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Policies & Criteria

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Health Net Clinical Policy Manual apply to Health Net members. Policies in the Health Net Clinical Policy Manual may have either a Health Net or a “Centene” heading. Health Net utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Health Net clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Health Net. In addition, Health Net may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Health Net.   

If you have any questions regarding these policies, please contact Provider Services 888-802-7001 (commercial) or 888-445-8913 (Medicare) and ask to be directed to the Medical Management department.

Code Title Description Date Adopted

CP.MP.157 (PDF)

25-hydroxyvitamin D testing in children and adolescents

Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents

05/19/2020

CP.MP.92 (PDF)

Acupuncture

Medical necessity guidelines for acupuncture

02/18/2020

CP.MP.124 (PDF)

ADHD Assessment and Treatment

Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD)

05/19/2020

CP.MP.100 (PDF)

Allergy Testing and Therapy

Medical necessity guidelines for allergy testing and treatment

02/18/2020

CP.MP.108 (PDF)

Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia

Medical necessity guidelines for allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia

02/18/2020

CP.MP.96 (PDF)

Ambulatory EEG

Medical necessity guidelines for the use of ambulatory electroencephalogram (EEG) testing in the outpatient setting

09/15/2020

CP.MP.158 (PDF)

Ambulatory Surgery Center Optimization

Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services

02/18/2020
CP.MP.179 (PDF) Antithrombin III (Thrombate III, Atryn) Medical necessity criteria for Antithrombin III (Thrombate III, Atryn) 02/18/2020

CP.BH.104 (PDF)

Applied Behavioral Analysis for Autism

Medical necessity guidelines for applied behavioral analysis for autism

09/15/2020

CP.MP.26 (PDF)

Articular Cartilage Defect Repairs

Medical necessity guidelines for articular cartilage defect repairs

09/15/2020

CP.MP.55 (PDF)

Assisted Reproductive Technology

Medical necessity guidelines for assisted reproductive technology

09/15/2020

CP.MP.119 (PDF)

Balloon sinus ostial dilation

Medical necessity guidelines for balloon sinus ostial dilation for chronic rhinosinusitus and recurrent acute rhinosinusitis

07/21/2020

CP.MP.37 (PDF)

Bariatric Surgery

Medical necessity guidelines for bariatric surgery for obesity in adolescents and adults

09/15/2020

CP.MP.168 (PDF)

Biofeedback

Medical necessity guidelines for biofeedback therapy

10/1/2019

CP.MP.93 (PDF)

Bone-anchored hearing aid

Medical necessity guidelines for bone-anchored hearing aid

10/1/2019

CP.MP.110 (PDF)

Bronchial Thermoplasty

Medical necessity guidelines for bronchial thermoplasty

07/21/2020

CP.MP.156 (PDF)

Cardiac biomarker testing

Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction

05/19/2020

CP.MP.83 (PDF)

Carrier Screening in Pregnancy

Medical necessity guidelines for carrier screening in pregnancy

09/15/2020

CP.MP.164 (PDF)

Caudal or Interlaminar Epidural Steroid Injections for Pain Management

Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management

09/15/2020

CP.MP.84 (PDF)

Cell-free Fetal DNA Testing

Medical necessity guidelines for cell-free fetal DNA testing

09/15/2020

CP.CPC.02 (PDF)

Clinical Policy Web Posting

Corporate and health plan responsibilities for initial posting and maintenance of clinical, payment, and specialty drug policies to public health plan websites

02/18/2020

CP.MP.94 (PDF)

Clinical Trials

Medical necessity guidelines for routine costs of clinical trials

09/15/2020

CP.MP.14 (PDF)

Cochlear Implant Replacements

Medical necessity guidelines for the replacement of cochlear implants and/or cochlear implant components. 

09/15/2020

CP.MP.31 (PDF)

Cosmetic and Reconstructive Surgery

Medical necessity guidelines for cosmetic and reconstructive surgery

09/15/2020
CP.MP.183
(PDF)
Diagnostic Testing Guidelines for 2019-Novel Coronavirus Medical necessity criteria for diagnosing coronavirus disease 2019 (COVID-19). COVID-19 is caused by the virus SARS-CoV-2 09/15/2020

CP.MP.61 (PDF)

Dental Anesthesia

Medical necessity guidelines for dental anesthesia

09/15/2020

CP.MP.105 (PDF)

Digital electroencephalography spike analysis

Medical necessity guidelines for digital EEG spike analysis

05/19/2020

CP.MP.114 (PDF)

Disc Decompression Procedures

Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression

09/15/2020

CP.MP.115 (PDF)

Discography

Medical necessity guidelines for discography

09/15/2020

CP.MP.125 (PDF)

DNA analysis of stool to screen for colorectal cancer

Medical necessity guidelines for DNA analysis of stool for colorectal cancer

09/15/2020

CP.MP.101 (PDF)

Donor lymphocyte infusion

Medical necessity guidelines for donor lymphocyte infusion

02/18/2020

CP.MP.107 (PDF)

Durable Medical Equipment (DME)

Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics

09/15/2020

CP.MP.145 (PDF)

Electric Tumor Treating Fields

Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM)

05/19/2020

CP.MP.155 (PDF)

Electroencephalography in the evaluation of headache

Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches

07/21/2020

CP.MP.106 (PDF)

Endometrial ablation

Medical necessity guidelines for endometrial ablation

09/15/2020

CP.MP.140 (PDF)

EpiFix Wound Treatment

Medical necessity guidelines for EpiFix® wound treatment

10/1/2019

CP.MP.131 (PDF)

Essure Removal

Medical necessity guidelines for removal of Essure®, a permanent birth control device

02/18/2020

CP.MP.134 (PDF)

Evoked Potential Testing

Medical necessity guidelines for evoked potential testing

05/19/2020

CP.MP.36 (PDF)

Experimental Technologies

General medical necessity guidelines to use in determining coverage of experimental or investigational or potentially experimental or investigational medical and behavioral health technologies.  These guidlines are to be used only when there is no other policy, criteria, or coverage statement available. 

05/19/2020

CP.MP.171 (PDF)

Facet Joint Interventions for pain management

Medical necessity guidelines for facet joint injections and facet joint radiofrequency neurotomy (ablation) for lumbar, thoracic, and cervical pain management

09/15/2020

CP.MP.137 (PDF)

Fecal incontinence treatments

Medical necessity guidelines for fecal incontinence treatments

09/15/2020

CP.MP.53 (PDF)

Ferriscan R2-MRI

Medical necessity guidelines for use of the FerriScan R2-MRI

10/1/2019

CP.MP.130 (PDF)

Fertility preservation

Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility

07/21/2020

CP.MP.129 (PDF)

Fetal surgery in utero for prenatally diagnosed malformations

Medical necessity guidelines for performing fetal surgery in utero

09/15/2020

CP.MP.175 (PDF)

Fixed Wing Air Transportation

Medical necessity guidelines for fixed wing air transportation

05/19/2020

CP.MP.103 (PDF)

Fractional exhaled nitric oxide

Medical necessity guidelines for use of fractional exhaled nitric oxide (FeNO) in asthma diagnosis and care

02/18/2020

CP.MP.43 (PDF)

Functional MRI

Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI).

