Skip to Main Content

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 1-888-802-7001 (Commercial) or 1-888-445-8913 (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

April 16, 2021

CP.MP.92 (PDF)

Acupuncture

Medical necessity guidelines for acupuncture

November 17. 2020

CP.MP.124 (PDF)

ADHD Assessment and Treatment

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

May 19, 2020
CP.MP.175 (PDF) Air Ambulance Medical necessity guidelines for fixed wing air transportation. November 17, 2020

CP.MP.100 (PDF)

Allergy Testing and Therapy

Medical necessity guidelines for allergy testing and treatment

February 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

February 16, 2021

CP.MP.96 (PDF)

Ambulatory EEG

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

September 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

March 16, 2021
CP.MP.179 (PDF) Antithrombin III (Thrombate III, Atryn) Medical necessity criteria for Antithrombin III (Thrombate III, Atryn) February 18, 2020

CP.BH.104 (PDF)

Applied Behavioral Analysis for Autism

Medical necessity guidelines for applied behavioral analysis for autism

September 15, 2020

CP.MP.26 (PDF)

Articular Cartilage Defect Repairs

Medical necessity guidelines for articular cartilage defect repairs

May 18, 2021

CP.MP.55 (PDF)

Assisted Reproductive Technology

Medical necessity guidelines for assisted reproductive technology

February 16, 2021

CP.MP.119 (PDF)

Balloon sinus ostial dilation

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

November 17, 2020

CP.MP.37 (PDF)

Bariatric Surgery

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

September 15, 2020

CP.MP.168 (PDF)

Biofeedback

Medical necessity guidelines for biofeedback therapy

October 1, 2019

CP.MP.93 (PDF)

Bone-anchored hearing aid

Medical necessity guidelines for bone-anchored hearing aid

November 17, 2020

CP.MP.110 (PDF)

Bronchial Thermoplasty

Medical necessity guidelines for bronchial thermoplasty

November 21, 2020

CP.MP.156 (PDF)

Cardiac biomarker testing

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

March 16, 2021

CP.MP.83 (PDF)

Carrier Screening in Pregnancy

Medical necessity guidelines for carrier screening in pregnancy

September 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

September 15, 2020

CP.MP.84 (PDF)

Cell-free Fetal DNA Testing

Medical necessity guidelines for cell-free fetal DNA testing

November 17, 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

February 16, 2021

CP.MP.94 (PDF)

Clinical Trials

Medical necessity guidelines for routine costs of clinical trials

September 15, 2020

CP.MP.14 (PDF)

Cochlear Implant Replacements

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

September 15, 2020

CP.MP.31 (PDF)

Cosmetic and Reconstructive Surgery

Medical necessity guidelines for cosmetic and reconstructive surgery

May 18, 2021

CP.MP.61 (PDF)

Dental Anesthesia

Medical necessity guidelines for dental anesthesia

May 18, 2021
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 September 15, 2020

CP.MP.105 (PDF)

Digital electroencephalography spike analysis

Medical necessity guidelines for digital EEG spike analysis

March 16, 2021

CP.MP.114 (PDF)

Disc Decompression Procedures

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

September 15, 2020

CP.MP.115 (PDF)

Discography

Medical necessity guidelines for discography

September 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

February 16, 2021

CP.MP.101 (PDF)

Donor lymphocyte infusion

Medical necessity guidelines for donor lymphocyte infusion

February 18, 2020

CP.MP.107 (PDF)

Durable Medical Equipment (DME)

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

February 16, 2021

CP.MP.145 (PDF)

Electric Tumor Treating Fields

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

May 18, 2021

CP.MP.155 (PDF)

Electroencephalography in the evaluation of headache

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

July 21, 2020

CP.MP.106 (PDF)

Endometrial ablation

Medical necessity guidelines for endometrial ablation

September 15, 2020

CP.MP.140 (PDF)

EpiFix Wound Treatment

Medical necessity guidelines for EpiFix® wound treatment

October 1, 2019

CP.MP.131 (PDF)

Essure Removal

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

February 18, 2020

CP.MP.134 (PDF)

Evoked Potential Testing

Medical necessity guidelines for evoked potential testing

November 17, 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. 

