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24-1000m Medical Policies - August 2024

Date: 09/20/24

Review the most recent changes to new and existing 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) for August 2024. 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. That document defines member benefits in addition to eligibility requirements, and coverage exclusions and limits.

  • For Medi-Cal plans, appropriate coverage guidelines take precedence over these plan policies and must be applied first.
  • 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 Policy

Medical policy

Policy statement

Sleep Studies, Adult

Added special article titled, ‘Clinical Practice Guideline for Diagnostic Testing
for Adult Obstructive Sleep Apnea’ from the American Academy of Sleep Medicine (AASM) clinical practice guidelines, Journal of Clinical Sleep Medicine.

Sleep Studies, Pediatric

Added special article titled, ‘Practice Parameters for Respiratory Indications for Polysomnography in Children‘ from the American Academy of Sleep Medicine (AASM) sleep study criteria.

Updated Policies

Policy number and name

Change

CP.BH. 300 –

Biofeedback for Behavioral Health Disorders

  • Removed coding implications section about billing for neurosound/biosound.
  • Added criteria point V. to indicate insufficient scientific evidence to support the efficacy of neurosound/biosound treatment.

CP.MP.203 –

Diaphragmatic/Phrenic Nerve Stimulation

  • Criteria I. updated to include the Spirit Diaphragm Pacing Transmitter.
  • Background updated to include information regarding full FDA approval of the Spirit Diaphragm Pacing Transmitter.

CP.MP.194 –

Osteogenic Stimulation

  • Updated Criteria I.A.3. to state, “appropriate fracture care
    and immobilization.”
  • Updated language in Criteria I.A.4., II.A.4 and III.A.6.a. from radiographs
    to imaging.
  • Updated Criteria II.A.3. to state, “appropriate fracture care
    and immobilization.”

CP.MP. 165 –

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

  • Annual review. In I.B.4.a. and c. and II.B.5.a. and c., changed duration from six weeks to four weeks.
  • Added Table 1 to give examples of particulate and non-particulate steroids.

CP.MP.169 –

Trigger Point Injections for Pain Management

  • Removed “with or without radiographic guidance” language in Criteria I.A. Criteria I.A.1.a. updated to state “myofascial pain.”
  • Removed Criteria II.C. regarding location of trigger point injection in the neck, shoulder, and/or back.

 

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal. Behavioral health providers can call
844-966-0298.
 

This information applies to Physicians, Participating Physician Groups (PPGs), and Behavioral Health Providers.

For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.



Last Updated: 09/18/2024