10/1/2019

CP.MP.40 (PDF)

Gastric electrical stimulation

Medical necessity guidelines for gastric electrical stimulation

10/1/2019

CP.MP.95 (PDF)

Gender Affirming Procedures

Medical necessity guidelines for surgery for the treatment of gender dysphoria

07/21/2020

CP.MP.89 (PDF)

Genetic and Pharmacogenetic Testing

Medical necessity criteria for genetic testing

09/15/2020

CP.MP.153 (PDF)

H. Pylori serology testing

Medical necessity guidelines for H. pylori serology testing

02/18/2020

CP.MP.132 (PDF)

Heart-Lung Transplant

Medical necessity guidelines for heart-lung transplantation

09/15/2020

CP.MP.113 (PDF)

Holter Monitors

Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring

07/21/2020

CP.MP.136 (PDF)

Home Birth

Medical necessity guidelines for planned home birth

10/1/2019

CP.MP.150 (PDF)

Home phototherapy for neonatal hyperbilirubinemia

Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia

02/18/2020

CP.MP.121 (PDF)

Homocysteine testing

Medical necessity guidelines for homocysteine testing

09/15/2020

CP.MP.54 (PDF)

Hospice Services

Medical necessity guidelines for hospice services

07/21/2020

CP.MP.34 (PDF)

Hyperemesis gravidarum treatment

Medical necessity guidelines for the treatment of hyperemesis gravidarum, including intravenous and subcutaneous infusions of ondansetron and metoclopramide, enteral therapy, and total parenteral nutrition (TPN)

05/19/2020

CP.MP.62 (PDF)

Hyperhidrosis treatments

Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands

05/19/2020
CP.MP.180 (PDF) Implantable Hypglossal Nerve Stimulation for Obstructive Sleep Apnea Medical necessity criteria for Implantable Hypoglossal Nerve Stimulation (Inspire) for Obstructive Sleep Apnea 02/18/2020

CP.MP.173 (PDF)

Implantable Intrathecal Pain Pump

Medical necessity guidelines for preliminary trial and implantation of intrathecal pain pumps

05/19/2020

CP.MP.160 (PDF)

Implantable Wireless Pulmonary Artery Pressure Monitoring

Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring

07/21/2020

CP.MP.159 (PDF)

Infusion Therapy Site of Care Optimization

Medical necessity criteria for IV or injectable therapy services in an outpatient setting.

02/18/2020

CP.MP.87 (PDF)

Inhaled nitric oxide

Medical necessity guidelines for the use of inhaled nitric oxide (iNO)

09/15/2020

CP.MP.69 (PDF)

Intensity-Modulated Radiotherapy

Medical necessity guidelines for intensity-modulated radiotherapy (IMRT)

05/19/2020

CP.MP.58 (PDF)

Intestinal and multivisceral transplant

Medical necessity guidelines for the review of intestinal and multivisceral transplant requests.

09/15/2020

CP.MP.167 (PDF)

Intradiscal Steroid Injections for Pain Management

Medical necessity criteria for intradiscal steroid injections for pain management

10/1/2019

CP.MP.123 (PDF)

Laser therapy for skin conditions

Medical necessity guidelines for excimer laser based targeted phototherapy

09/15/2020

CP.MP.71 (PDF)

Long Term Care Placement Criteria

Medical necessity guidelines for long term care (LTC) placement

07/21/2020

CP.MP.139 (PDF)

Low-frequency ultrasound therapy for wound management

Medical necessity guidelines for low-frequency ultrasound therapy for wound management

02/18/2020

CP.MP.57 (PDF)

Lung Transplantation

Medical necessity guidelines for review of lung transplantation requests

05/19/2020

CP.MP.116 (PDF)

Lysis of Epidural Lesions

Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty

09/15/2020

CP.MP.152 (PDF)

Measurement of serum 1,25-dihydroxyvitamin D

Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D

02/18/2020

CP.MP.144 (PDF)

Mechanical Stretching Devices for Joint Stiffness and Contracture

Medical necessity guidelines for mechanical stretch devices, including low-load prolonged-duration stretch (LLPS) devices/dynamic stretch devices, static progressive (SP) stretch devices, and patient-actuated serial stretch devices.

07/21/2020

CP.CPC.05 (PDF)

Medical Necessity Criteria

This policy identifies the medical necessity guidelines used by the health plan and related definitions.

07/21/2020

CP.MP.24 (PDF)

Multiple Sleep Latency Testing

Medical necessity criteria for multiple sleep latency testing (MSLT)

07/21/2020

CP.MP.86 (PDF)

Neonatal abstinence syndrome guidelines

Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU)

02/18/2020

CP.MP.85 (PDF)

Neonatal sepsis management

Medical necessity guidelines for neonates requiring comprehensive assessment, treatment, and discharge planning for neonatal intensive care unit (NICU) stays related to sepsis management

09/15/2020

CP.MP.170 (PDF)

Nerve Blocks for Pain Management

Medical necessity criteria for nerve blocks for pain management

05/19/2020

CP.MP.82 (PDF)

NICU Apnea Bradycardia Guidelines

Medical necessity guidelines to assist with continuing care, discharge planning, and the transition to outpatient and home care of babies affected by ongoing neonatal apnea and bradycardia events

09/15/2020

CP.MP.81 (PDF)

NICU discharge guidelines

Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home.

09/15/2020
CP.MP.184 (PDF) Non-Invasive Home Ventilators Medical necessity guidelines for non-invasive home ventilators 05/19/2020

CP.MP.141 (PDF)

Non-myeloablative allogeneic stem cell transplants

Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants

05/19/2020

CP.MP.91 (PDF)

Obstetrical Home Health Care Programs

Medical necessity guidelines for OB home health programs

05/19/2020

CP.MP.128 (PDF)

Optic nerve decompression surgery

Medical necessity guidelines for optic nerve sheath decompression surgery

10/1/2019

CP.MP.176 (PDF)

Outpatient Cardiac Rehabilitation

Medical necessity criteria for conventional and intensive outpatient cardiac rehabiliation programs.

09/15/2020

CP.MP.50 (PDF)

Outpatient testing for drugs of abuse

Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. 

09/15/2020

CP.MP.102 (PDF)

Pancreas transplant

Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant.

05/19/2020

CP.MP.109 (PDF)

Panniculectomy

Medical necessity guidelines for panniculectomy

05/19/2020

CP.MP.138 (PDF)

Pediatric heart transplant

Medical necessity guidelines for pediatric heart transplant

05/19/2020

CP.MP.120 (PDF)

Pediatric Liver Transplant

Medical necessity guidelines for pediatric liver transplant for end-stage liver disease

05/19/2020

CP.MP.147 (PDF)

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention

Medical necessity guidelines for left atrial appendage closure devices for stroke prevention.