May 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

September 15, 2020

CP.MP.137 (PDF)

Fecal incontinence treatments

Medical necessity guidelines for fecal incontinence treatments

September 15, 2020

CP.MP.53 (PDF)

Ferriscan R2-MRI

Medical necessity guidelines for use of the FerriScan R2-MRI

October 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

November 17, 2020

CP.MP.129 (PDF)

Fetal surgery in utero for prenatally diagnosed malformations

Medical necessity guidelines for performing fetal surgery in utero

September 15, 2020

CP.MP.175 (PDF)

Fixed Wing Air Transportation

Medical necessity guidelines for fixed wing air transportation

May 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

February 16, 2021

CP.MP.43 (PDF)

Functional MRI

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

November 17, 2020

CP.MP.40 (PDF)

Gastric electrical stimulation

Medical necessity guidelines for gastric electrical stimulation

November 17, 2020

CP.MP.95 (PDF)

Gender Affirming Procedures

Medical necessity guidelines for surgery for the treatment of gender dysphoria

November 17, 2020

CP.MP.89 (PDF)

Genetic and Pharmacogenetic  Testing

Medical necessity criteria for genetic testing

May 18, 2021

CP.MP.153 (PDF)

H. Pylori serology testing

Medical necessity guidelines for H. pylori serology testing

February 18, 2020

CP.MP.132 (PDF)

Heart-Lung Transplant

Medical necessity guidelines for heart-lung transplantation

September 15, 2020

CP.MP.113 (PDF)

Holter Monitors

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

July 21, 2020

CP.MP.136 (PDF)

Home Birth

Medical necessity guidelines for planned home birth

November 17, 2020

CP.MP.150 (PDF)

Home phototherapy for neonatal hyperbilirubinemia

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

February 18, 2020

CP.MP.121 (PDF)

Homocysteine testing

Medical necessity guidelines for homocysteine testing

September 15, 2020

CP.MP.54 (PDF)

Hospice Services

Medical necessity guidelines for hospice services

July 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)

May 18, 2021

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

March 16, 2021

CP.MP.173 (PDF)

Implantable Intrathecal Pain Pump

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

March 16, 2021
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 February 16, 2021

CP.MP.160 (PDF)

Implantable Wireless Pulmonary Artery Pressure Monitoring

Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring

July 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.

February 18, 2020

CP.MP.87 (PDF)

Inhaled nitric oxide

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

February 16, 2021

CP.MP.69 (PDF)

Intensity-Modulated Radiotherapy

Medical necessity guidelines for intensity-modulated radiotherapy (IMRT)

February 16, 2021

CP.MP.58 (PDF)

Intestinal and multivisceral transplant

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

September 15, 2020

CP.MP.167 (PDF)

Intradiscal Steroid Injections for Pain Management

Medical necessity criteria for intradiscal steroid injections for pain management

November 17, 2020

CP.MP.123 (PDF)

Laser therapy for skin conditions

Medical necessity guidelines for excimer laser based targeted phototherapy

September 15, 2020

CP.MP.71 (PDF)

Long Term Care Placement Criteria

Medical necessity guidelines for long term care (LTC) placement

July 21, 2020

CP.MP.139 (PDF)

Low-frequency ultrasound therapy for wound management

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

November 17, 2020

CP.MP.57 (PDF)

Lung Transplantation

Medical necessity guidelines for review of lung transplantation requests

November 17, 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

November 17, 2020

CP.MP.152 (PDF)

Measurement of serum 1,25-dihydroxyvitamin D

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

February 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.

July 21, 2020

CP.CPC.05 (PDF)

Medical Necessity Criteria

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

July 21, 2020

CP.MP.24 (PDF)

Multiple Sleep Latency Testing

Medical necessity criteria for multiple sleep latency testing (MSLT)

July 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)

July 17, 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

September 15, 2020

CP.MP.170 (PDF)

Nerve Blocks for Pain Management

Medical necessity criteria for nerve blocks for pain management

February 16, 2021

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

September 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.

September 15, 2020
CP.MP.184 (PDF) Non-Invasive Home Ventilators Medical necessity guidelines for non-invasive home ventilators November 17, 2020

CP.MP.141 (PDF)

Non-myeloablative allogeneic stem cell transplants

Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants

May 18, 2021

CP.MP.91 (PDF)

Obstetrical Home Health Care Programs

Medical necessity guidelines for OB home health programs

February 16, 2021

CP.MP.128 (PDF)

Optic nerve decompression surgery

Medical necessity guidelines for optic nerve sheath decompression surgery

November 17, 2020

CP.MP.176 (PDF)

Outpatient Cardiac Rehabilitation

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

September 15, 2020

CP.MP.50 (PDF)

Drugs of Abuse, Definitive Testing 

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

May 18, 2021
CP.MP.208 (PDF) Drugs of Abuse, Presumptive Testing Medical Necessity criteria for presumptive drug testing. May 18, 2021
CP.MP.190 (PDF) Oxygen Use and Concentrators Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxemia. February 16, 2021

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.

