25-175m Medical Policies - January 2025
Date:
02/21/25
Review the most recent 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 January 2025. For a complete description of the background, criteria, references, and coding implications for the medical policies, go to 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.
Updated Policy
|
|---|
Policy number and name
| Change
|
CP.MP.62
Hyperhidrosis Treatments
| - Updated criteria I.E.3. by removing (hyperhidrosis often improves pregnancy).
- Removed previous Criteria I.E.5. regarding cracked skin near the treatment area.
- Added epilepsy to Criteria I.E.5.
- Updated Criteria II.A. to include through Criteria I.E.
- Updated Criteria III.A. to include through Criteria I.E.
- Updated verbiage in Criteria III.B., Criteria III.F., Criteria III.G., Criteria III.H., and Criteria III.I. with no impact to criteria.
- Updated verbiage in Note section at the end of Criteria III. with no impact to criteria.
- Added diathermy to notation at end of coding section regarding insufficient evidence in the peer-reviewed literature.
|
CP.MP.70
Proton and Neutron Beam Therapies
| - Updated Criteria I.A. to include intraocular melanomas and removed language regarding fiducial markers.
- Added clarifying language to Criteria I.B. regarding primary spine or spinal cord tumors or metastatic tumors of the spine or spinal cord where organ at risk tolerance may be exceeded with photon treatments.
- Updated Criteria I.D. by removing “Primary” and including intra-hepatic biliary cancers.
- Updated Criteria I.E. by adding “or other hematologic malignancies” and changing ≤ 18 years old to ≤ 21 years old.
- Updated verbiage in Criteria I.F to state “Tumors/cancers that can be treated with any other type of radiation in members/enrollees with a known genetic mutation/syndrome.”
- Updated verbiage in Criteria I.G. to include malignant and benign primary CNS tumors, excluding IDH wild-type glioblastoma (GBM).
- Added clarifying language to Criteria I.J. and removed additional language regarding when normal tissue constraints cannot be met be met by photon-based therapy.
- Added cancers of the nasopharynx and nasal cavity to Criteria I.J.
- Removed “i.e., preoperative treatment of resectable disease or primary treatment for those with unresectable disease” in Criteria I.K.
- Combined previous Criteria I.N. regarding thymomas and thymic carcinoma with Criteria I.M. regarding primary tumors of the mediastinum.
- Added Criteria I.O. for malignant pleural mesothelioma.
- Added Criteria I.P. for primary malignant or benign bone tumors.
- Added Criteria I.Q. for medically inoperable patients with a diagnosis of cancer typically treated with surgery where dose escalation is required due to the inability to receive surgery.
- Added Criteria I.R. for primary and metastatic tumors requiring craniospinal irradiation.
- Added Criteria I.S. for primary cancers of the esophagus.
- Added Criteria I.T. for advanced and unresectable pelvic tumors with significant pelvic and/or peri-aortic nodal disease.
- Added Criteria I.U. for members/enrollees with a single kidney or transplanted pelvic kidney with treatment of an adjacent target volume and in whom maximal avoidance of the organ is critical.
- Added Criteria I.V. for salivary gland tumors.
|
CP.MP.107
DME
| - Replaced codes K1032 and K1033 with E0678 and E0679 under non-pneumatic compression devices.
- Added additional note to enclosed bed section.
- Removed halo procedure and equipment criteria due to no prior auth.
- Removed lumbar sacral orthotics criteria, defer to InterQual.
- Updated verbiage and coding in spinal orthotics section.
- Updated criteria under hip orthotics.
- Added section and code L2006 for microprocessor-controlled knee-ankle-foot orthoses (KAFO).
- Removed code L4130 under shoulder, elbow, wrist, hand, finger orthotics.
- Updated code E2300 to E2298 under power seat elevator on power wheelchair.
- Updated wheelchair repairs section to include wheelchair and other DME repairs.
|
CP.MP.142
Urinary Incontinence Devices and Treatments
| - Added language to Criteria I. regarding a United Sates Food and Drug Administration (FDA) approved device.
- Minor rewording in Criteria I.B. with no impact to criteria.
- Added language to Criteria II. to include an FDA approved device.
- Updated verbiage in Criteria II.B. to state “at least” a 50% reduction in incontinence.
- Reworded Criteria III.B. for flow and changed Kegel exercises to pelvic floor therapy.
|
CP.MP.168
Biofeedback
| - Reworded Criteria I. for clarity and removed statement in Criteria I. regarding reconsideration of medical necessity if more than 14 biofeedback treatment sessions in a 12-month period.
- Reworded Criteria I.A. for clarity and removed criterion regarding individual being capable of participating in treatment plan and incorporated this into Criteria I.A.
- Removed criterion requiring a readily identifiable and measurable response and criterion regarding qualified practitioners who can perform biofeedback training.
- Reworded Criteria I.B. for clarity.
- Removed gender specific verbiage, no cognitive impairments, and Kegel exercise verbiage in Criteria I.B.1.
- Updated Criteria I.B.4. to only state “chronic constipation” for clarity.
- Updated Criteria I.B.5. to only state “tension or migraine headaches” for clarity.
- Removed verbiage regarding a rehabilitation program in Criteria I.B.6. for chronic pain.
- Removed verbiage regarding more conventional treatments being unsuccessful in Criteria I.B.7. for clarity.
|
CP.MP.173
Implantable Intrathecal or Epidural Pain Pump
| - Removed criteria I.A.2.f. regarding active participation in psychotherapeutic interventions.
|
CP.MP.180
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
| - Updated I.C.3.a. from apnea-hypopnea index (AHI) of >15 and < 100 to ≥ 15 and ≤ 100.
- Added contraindication I.D.8. Member/enrollee has rhabdomyolysis.
|
CP.MP.190
Outpatient Oxygen Use
| - Removed criteria I.C. The qualifying blood gas study or pulse oximetry measurement was performed by a physician or by a qualified provider or supplier of laboratory services.
- Added CPT E0447 to coding table.
|
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.
Provider Portal
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.