09/15/2020

CP.MP.133 (PDF)

Posterior tibial nerve stimulation for voiding dysfunction

Medical necessity guidelines for posterior tibial nerve stimulation for the treatment of voiding dysfunction, including urinary incontinence and overactive bladder

05/19/2020

CP.CPC.03 (PDF)

Preventive Health and Clinical Practice Guideline Policy

The process by which the Plan adopts/develops and distributes preventive health and clinical practice guidelines to assist practitioners and members in making decisions about appropriate health care for specific clinical circumstances.

07/21/2020

CP.MP.70 (PDF)

Proton and neutron beam therapy

Medical necessity guidelines for proton beam and neutron beam radiation therapy

05/19/2020

CP.MP.148 (PDF)

Radial Head Implant

Medical necessity guidelines for radial head implant, also known as arthroplasty

09/15/2020

CP.MP.51 (PDF)

Reduction mammoplasty and gynecomastia surgery

Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men

09/15/2020

CP.MP.126 (PDF)

Sacroiliac joint fusion

Medical necessity guidelines for sacroiliac joint fusion

09/15/2020

CP.MP.166 (PDF)

Sacroiliac Joint Interventions for Pain Management

Medical necessity criteria for sacroiliac joint interventions for pain management

05/19/2020

CP.MP.146 (PDF)

Sclerotherapy for Varicose Veins

Medical necessity guidelines for sclerotherapy for treatment of vericose veins

07/31/2020

CP.MP.174 (PDF)

Selective Dorsal Rhizotomy

Medical necessity criteria for Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy.

05/19/2020

CP.MP.165 (PDF)

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management

Medical necessity criteria for selective nerve root blocks and transforaminal epidural injections for pain management

02/18/2020
CP.MP.182 (PDF) Short Inpatient Hospital Stay Medical necessity criteria for inpatient hospital stays of 2 days or less 07/21/2020

CP.MP.88 (PDF)

Sickle cell disease observation

Medical necessity criteria for observation stay for sickle cell disease

09/15/2020

CP.MP.117 (PDF)

Spinal Cord Stimulation

Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation

05/19/2020

CP.CPC.04 (PDF)

State specific clinical policy process

This policy describes the process for creating, maintaining, and posting state-specific clinical policies

02/18/2020

CP.MP.22 (PDF)

Stereotactic Body Radiation Therapy

Medical necessity guidelines for stereotactic body radiation therapy

09/15/2020

CP.MP.162 (PDF)

Tandem Transplant

Medical necessity guidelines for tandem transplant

09/15/2020

CP.MP.149 (PDF)

Testing for rupture of fetal membranes

Medical necessity guidelines for testing for rupture of fetal membranes

09/15/2020

CP.MP.97 (PDF)

Testing for select genitourinary conditions

Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis

10/1/2019

CP.MP.49 (PDF)

Therapy Services (PT/OT/ST)

Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment.

05/19/2020
CP.MP.189 (PDF) Thymus Transplantation Complete DiGeorge anomaly is a disorder in which a person has no thymus function. Without thymus function, bone marrow stem cells do not develop into T cells, which results in immunodeficiency. Without successful treatment, patients usually die by 2 years of age. Thymus transplantation with and without immunosuppression has resulted in the development good T cell function in complete DiGeorge anomaly subjects 07/21/2020

CP.MP.154 (PDF)

Thyroid hormones and insulin testing in pediatrics

Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics

02/18/2020

CP.MP.127 (PDF)

Total artificial heart

Medical necessity guidelines for a total artificial heart (TAH)

02/18/2020

CP.MP.163 (PDF)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN)

07/21/2020

CP.MP.151 (PDF)

Transcatheter closure of patent foramen ovale

Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder.

02/18/2020

CP.BH.200 (PDF)

Transcranial magnetic stimulation

This policy describes medical necessity guidelines for the use of transcranial magnetic stimulation

09/15/2020

CP.MP.169 (PDF)

Trigger Point Injections for Pain Management

Medical necessity criteria for trigger point injections for pain management

07/21/2020

CP.MP.38 (PDF)

Ultrasound in Pregnancy

Medical necessity guidelines for ultrasound use in pregnancy. 

09/15/2020

CP.MP.142 (PDF)

Urinary Incontinence Devices and Treatments

Medical necessity guidelines for treatments and devices for urinary incontinence including sacral neuromodulation (sacral nerve stimulation) and urethral bulking agents

05/19/2020

CP.MP.98 (PDF)

Urodynamic testing

Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction

10/1/2019

CP.MP.12 (PDF)

Vagus Nerve Stimulation

Medical necessity guidelines for vagus nerve stimulation.

10/1/2019

CP.MP.46 (PDF)

Ventricular Assist Devices

Medical necessity guidelines for ventricular assist devices.

09/15/2020

CP.MP.56 (PDF)

Ventriculectomy and cardiomyoplasty

Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures

07/21/2020
CP.MP.177 (PDF) Video Electroencephalographic Monitoring Medical necessity criteria for video electroencephalographic (EEG) monitoring 07/21/2020

CP.MP.99 (PDF)

Wheelchair seating

Medical necessity guidelines for special wheelchair seating and cushions

02/18/2020

CP.MP.143 (PDF)

Wireless Motility Capsule

Medical necessity guidelines for wireless motility capsule

05/19/2020
CP.MP.185 (PDF) Skin Substitutes for Chronic Wounds Medical necessity criteria for skin substitutes in the treatment of chronic wounds. 09/15/2020
CP.MP.186 (PDF) Burn Surgery Medical necessity guidelines for burn surgery, including debridement and application of skin substitutes for burns. 09/15/2020
CP.MP.187 (PDF) Radiofrequency Ablation of Uterine Fibroids Medical necessity criteria for radiofrequency ablation of uterine fibroids. 09/15/2020
CP.MP.188 (PDF) Pediatric Oral Function Therapy Medical necessity guidelines for pediatric oral function therapy. 09/15/2020
Code Title Description Date Adopted

CP.MP.157 (PDF)

25-hydroxyvitamin D testing in children and adolescents

Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents

05/19/2020

CP.MP.92 (PDF)

Acupuncture

Medical necessity guidelines for acupuncture

02/18/2020

CP.MP.124 (PDF)

ADHD Assessment and Treatment

Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD)

05/19/2020

CP.MP.100 (PDF)

Allergy Testing and Therapy

Medical necessity guidelines for allergy testing and treatment

02/18/2020

CP.MP.108 (PDF)

Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia

Medical necessity guidelines for allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia

02/18/2020

CP.MP.96 (PDF)

Ambulatory EEG

Medical necessity guidelines for the use of ambulatory electroencephalogram (EEG) testing in the outpatient setting

09/15/2020

CP.MP.158 (PDF)

Ambulatory Surgery Center Optimization

Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services

02/18/2020
CP.MP.179 (PDF) Antithrombin III (Thrombate III, Atryn) Medical necessity criteria for Antithrombin III (Thrombate III, Atryn) 02/18/2020