May 18, 2021

CP.MP.109 (PDF)

Panniculectomy

Medical necessity guidelines for panniculectomy

May 18, 2021

CP.MP.138 (PDF)

Pediatric heart transplant

Medical necessity guidelines for pediatric heart transplant

February 16, 2021

CP.MP.120 (PDF)

Pediatric Liver Transplant

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

March 16, 2021

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.

September 15, 2020
CP.MP.181 (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing. November 7, 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

November 17, 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.

February 16, 2021

CP.MP.70 (PDF)

Proton and neutron beam therapy

Medical necessity guidelines for proton beam and neutron beam radiation therapy

February 16, 2021

CP.MP.148 (PDF)

Radial Head Implant

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

September 15, 2020

CP.MP.51 (PDF)

Reduction mammoplasty and gynecomastia surgery

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

September 15, 2020

CP.MP.126 (PDF)

Sacroiliac joint fusion

Medical necessity guidelines for sacroiliac joint fusion

September 15, 2020

CP.MP.166 (PDF)

Sacroiliac Joint Interventions for Pain Management

Medical necessity criteria for sacroiliac joint interventions for pain management

November 17, 2020

CP.MP.146 (PDF)

Sclerotherapy for Varicose Veins

Medical necessity guidelines for sclerotherapy for treatment of vericose veins

November 17, 2020

CP.MP.174 (PDF)

Selective Dorsal Rhizotomy

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

May 18, 2021

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

November 17, 2020
CP.MP.182 (PDF) Short Inpatient Hospital Stay Medical necessity criteria for inpatient hospital stays of 2 days or less May 18, 2021

CP.MP.88 (PDF)

Sickle cell disease observation

Medical necessity criteria for observation stay for sickle cell disease

September 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

May 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

February 16, 2021

CP.MP.22 (PDF)

Stereotactic Body Radiation Therapy

Medical necessity guidelines for stereotactic body radiation therapy

March 16, 2021

CP.MP.162 (PDF)

Tandem Transplant

Medical necessity guidelines for tandem transplant

September 15, 2020

CP.MP.149 (PDF)

Testing for rupture of fetal membranes

Medical necessity guidelines for testing for rupture of fetal membranes

September 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

March 16, 2021

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.

February 16, 2021
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 July 21, 2020

CP.MP.154 (PDF)

Thyroid hormones and insulin testing in pediatrics

Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics

February 18, 2020

CP.MP.127 (PDF)

Total artificial heart

Medical necessity guidelines for a total artificial heart (TAH)

February 16, 2021

CP.MP.163 (PDF)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

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

July 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.

February 16, 2021

CP.BH.200 (PDF)

Transcranial magnetic stimulation

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

September 15, 2020

CP.MP.169 (PDF)

Trigger Point Injections for Pain Management

Medical necessity criteria for trigger point injections for pain management

November 17, 2020

CP.MP.38 (PDF)

Ultrasound in Pregnancy

Medical necessity guidelines for ultrasound use in pregnancy. 

November 17, 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

May 18, 2021

CP.MP.98 (PDF)

Urodynamic testing

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

February 16, 2021

CP.MP.12 (PDF)

Vagus Nerve Stimulation

Medical necessity guidelines for vagus nerve stimulation.

November 17, 2020

CP.MP.46 (PDF)

Ventricular Assist Devices

Medical necessity guidelines for ventricular assist devices.

May 18, 2021

CP.MP.56 (PDF)

Ventriculectomy and cardiomyoplasty

Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures

July 21, 2020
CP.MP.177 (PDF) Video Electroencephalographic Monitoring Medical necessity criteria for video electroencephalographic (EEG) monitoring November 17, 2020

CP.MP.99 (PDF)

Wheelchair seating

Medical necessity guidelines for special wheelchair seating and cushions

November 17, 2020

CP.MP.143 (PDF)

Wireless Motility Capsule

Medical necessity guidelines for wireless motility capsule

March 16, 2021
CP.MP.185 (PDF) Skin Substitutes for Chronic Wounds Medical necessity criteria for skin substitutes in the treatment of chronic wounds. September 15, 2020
CP.MP.186 (PDF) Burn Surgery Medical necessity guidelines for burn surgery, including debridement and application of skin substitutes for burns. September 15, 2020
CP.MP.187 (PDF) Radiofrequency Ablation of Uterine Fibroids Medical necessity criteria for radiofrequency ablation of uterine fibroids. September 15, 2020
CP.MP.188 (PDF) Pediatric Oral Function Therapy Medical necessity guidelines for pediatric oral function therapy. September 15, 2020
CP.MP.206 (PDF) Skilled Nursing Facility Leveling Medical necessity criteria for skilled nursing facility levels of care  March 16, 2021
CP.MP.203 (PDF) Diaphragmatic/Phrenic Nerve Stimulation Medical necessity guidelines for diaphragmatic/phrenic nerve stimulation February 16, 2021
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

