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24-403m Medical Policies - March 2024

Date: 04/30/24

Check out the new policies and the latest changes to 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 March 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.
The codes in the below tables refer to HCPCS codes and ICD-10-CM diagnosis codes.
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Updated Policies

Policy number and name

Change

CP.MP.40 –

Gastric Electrical Stimulation

  • Added I.A. "Member/enrollee is ≥ 18 years of age.”
  • Updated I.B. to include "diabetic or" in describing type of gastroparesis.

CP.MP.91 –

OB Home Programs

  • Updated A. to note that the assessment is applicable to sections B to F.
  • Added criteria I.B.1. to include medication infusion therapy is considered medically necessary when meeting all of the following criteria: member/enrollee has tried and failed conservative treatment including medications by mouth and/or per rectum and/or other non-pharmacological treatments.
  • In I.B.2, added: “If re-authorization is requested, the ordering provider has reassessed the member since the previous authorization and documented the need for continuation of infusion therapy.”
  • Combined sections I.E. and I.D. along with sections I.F. and I.G. with no impact to criteria.
  • Removed mention of the case rate in section D.
  • Minor rewording of I.D. and I.E. for clarity.
  • In I.D., specified that the program is for those with gestational hypertension as well as pre-existing type I and II diabetes.
  • In I.D.1., added requirement that the program includes diabetic nutrition education.
  • In I.E., clarified that the program also applies to chronic hypertension and added a note stating that preeclampsia with severe features is managed inpatient.
  • In I.E.b.1., added the option for a previous episode of postpartum hypertension.
  • Added to I.E.2. that virtual follow up would include remote blood pressure monitoring.
  • Removed section I.H. including related content and criteria.
  • Added II.G.
  • Preterm labor management and II.H 17-hydroxyprogesterone caproate.
  • Added HCPCS codes G0162, G0299, S9145, S9351, S9353, and S9379.
  • Added CPT codes 99601 and 99602.

CP.MP.132 –

Heart-Lung Transplant

  • Added indication to criteria I.A.1.j. Expanded criteria I.C.1. to I.C.1.a. through c.
  • Removed contraindication I.C.17., active peptic ulcer disease.

CP.MP.102 –

Pancreas Transplantation

  • Expanded criteria I.B. to I.B.a. through c.

CP.MP.141 –

Non-Myeloablative Allogeneic Stem Cell Transplants

  • Removed Hodgkin’s lymphoma from Criteria I.A.9. per updated National Comprehensive Cancer Network (NCCN) recommendations.
  • Added Criteria I.A.13.e. to include polycythemia vera.
  • Updated Criteria I.B.4.b. from diffusing capacity of the lung for carbon monoxide (DLCO) ≤ 50% of predicted value to DLCO ≤ 60% of predicted value.
  • Removed absolute contraindications in Criteria I.C.

CP.MP.162 –

Tandem Transplantation

  • Added a. through c. to I.B.10.; a. CD4 cell count > 200 cells/mm3, b. Absence of active AIDS-defining opportunistic infection, and c.
  • Member/enrollee is currently on effective ART (antiretroviral therapy).

CP.MP.250 –

Lantidra

  • Added note to description regarding Medicare policy version.
  • Removed maximum age requirement from Criteria I.A.

HNCA.CP.MP.150 –

Benign Skin Lesion Removal

  • Change in Section IV to remove the limitation for PDT with blue light for just the face and scalp.

Inactive policies

The following policies have been retired:

Policy number

Policy name

HNCA.CP.MP.375

Central Auditory Processing Disorder

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.

Line of business

Phone number

Ambetter from Health Net IFP
Ambetter PPO

844-463-8188

Ambetter HMO

888-926-2164

Health Net Employer Group HMO, POS, & PPO

800-641-7761

Medi-Cal (including CS and ECM providers)

800-675-6110

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: 04/26/2024