CP.BH.104 (PDF)

Applied Behavioral Analysis for Autism

Medical necessity guidelines for applied behavioral analysis for autism

09/15/2020

CP.MP.26 (PDF)

Articular Cartilage Defect Repairs

Medical necessity guidelines for articular cartilage defect repairs

09/15/2020

CP.MP.55 (PDF)

Assisted Reproductive Technology

Medical necessity guidelines for assisted reproductive technology

09/15/2020

CP.MP.119 (PDF)

Balloon sinus ostial dilation

Medical necessity guidelines for balloon sinus ostial dilation for chronic rhinosinusitus and recurrent acute rhinosinusitis

07/21/2020

CP.MP.37 (PDF)

Bariatric Surgery

Medical necessity guidelines for bariatric surgery for obesity in adolescents and adults

09/15/2020

CP.MP.168 (PDF)

Biofeedback

Medical necessity guidelines for biofeedback therapy

10/1/2019

CP.MP.93 (PDF)

Bone-anchored hearing aid

Medical necessity guidelines for bone-anchored hearing aid

10/1/2019

CP.MP.110 (PDF)

Bronchial Thermoplasty

Medical necessity guidelines for bronchial thermoplasty

07/21/2020

CP.MP.156 (PDF)

Cardiac biomarker testing

Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction

05/19/2020

CP.MP.83 (PDF)

Carrier Screening in Pregnancy

Medical necessity guidelines for carrier screening in pregnancy

09/15/2020

CP.MP.164 (PDF)

Caudal or Interlaminar Epidural Steroid Injections for Pain Management

Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management

09/15/2020

CP.MP.84 (PDF)

Cell-free Fetal DNA Testing

Medical necessity guidelines for cell-free fetal DNA testing

09/15/2020

CP.CPC.02 (PDF)

Clinical Policy Web Posting

Corporate and health plan responsibilities for initial posting and maintenance of clinical, payment, and specialty drug policies to public health plan websites

02/18/2020

CP.MP.94 (PDF)

Clinical Trials

Medical necessity guidelines for routine costs of clinical trials

09/15/2020

CP.MP.14 (PDF)

Cochlear Implant Replacements

Medical necessity guidelines for the replacement of cochlear implants and/or cochlear implant components. 

09/15/2020

CP.MP.31 (PDF)

Cosmetic and Reconstructive Surgery

Medical necessity guidelines for cosmetic and reconstructive surgery

09/15/2020

CP.MP.61 (PDF)

Dental Anesthesia

Medical necessity guidelines for dental anesthesia

09/15/2020
CP.MP.183
(PDF)
Diagnostic Testing Guidelines for 2019-Novel Coronavirus Medical necessity criteria for diagnosing coronavirus disease 2019 (COVID-19). COVID-19 is caused by the virus SARS-CoV-2 09/15/2020

CP.MP.105 (PDF)

Digital electroencephalography spike analysis

Medical necessity guidelines for digital EEG spike analysis

05/19/2020

CP.MP.114 (PDF)

Disc Decompression Procedures

Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression

09/15/2020

CP.MP.115 (PDF)

Discography

Medical necessity guidelines for discography

09/15/2020

CP.MP.125 (PDF)

DNA analysis of stool to screen for colorectal cancer

Medical necessity guidelines for DNA analysis of stool for colorectal cancer

09/15/2020

CP.MP.101 (PDF)

Donor lymphocyte infusion

Medical necessity guidelines for donor lymphocyte infusion

02/18/2020

CP.MP.107 (PDF)

Durable Medical Equipment (DME)

Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics

09/15/2020

CP.MP.145 (PDF)

Electric Tumor Treating Fields

Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM)

05/19/2020

CP.MP.155 (PDF)

Electroencephalography in the evaluation of headache

Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches

07/21/2020

CP.MP.106 (PDF)

Endometrial ablation

Medical necessity guidelines for endometrial ablation

09/15/2020

CP.MP.140 (PDF)

EpiFix Wound Treatment

Medical necessity guidelines for EpiFix® wound treatment

10/1/2019

CP.MP.131 (PDF)

Essure Removal

Medical necessity guidelines for removal of Essure®, a permanent birth control device

02/18/2020

CP.MP.134 (PDF)

Evoked Potential Testing

Medical necessity guidelines for evoked potential testing

05/19/2020

CP.MP.36 (PDF)

Experimental Technologies

General medical necessity guidelines to use in determining coverage of experimental or investigational or potentially experimental or investigational medical and behavioral health technologies.  These guidlines are to be used only when there is no other policy, criteria, or coverage statement available. 

05/19/2020

CP.MP.171 (PDF)

Facet Joint Interventions for pain management

Medical necessity guidelines for facet joint injections and facet joint radiofrequency neurotomy (ablation) for lumbar, thoracic, and cervical pain management

09/15/2020

CP.MP.137 (PDF)

Fecal incontinence treatments

Medical necessity guidelines for fecal incontinence treatments

09/15/2020

CP.MP.53 (PDF)

Ferriscan R2-MRI

Medical necessity guidelines for use of the FerriScan R2-MRI

10/1/2019

CP.MP.130 (PDF)

Fertility preservation

Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility

07/21/2020

CP.MP.129 (PDF)

Fetal surgery in utero for prenatally diagnosed malformations

Medical necessity guidelines for performing fetal surgery in utero

09/15/2020

CP.MP.175 (PDF)

Fixed Wing Air Transportation

Medical necessity guidelines for fixed wing air transportation

05/19/2020

CP.MP.103 (PDF)

Fractional exhaled nitric oxide

Medical necessity guidelines for use of fractional exhaled nitric oxide (FeNO) in asthma diagnosis and care

02/18/2020

CP.MP.43 (PDF)

Functional MRI

Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI).

10/1/2019

CP.MP.40 (PDF)

Gastric electrical stimulation

Medical necessity guidelines for gastric electrical stimulation

10/1/2019

CP.MP.95 (PDF)

Gender Affirming Procedures

Medical necessity guidelines for surgery for the treatment of gender dysphoria

07/21/2020

CP.MP.89 (PDF)

Genetic and Pharmacogenetic  Testing

Medical necessity criteria for genetic testing

09/15/2020

CP.MP.153 (PDF)

H. Pylori serology testing

Medical necessity guidelines for H. pylori serology testing

02/18/2020

CP.MP.132 (PDF)

Heart-Lung Transplant

Medical necessity guidelines for heart-lung transplantation

09/15/2020

CP.MP.113 (PDF)

Holter Monitors

Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring

07/21/2020

CP.MP.136 (PDF)

Home Birth

Medical necessity guidelines for planned home birth

10/1/2019

CP.MP.150 (PDF)

Home phototherapy for neonatal hyperbilirubinemia

Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia

02/18/2020

CP.MP.121 (PDF)

Homocysteine testing

Medical necessity guidelines for homocysteine testing

09/15/2020

CP.MP.54 (PDF)

Hospice Services

Medical necessity guidelines for hospice services

07/21/2020

CP.MP.34 (PDF)

