22-077 Medical Policies - 4th Quarter 2021
Date: 02/04/22
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 fourth quarter of 2021. Visit our medical policies for a complete description of the background, criteria, references, and coding implications for the medical policies.
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 benefit plan coverage document states otherwise. This document 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.
For Cal MediConnect plans, Medicare and Medicaid national and local policies must be applied first for primary coverage guidance.
Medical policy | Policy statement |
|---|---|
CP.MP.209 – Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing | This policy addresses the medical necessity criteria for gastrointestinal pathogen nucleic acid detection panel testing. |
CP.MP.202 Orthognathic Surgery | This policy describes the medical necessity requirements for orthognathic surgery. |
CP.MP.194 Osteogenic Stimulation | This policy outlines the medical necessity criteria for electrical and ultrasonic osteogenic stimulators to enhance the bone healing process. |
Policy number and name | Change |
|---|---|
CP.MP. 158 – Ambulatory Surgery Center Optimization |
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CP.MP. 164 – Caudal or Interlaminar Epidural Steroid Injections | Removed “Request is not for cervical interlaminar ESI above C7” from B.5, C.3 and D.5. |
CP.MP. 53 – Ferriscan | Added I.H., “Hemodialysis for end stage renal failure” as an indication. |
CP.MP.136 – Home Birth |
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CP.MP.170 – Nerve Blocks for Pain Management | Edited note in section VI to state: If administered as part of a surgery or other procedure, coding for peripheral/ganglion nerve blocks should follow proper coding practices and would not be subject to prior authorization or payment separately from the procedure. |
CP.MP.190 – Oxygen Use and Concentrators |
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CP.MP.51 – Reduction Mammoplasty & Gynecomastia Surgery |
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CP.MP.151 – Transcatheter Closure of Patent Foramen Ovale
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CP.MP.152 – Vitamin D, Measurement of Serum |
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Clinical Practice Guidelines Grid |
|
Policy number | Policy name |
|---|---|
CP.MP.119 | Balloon Sinus Ostial Dilation |
HNCA.CP.MP.283 | Neovascular Macular Degeneration |
CP.MP.84 | Cell-free Fetal DNA Testing |
CP.MP.125 | DNA Analysis of Stool |
CP.MP.103 | FeNo |
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center within 60 days, by phone or through the Health Net provider website as listed below.
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
EnhancedCare PPO (IFP) | 1-844-463-8188 | ||
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 Advantage (HMO/PPO) (Wellcare By Health Net) | 1-800-929-9224 | ||
Medi-Cal | 1-800-675-6110 | N/A | |
Cal MediConnect – Los Angeles County | 1-855-464-3571 | N/A | |
Cal MediConnect – San Diego County | 1-855-464-3572 | N/A |