25-730m Medical Policies - June 2025
Date:
07/17/25
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 June 2025. For a complete description of the background, criteria, references, and coding implications for the medical policies, go to Health Net 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 Policies
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Policy number and name
| Change
|
|---|
CP.MP.249
Allogeneic Hematopoietic Progennitor Cell Therapy
| - Removed Omisirge specific language from title of policy due to expanding policy.
- Updated Description of policy to include RegeneCyte and updated title in the Note referencing the Medicare version of policy.
- Added Criteria II. to include medically necessary criteria for RegeneCyte…
- Background updated to include RegeneCyte information to align with updated criteria.
|
CP.MP.164
Caudal or Interlaminar Epidural Steroid Injections
| - In Policy/Criteria, removed “and the member/enrollee is not currently being treated with full anticoagulation therapy.”
- If on warfarin, international normalized ratio (INR) should be ≤ 1.4 prior to the procedure” removed from criteria.
|
CP.MP.171
Facet Joint Interventions
| - Updated Criteria I.A.1.b.i. regarding physical therapy.
- Note added under Criteria I.A.1.b.i. regarding physical therapy or prescribed home exercise program in the presence of a facet joint synovial cyst.
- Removed Criteria I.A.1.b.ii. regarding activity modification.
- Updated Criteria I.A.1.c. to include notation about facet joint synovial cyst.
|
CP.MP.137
Fecal Incontinence Treatments
| - Added criteria I.B.1.d., Member/enrollee demonstrates the ability…
- Removed I.B.1.e.iii. Inadequate response to test stimulation…and I.B.3.d., Absence of any physical or mental illness…
- Removed previous criteria I.B.2. for sphincteroplasty.
- Added CPT 44320 and HCPCS C1767, C1778 to coding tables.
|
CP.MP.129
Fetal Surgery in Utero for Prenatally Diagnosed Malformations
| - Removed specific degree requirement for severe kyphosis in Criteria I.G.5.a.
- Removed previous Criteria I.G.5.d. regarding maternal body mass index (BMI) contraindication.
|
CP.MP.206
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing
| - Removed “Note: Atypical clinical presentations…” from I.A.1.
- Minor rewording with no clinical significance to I.F., I.G.3, and II.A.2.a.
- Corrected “…lasting less than…” to “…lasting greater than…” in American College of Gastroenterology section.
- Added CPT code 0369U to Table 2.
- Added ICD-10 code D61.03 to Table 5.
|
CP.MP.120
Pediatric Liver Transplant
| - Removed “at time of diagnosis” from criteria I.B.5.d. and I.B.5.k.
- Under I.B.7.c., reformatted criteria with no impact to criteria.
- Under I.C.4., updated glomerular filtration rate from < 40 to < 30.
|
CP.MP.242
Pulmonary Function Testing
| - Updated Criteria I. for clarity and removed age limit.
- Updated Criteria I.A.1. and I.A.2. regarding the presence or absence of lung dysfunction…
- Updated Criteria I.A.3., I.A.4., I.A.5., and I.A.6. regarding assessment of severity of known lung disease, assessment of the change in lung function…and assessment of the risk for surgical procedures…
- Updated Criteria I.A.7.a. and I.A.7.c. for clarity and to include nonreversibility in Criteria I.A.7.c.
- Added Note under Criteria I.A.7.c. about repeat studies…
- Updated Criteria I.B.1., I.B.2. and I.B.3. regarding evaluation and early detection of pulmonary dysfunction and symptoms…
- Updated Criteria I.B.4., I.B.5., I.B.6., I.B.7., and I.B.8. regarding assessment and response to therapy…preoperative and postoperative evaluations…tracking of pulmonary disease progression, and assessment of effectiveness…
- Note added under Criteria I.B.8. regarding repeat testing...
- Updated Criteria I.C.1. through I.C.9. regarding evaluation and follow up of parenchymal lung diseases…emphysema and cystic fibrosis…differentiating between chronic bronchitis, emphysema and asthma…evaluation of pulmonary involvement in systemic diseases…some types of cardiovascular disease…prediction of arterial desaturation…evaluation and quantification of the disability associated with interstitial lung disease, evaluation of the effects of chemotherapy agents or other drugs…and evaluation of hemorrhagic disorders.
- Added clarifying language to Criteria I.E.2.c.
|
CP.MP. 51
Reduction Mammoplasty and Gynecomastia Surgery
| - Added clarifying language to Criteria I.A.
- Removed “persistent” and “for at least one year” in Criteria I.A.3.
- Added clarifying language to Criteria I.A.3.c. regarding breast pain.
- Added clarifying language regarding inframammary folds in Criteria I.A.3.g.
- Removed criteria II.A.4. requiring adult testicular size to be attained.
|
CP.MP.127
Total Artificial Heart
| Under I.F., added “due to irreversible biventricular heart failure.”
|
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.
Provider Services
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.
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