Hyperemesis gravidarum treatment

Medical necessity guidelines for the treatment of hyperemesis gravidarum, including intravenous and subcutaneous infusions of ondansetron and metoclopramide, enteral therapy, and total parenteral nutrition (TPN)

05/19/2020

CP.MP.62 (PDF)

Hyperhidrosis treatments

Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands

05/19/2020

CP.MP.173 (PDF)

Implantable Intrathecal Pain Pump

Medical necessity guidelines for preliminary trial and implantation of intrathecal pain pumps

05/19/2020
CP.MP.180 (PDF) Implantable Hypglossal Nerve Stimulation for Obstructive Sleep Apnea Medical necessity criteria for Implantable Hypoglossal Nerve Stimulation (Inspire) for Obstructive Sleep Apnea 02/18/2020

CP.MP.160 (PDF)

Implantable Wireless Pulmonary Artery Pressure Monitoring

Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring

07/21/2020

CP.MP.159 (PDF)

Infusion Therapy Site of Care Optimization

Medical necessity criteria for IV or injectable therapy services in an outpatient setting.

02/18/2020

CP.MP.87 (PDF)

Inhaled nitric oxide

Medical necessity guidelines for the use of inhaled nitric oxide (iNO)

09/15/2020

CP.MP.69 (PDF)

Intensity-Modulated Radiotherapy

Medical necessity guidelines for intensity-modulated radiotherapy (IMRT)

05/19/2020

CP.MP.58 (PDF)

Intestinal and multivisceral transplant

Medical necessity guidelines for the review of intestinal and multivisceral transplant requests.

09/15/2020

CP.MP.167 (PDF)

Intradiscal Steroid Injections for Pain Management

Medical necessity criteria for intradiscal steroid injections for pain management

10/1/2019

CP.MP.123 (PDF)

Laser therapy for skin conditions

Medical necessity guidelines for excimer laser based targeted phototherapy

09/15/2020

CP.MP.71 (PDF)

Long Term Care Placement Criteria

Medical necessity guidelines for long term care (LTC) placement

07/21/2020

CP.MP.139 (PDF)

Low-frequency ultrasound therapy for wound management

Medical necessity guidelines for low-frequency ultrasound therapy for wound management

02/18/2020

CP.MP.57 (PDF)

Lung Transplantation

Medical necessity guidelines for review of lung transplantation requests

05/19/2020

CP.MP.116 (PDF)

Lysis of Epidural Lesions

Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty

09/15/2020

CP.MP.152 (PDF)

Measurement of serum 1,25-dihydroxyvitamin D

Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D

02/18/2020

CP.MP.144 (PDF)

Mechanical Stretching Devices for Joint Stiffness and Contracture

Medical necessity guidelines for mechanical stretch devices, including low-load prolonged-duration stretch (LLPS) devices/dynamic stretch devices, static progressive (SP) stretch devices, and patient-actuated serial stretch devices.

07/21/2020

CP.CPC.05 (PDF)

Medical Necessity Criteria

This policy identifies the medical necessity guidelines used by the health plan and related definitions.

07/21/2020

CP.MP.24 (PDF)

Multiple Sleep Latency Testing

Medical necessity criteria for multiple sleep latency testing (MSLT)

07/21/2020

CP.MP.86 (PDF)

Neonatal abstinence syndrome guidelines

Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU)

02/18/2020

CP.MP.85 (PDF)

Neonatal sepsis management

Medical necessity guidelines for neonates requiring comprehensive assessment, treatment, and discharge planning for neonatal intensive care unit (NICU) stays related to sepsis management

09/15/2020

CP.MP.170 (PDF)

Nerve Blocks for Pain Management

Medical necessity criteria for nerve blocks for pain management

05/19/2020

CP.MP.82 (PDF)

NICU Apnea Bradycardia Guidelines

Medical necessity guidelines to assist with continuing care, discharge planning, and the transition to outpatient and home care of babies affected by ongoing neonatal apnea and bradycardia events

09/15/2020

CP.MP.81 (PDF)

NICU discharge guidelines

Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home.

09/15/2020
CP.MP.184 (PDF) Non-Invasive Home Ventilators Medical necessity guidelines for non-invasive home ventilators 05/19/2020

CP.MP.141 (PDF)

Non-myeloablative allogeneic stem cell transplants

Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants

05/19/2020

CP.MP.91 (PDF)

Obstetrical Home Health Care Programs

Medical necessity guidelines for OB home health programs

05/19/2020

CP.MP.128 (PDF)

Optic nerve decompression surgery

Medical necessity guidelines for optic nerve sheath decompression surgery

10/1/2019

CP.MP.176 (PDF)

Outpatient Cardiac Rehabilitation

Medical necessity criteria for conventional and intensive outpatient cardiac rehabiliation programs.

09/15/2020

CP.MP.50 (PDF)

Outpatient testing for drugs of abuse

Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. 

09/15/2020

CP.MP.102 (PDF)

Pancreas transplant

Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant.

05/19/2020

CP.MP.109 (PDF)

Panniculectomy

Medical necessity guidelines for panniculectomy

05/19/2020

CP.MP.138 (PDF)

Pediatric heart transplant

Medical necessity guidelines for pediatric heart transplant

05/19/2020

CP.MP.120 (PDF)

Pediatric Liver Transplant

Medical necessity guidelines for pediatric liver transplant for end-stage liver disease

05/19/2020

CP.MP.147 (PDF)

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention

Medical necessity guidelines for left atrial appendage closure devices for stroke prevention.

09/15/2020

CP.MP.133 (PDF)

Posterior tibial nerve stimulation for voiding dysfunction

Medical necessity guidelines for posterior tibial nerve stimulation for the treatment of voiding dysfunction, including urinary incontinence and overactive bladder

05/19/2020

CP.CPC.03 (PDF)

Preventive Health and Clinical Practice Guideline Policy

The process by which the Plan adopts/develops and distributes preventive health and clinical practice guidelines to assist practitioners and members in making decisions about appropriate health care for specific clinical circumstances.

07/21/2020

CP.MP.70 (PDF)

Proton and neutron beam therapy

Medical necessity guidelines for proton beam and neutron beam radiation therapy

05/19/2020

CP.MP.148 (PDF)

Radial Head Implant

Medical necessity guidelines for radial head implant, also known as arthroplasty

09/15/2020

CP.MP.51 (PDF)

Reduction mammoplasty and gynecomastia surgery

Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men

09/15/2020

CP.MP.126 (PDF)

Sacroiliac joint fusion

Medical necessity guidelines for sacroiliac joint fusion

09/15/2020

CP.MP.166 (PDF)

Sacroiliac Joint Interventions for Pain Management

Medical necessity criteria for sacroiliac joint interventions for pain management

05/19/2020

CP.MP.146 (PDF)

Sclerotherapy for Varicose Veins

Medical necessity guidelines for sclerotherapy for treatment of vericose veins

07/31/2020

CP.MP.174 (PDF)

Selective Dorsal Rhizotomy

Medical necessity criteria for Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy.

