Cal Mediconnect – Los Angeles County	1-855-464-3571	N/A	provider_services@healthnet.com
Cal Mediconnect – San Diego County	1-855-464-3572	N/A	provider_services@healthnet.com

Last Updated: 11/05/2021