05/19/2020

CP.MP.165 (PDF)

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management

Medical necessity criteria for selective nerve root blocks and transforaminal epidural injections for pain management

02/18/2020
CP.MP.182 (PDF) Short Inpatient Hospital Stay Medical necessity criteria for inpatient hospital stays of 2 days or less 07/21/2020

CP.MP.88 (PDF)

Sickle cell disease observation

Medical necessity criteria for observation stay for sickle cell disease

09/15/2020

CP.MP.117 (PDF)

Spinal Cord Stimulation

Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation

05/19/2020

CP.CPC.04 (PDF)

State specific clinical policy process

This policy describes the process for creating, maintaining, and posting state-specific clinical policies

02/18/2020

CP.MP.22 (PDF)

Stereotactic Body Radiation Therapy

Medical necessity guidelines for stereotactic body radiation therapy

09/15/2020

CP.MP.162 (PDF)

Tandem Transplant

Medical necessity guidelines for tandem transplant

09/15/2020

CP.MP.149 (PDF)

Testing for rupture of fetal membranes

Medical necessity guidelines for testing for rupture of fetal membranes

09/15/2020

CP.MP.97 (PDF)

Testing for select genitourinary conditions

Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis

10/1/2019

CP.MP.49 (PDF)

Therapy Services (PT/OT/ST)

Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment.

05/19/2020
CP.MP.189 (PDF) Thymus Transplantation Complete DiGeorge anomaly is a disorder in which a person has no thymus function. Without thymus function, bone marrow stem cells do not develop into T cells, which results in immunodeficiency. Without successful treatment, patients usually die by 2 years of age. Thymus transplantation with and without immunosuppression has resulted in the development good T cell function in complete DiGeorge anomaly subjects 07/21/2020

CP.MP.154 (PDF)

Thyroid hormones and insulin testing in pediatrics

Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics

02/18/2020

CP.MP.127 (PDF)

Total artificial heart

Medical necessity guidelines for a total artificial heart (TAH)

02/18/2020

CP.MP.163 (PDF)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN)

07/21/2020

CP.MP.151 (PDF)

Transcatheter closure of patent foramen ovale

Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder.

02/18/2020

CP.BH.200 (PDF)

Transcranial magnetic stimulation

This policy describes medical necessity guidelines for the use of transcranial magnetic stimulation

09/15/2020

CP.MP.169 (PDF)

Trigger Point Injections for Pain Management

Medical necessity criteria for trigger point injections for pain management

07/21/2020

CP.MP.38 (PDF)

Ultrasound in Pregnancy

Medical necessity guidelines for ultrasound use in pregnancy. 

09/15/2020

CP.MP.142 (PDF)

Urinary Incontinence Devices and Treatments

Medical necessity guidelines for treatments and devices for urinary incontinence including sacral neuromodulation (sacral nerve stimulation) and urethral bulking agents

05/19/2020

CP.MP.98 (PDF)

Urodynamic testing

Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction

10/1/2019

CP.MP.12 (PDF)

Vagus Nerve Stimulation

Medical necessity guidelines for vagus nerve stimulation.

10/1/2019

CP.MP.46 (PDF)

Ventricular Assist Devices

Medical necessity guidelines for ventricular assist devices.

09/15/2020

CP.MP.56 (PDF)

Ventriculectomy and cardiomyoplasty

Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures

07/21/2020
CP.MP.177 (PDF) Video Electroencephalographic Monitoring Medical necessity criteria for video electroencephalographic (EEG) monitoring 07/21/2020

CP.MP.99 (PDF)

Wheelchair seating

Medical necessity guidelines for special wheelchair seating and cushions

02/18/2020

CP.MP.143 (PDF)

Wireless Motility Capsule

Medical necessity guidelines for wireless motility capsule

05/19/2020
CP.MP.185 (PDF) Skin Substitutes for Chronic Wounds Medical necessity criteria for skin substitutes in the treatment of chronic wounds. 09/15/2020
CP.MP.186 (PDF) Burn Surgery Medical necessity guidelines for burn surgery, including debridement and application of skin substitutes for burns. 09/15/2020
CP.MP.187 (PDF) Radiofrequency Ablation of Uterine Fibroids Medical necessity criteria for radiofrequency ablation of uterine fibroids. 09/15/2020
CP.MP.188 (PDF) Pediatric Oral Function Therapy Medical necessity guidelines for pediatric oral function therapy. 09/15/2020

Pharmacy Criteria

Health Net’s goal is to offer the right drug coverage to our members. Trillium Oregon Health Plan (OHP) covers prescription and some over the counter drugs when they are ordered by a licensed prescriber registered with the state of Oregon to provide services to OHP members. The pharmacy program does not cover all drugs. Some drugs need prior approval and some have a limit on the amount of drug that can be given.

Clinical policies are one set of guidelines used to assist in administering health plan benefits. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

The Pharmacy and Therapeutics (P&T) Committee is comprised of community doctors and pharmacists. Together we work to offer drugs used to treat many conditions and illnesses. All clinical policies are reviewed annually by the P&T Committee, which meets quarterly. Approved criteria and revisions made by the P&T Committee go into effect the first day of the month the start of the following quarter. All medications newly approved by the FDA (Food and Drug Administration) require prior approval until reviewed by our P&T Committee.

All policies found in the Health Net Clinical Policy Manual apply to Health Net members. Policies in the Health Net Clinical Policy Manual may have either a Health Net or a “Centene” heading. 

If you have any questions regarding these policies, please contact Provider Services and ask to be directed to the Pharmacy department.

Commercial Pharmacy Criteria

Amebicides

Amnoglycosides

Antifungals

Antihelmintics

Anti-Infective Agents - Misc.

Antimalarials

Antimycobacterial Agents

Antivirals

Fluoroqunolones

Passive Immunizing and Treatment Agents

Tetracyclines

Alkylating Agents

Antimetabolites

Antineoplastic – Angiogenesis Inhibitors

Antineoplastic – Antibodies

Antineoplastic – BCL-2 Inhibitors

Antineoplastic – Cellular Immunotherapy

Antineoplastic – Hedgehog Pathway Inhibitors

Antineoplastic – Hormonal and Related Agents

Antineoplastic – Immunomodulators

Antineoplastic Antibiotics

Antineoplastic Combinations

Antineoplastic Enzyme Inhibitors

Antineoplastic Enzymes

Antineoplastic Radiopharmaceuticals

Antineoplastics Misc.

Chemotherapy Rescue/Antidote Agents

Mitotic Inhibitors

Topoisomerase I Inhibitors

 

Androgens/Anabolic

Antidiabetics

Bone Density Regulators

Contraceptives

Corticosteroids

Corticotropin

Fertility Regulators

GNRH/LHRH Antagonists

Growth Hormone Receptor Antagonists

Growth Hormone Releasing Hormones (GHRH)

Growth Hormones

Hormone Receptor Modulators

Insulin-Like Growth Factors (Somatomedins)

Insulin-Like Growth Factors (Misc.)

Metabolic Modifiers

Miscellaneous Endochrine Agents

Posterior Pituitary Hormones

Progesterone Receptor Antagonists

Progestins

Somatostatic Agents

Vasopressin Receptor Antagonists

Anti-Diarrheal/Probiotic Agents

Antiemetics

Diuretics

Gastrointestinal Agents – Misc.

Genitourinary Agents – Misc.

Gout Agents

Laxatives

Vaginal Products

Anticoagulants

Hematological Agents – Misc.

Hematopoietic Agents

 

ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants

Anticonvulsants

Antidepressants

Anti-myasthenic/Cholinergic Agents

Antiparkinson and Related Therapy Agents

Antipsychotics/Antimanic Agents

Hypnotics/Sedatives/Sleep Disorder Agents

Migraine Products

Psychotherapeutic and Neurological Agents – Misc.

 

Medicare Pharmacy Criteria

For the most up-to-date information, please visit the prior authorization, step therapy and quantity limits page.

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Health Net Payment Policy Manual apply with respect to Health Net members. Policies in the Health Net Payment Policy Manual may have either a Health Net or a “Centene” heading.  In addition, Health Net may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Health Net.     

If you have any questions regarding these policies, please contact Provider Services and ask to be directed to the Medical Management department.

Policy Reference Number

Policy Name

Description

CC.PP.501 (PDF)

30 Day Readmission

This policy is based, in part, on the methodology set forth in the Quality Improvement Organization Manual, CMS Publication 100-10, Chapter 4, Section 4240, for determining an inappropriate readmission.

For a readmission that is determined to have been inappropriate or preventable according to the clinical review guidelines set forth below, Health Net will deny payment or reimbursement.

CC.PP.500 (PDF)

3-day Payment Window

The purpose of this policy is to serve as one component of the guidelines used to assist in making coverage decisions and administering benefits. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), and to applicable law.

CP.MP.100 (PDF) Allergy Testing (effective 10/1/19)

Allergy testing is performed to determine immunologic sensitivity or reaction to antigens for the purpose of identifying the cause of the allergic state.  This policy addresses immediate (IgE-mediated) hypersensitivity and delayed (cell-mediated) hypersensitivity.  Allergen immunotherapy is the repeated administration of specific allergens to patients with IgE-mediated conditions, for the purpose of providing protection against the allergic symptoms and inflammatory reactions associated with exposure to these allergens.

Please note: unit limitations for allergy testing and treatment are based on state specific guidelines (defined in the provider fee schedule).  In the absence of state-specific rules, the CMS Medicaid/Medicare NCCI MUE limitations are applied.

CP.MP.140 (PDF) EpiFix Wound Treatment (effective 10/1/19) EpiFix® (MiMedx Group) is dehydrated human amniotic tissue that is used as an allograft material (or tissue graft) to treat nonhealing wounds.   It is the policy of health plans affiliated with Centene Corporation® that Epifix is medically necessary for the treatment of chronic foot ulcers when all criteria are met. It is the policy of health plans affiliated with Centene Corporation that continued treatment with EpiFix is not medically necessary when the ulcer fails to heal by ≥ 50% within the first 6 weeks of treatment.  Treatment beyond 12 weeks is considered not medically necessary regardless of wound status.

CC.PI.04 (PDF)

Equian for Clean Claims Reviews

The purpose of this policy is to define the referral criteria, review components, and guidelines used to support the inpatient clean claim reviews.

Criteria for high-dollar clean claim review includes, but is not limited to, pre-payment, inpatient claims greater than $50,000 payable for Medicare for inpatient claims that hit DRG outlier. These reviews will also be applied to claims paying on a percentage of billed charges methodology, payable greater than $50,000.

CC.PP.053 (PDF) Leveling of ED Services (Effective Date: 10/1/2019)

This policy outlines enhancement of the claims review process for emergency department (ED) facility and professional claims.

Prepayment policy to down-grade non-emergent, high-level billings to a more appropriate level of payment based on primary diagnosis code.

CP.MP.149 (PDF)

Non-invasive Testing for Rupture of Fetal Membranes

The purpose of this policy is to define medical necessity criteria for the non-invasive testing for rupture of fetal membranes testing (e.g. AmniSure®, Actim®PROM and the ROM Plus Fetal Membranes Rupture Test) for the diagnostic evaluation of premature rupture of membranes.

CC.PP.061 (PDF)

Non-obstetrical Pelvic and Transvaginal Ultrasounds

The purpose of this policy is to define payment criteria for multiple non-obstetrical ultrasound images in a single session.

CC.PP.063 (PDF)

Place of Service Mismatch

The purpose of this policy is to identify instances in which a procedure code is billed with an inappropriate place of service per CPT/HCPCS guidelines.

CC.PP.057 (PDF)

Problem Oriented Visits with Preventive Visits

The purpose of this policy is to define payment criteria for problem-oriented visits when billed with preventive visits to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for both a preventive E&M service and a problem-oriented E&M service during the same patient encounter.

Providers do not incur duplicate indirect expenses with the original E&M (preventive service) when there is a problem-oriented visit on the same date of service. For example, obtaining vital signs, scheduling the visits, staffing, lighting, and supplying the examination room costs are not incurred twice by the provider. Health Net will reimburse the preventive medicine code plus 50 percent of the problem-oriented E&M code.

CP.PP.052 (PDF)

Problem Oriented Visits with Surgical Procedures

The purpose of this policy is to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented evaluation and management (E&M) service on the same day of a procedure with a 0-, 10- or 90- day global surgical period if the physician indicates that the service is a significant and separately identifiable E&M service that is above and beyond the usual pre- and post-operative work associated with the procedure. 

The purpose of this policy is to prevent duplicate payments that occur when a provider is reimbursed for resources not directly consumed during the provision of a service.  Furthermore, to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure with a 0-, 10- or 90- day global period when making payment decisions and administering benefits.

CC.PP.049 (PDF) Status "P" Bundled Services (Effective Date: 10/1/19)

The Centers for Medicare and Medicaid Services (CMS) classifies certain procedure codes as always bundled when billed on the same claim or a historical claim containing another procedure code or codes to which the bundled code shares an incidental relationship.  

The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another physician’s procedure or service to be used in making payment decisions and administering benefits.

CC.PP.056 (PDF)

Urine Specimen Validity Testing

The purpose of this policy is to define payment criteria for urine specimen validity testing to be used in making payment decisions and administering benefits.

Health Net will disallow separate reimbursement for testing to confirm that a urine drug specimen is unadulterated. Validity testing in an internal control process that is not separately reportable.

CP.MP.98 (PDF)

Urodynamic Testing

Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction. The clinician must exercise clinical judgment in the appropriate selection of urodynamic tests following an appropriate evaluation and symptom characterization. The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies.
CC.PP.065 (PDF) Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (Effective 10/01/2020) When multiple procedures are performed on the same day, for the same patient, and by the same physician (or by multiple physicians in the same group practice, i.e., same group national provider identifier (NPI)), the majority of clinical labor activities are not performed or furnished twice. Some examples of clinical labor activities include; 1) greeting the patient; 2) gowning the patient, 3) positioning and escorting the patient, 4) providing education and obtaining consent, 5) retrieving prior exams, 6) setting up an IV, and 7) preparing and cleaning the room. Therefore, payment at 100% for the secondary and subsequent procedures represent duplicative componentsof the primary procedure.
CC.MP.50 (PDF) Outpatient Testing for Drugs of Abuse (Effective 10/01/2020) Urine drug testing is a key diagnostic and therapeutic tool that is useful for patient care and monitoring of adherence to a controlled substance treatment regimen (e.g., for chronic noncancer pain) and to identify drug misuse or addiction prior to starting or during treatment with controlled substances. 

Policy Reference Number

Policy Name

Description

CC.PP.501 (PDF)

30 Day Readmission

This policy is based, in part, on the methodology set forth in the Quality Improvement Organization Manual, CMS Publication 100-10, Chapter 4, Section 4240, for determining an inappropriate readmission.

For a readmission that is determined to have been inappropriate or preventable according to the clinical review guidelines set forth below, Health Net will deny payment or reimbursement.

CC.PP.500 (PDF)

3-day Payment Window

The purpose of this policy is to serve as one component of the guidelines used to assist in making coverage decisions and administering benefits. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), and to applicable law.

CP.MP.100 (PDF) Allergy Testing (Effective 10/01/2019)

Allergy testing is performed to determine immunologic sensitivity or reaction to antigens for the purpose of identifying the cause of the allergic state.  This policy addresses immediate (IgE-mediated) hypersensitivity and delayed (cell-mediated) hypersensitivity.  Allergen immunotherapy is the repeated administration of specific allergens to patients with IgE-mediated conditions, for the purpose of providing protection against the allergic symptoms and inflammatory reactions associated with exposure to these allergens.

Please note: unit limitations for allergy testing and treatment are based on state specific guidelines (defined in the provider fee schedule).  In the absence of state-specific rules, the CMS Medicaid/Medicare NCCI MUE limitations are applied.

CP.MP.140 (PDF) EpiFix Wound Treatment (effective 10/1/19) EpiFix® (MiMedx Group) is dehydrated human amniotic tissue that is used as an allograft material (or tissue graft) to treat nonhealing wounds.   It is the policy of health plans affiliated with Centene Corporation® that Epifix is medically necessary for the treatment of chronic foot ulcers when all criteria are met. It is the policy of health plans affiliated with Centene Corporation that continued treatment with EpiFix is not medically necessary when the ulcer fails to heal by ≥ 50% within the first 6 weeks of treatment.  Treatment beyond 12 weeks is considered not medically necessary regardless of wound status.

CC.PI.04 (PDF)

Equian for Clean Claims Reviews

The purpose of this policy is to define the referral criteria, review components, and guidelines used to support the inpatient clean claim reviews.

Criteria for high-dollar clean claim review includes, but is not limited to, pre-payment, inpatient claims greater than $50,000 payable for Medicare for inpatient claims that hit DRG outlier. These reviews will also be applied to claims paying on a percentage of billed charges methodology, payable greater than $50,000.

CC.PP.053 (PDF) Leveling of ED Services (Effective Date: 10/1/2019)

This policy outlines enhancement of the claims review process for emergency department (ED) facility and professional claims.

Prepayment policy to down-grade non-emergent, high-level billings to a more appropriate level of payment based on primary diagnosis code.

CP.MP.149 (PDF)

Non-invasive Testing for Rupture of Fetal Membranes

The purpose of this policy is to define medical necessity criteria for the non-invasive testing for rupture of fetal membranes testing (e.g. AmniSure®, Actim®PROM and the ROM Plus Fetal Membranes Rupture Test) for the diagnostic evaluation of premature rupture of membranes.

CC.PP.061 (PDF)

Non-obstetrical Pelvic and Transvaginal Ultrasounds

The purpose of this policy is to define payment criteria for multiple non-obstetrical ultrasound images in a single session.

CC.PP.063 (PDF)

Place of Service Mismatch

The purpose of this policy is to identify instances in which a procedure code is billed with an inappropriate place of service per CPT/HCPCS guidelines.

CC.PP.057 (PDF)

Problem Oriented Visits with Preventive Visits

The purpose of this policy is to define payment criteria for problem-oriented visits when billed with preventive visits to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for both a preventive E&M service and a problem-oriented E&M service during the same patient encounter.

Providers do not incur duplicate indirect expenses with the original E&M (preventive service) when there is a problem-oriented visit on the same date of service. For example, obtaining vital signs, scheduling the visits, staffing, lighting, and supplying the examination room costs are not incurred twice by the provider. Health Net will reimburse the preventive medicine code plus 50 percent of the problem-oriented E&M code.

CP.PP.052 (PDF)

Problem Oriented Visits with Surgical Procedures

The purpose of this policy is to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented evaluation and management (E&M) service on the same day of a procedure with a 0-, 10- or 90- day global surgical period if the physician indicates that the service is a significant and separately identifiable E&M service that is above and beyond the usual pre- and post-operative work associated with the procedure. 

The purpose of this policy is to prevent duplicate payments that occur when a provider is reimbursed for resources not directly consumed during the provision of a service.  Furthermore, to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure with a 0-, 10- or 90- day global period when making payment decisions and administering benefits.

CC.PP.049 (PDF) Status "P" Bundled Services (Effective Date: 10/1/19)

The Centers for Medicare and Medicaid Services (CMS) classifies certain procedure codes as always bundled when billed on the same claim or a historical claim containing another procedure code or codes to which the bundled code shares an incidental relationship.  

The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another physician’s procedure or service to be used in making payment decisions and administering benefits.

CC.PP.056 (PDF)

Urine Specimen Validity Testing

The purpose of this policy is to define payment criteria for urine specimen validity testing to be used in making payment decisions and administering benefits.

Health Net will disallow separate reimbursement for testing to confirm that a urine drug specimen is unadulterated. Validity testing in an internal control process that is not separately reportable.

CP.MP.98 (PDF)

Urodynamic Testing

Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction. The clinician must exercise clinical judgment in the appropriate selection of urodynamic tests following an appropriate evaluation and symptom characterization. The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies.

CC.PP.065 (PDF) Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (Effective 10/01/2020) When multiple procedures are performed on the same day, for the same patient, and by the same physician (or by multiple physicians in the same group practice, i.e., same group national provider identifier (NPI)), the majority of clinical labor activities are not performed or furnished twice. Some examples of clinical labor activities include; 1) greeting the patient; 2) gowning the patient, 3) positioning and escorting the patient, 4) providing education and obtaining consent, 5) retrieving prior exams, 6) setting up an IV, and 7) preparing and cleaning the room. Therefore, payment at 100% for the secondary and subsequent procedures represent duplicative componentsof the primary procedure.