March 16, 2021

CP.MP.92 (PDF)

Acupuncture

Medical necessity guidelines for acupuncture

November 17, 2020

CP.MP.124 (PDF)

ADHD Assessment and Treatment

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

May 19, 2020
CP.MP.175 (PDF) Air Ambulance Medical necessity guidelines for fixed wing air transportation. November 17, 2020

CP.MP.100 (PDF)

Allergy Testing and Therapy

Medical necessity guidelines for allergy testing and treatment

February 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

February 16, 2021

CP.MP.96 (PDF)

Ambulatory EEG

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

September 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

March 16, 2021
CP.MP.179 (PDF) Antithrombin III (Thrombate III, Atryn) Medical necessity criteria for Antithrombin III (Thrombate III, Atryn) February 18, 2020

CP.BH.104 (PDF)

Applied Behavioral Analysis for Autism

Medical necessity guidelines for applied behavioral analysis for autism

September 15, 2020

CP.MP.26 (PDF)

Articular Cartilage Defect Repairs

Medical necessity guidelines for articular cartilage defect repairs

May 18, 2021

CP.MP.55 (PDF)

Assisted Reproductive Technology

Medical necessity guidelines for assisted reproductive technology

February 16, 2021

CP.MP.119 (PDF)

Balloon sinus ostial dilation

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

November 17, 2020

CP.MP.37 (PDF)

Bariatric Surgery

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

September 15, 2020

CP.MP.168 (PDF)

Biofeedback

Medical necessity guidelines for biofeedback therapy

October 1, 2019

CP.MP.93 (PDF)

Bone-anchored hearing aid

Medical necessity guidelines for bone-anchored hearing aid

November 17, 2020

CP.MP.110 (PDF)

Bronchial Thermoplasty

Medical necessity guidelines for bronchial thermoplasty

July 21, 2020

CP.MP.156 (PDF)

Cardiac biomarker testing

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

March 16, 2021

CP.MP.83 (PDF)

Carrier Screening in Pregnancy

Medical necessity guidelines for carrier screening in pregnancy

September 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

September 15, 2020

CP.MP.84 (PDF)

Cell-free Fetal DNA Testing

Medical necessity guidelines for cell-free fetal DNA testing

November 17, 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

February 16, 2021

CP.MP.94 (PDF)

Clinical Trials

Medical necessity guidelines for routine costs of clinical trials

September 15, 2020

CP.MP.14 (PDF)

Cochlear Implant Replacements

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

September 15, 2020

CP.MP.31 (PDF)

Cosmetic and Reconstructive Surgery

Medical necessity guidelines for cosmetic and reconstructive surgery

May 18, 2021
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 September 15, 2020

CP.MP.61 (PDF)

Dental Anesthesia

Medical necessity guidelines for dental anesthesia

May 18, 2021

CP.MP.105 (PDF)

Digital electroencephalography spike analysis

Medical necessity guidelines for digital EEG spike analysis

March 16, 2021

CP.MP.114 (PDF)

Disc Decompression Procedures

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

September 15, 2020

CP.MP.115 (PDF)

Discography

Medical necessity guidelines for discography

September 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

February 16, 2021

CP.MP.101 (PDF)

Donor lymphocyte infusion

Medical necessity guidelines for donor lymphocyte infusion

February 18, 2020

CP.MP.107 (PDF)

Durable Medical Equipment (DME)

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

February 16, 2021

CP.MP.145 (PDF)

Electric Tumor Treating Fields

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

May 18, 2021

CP.MP.155 (PDF)

Electroencephalography in the evaluation of headache

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

July 21, 2020

CP.MP.106 (PDF)

Endometrial ablation

Medical necessity guidelines for endometrial ablation

September 15, 2020

CP.MP.140 (PDF)

EpiFix Wound Treatment

Medical necessity guidelines for EpiFix® wound treatment

October 1, 2019

CP.MP.131 (PDF)

Essure Removal

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

February 18, 2020

CP.MP.134 (PDF)

Evoked Potential Testing

Medical necessity guidelines for evoked potential testing

November 17, 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. 

May 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

September 15, 2020

CP.MP.137 (PDF)

Fecal incontinence treatments

Medical necessity guidelines for fecal incontinence treatments

September 15, 2020

CP.MP.53 (PDF)

Ferriscan R2-MRI

Medical necessity guidelines for use of the FerriScan R2-MRI

October 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

November 17, 2020

CP.MP.129 (PDF)

Fetal surgery in utero for prenatally diagnosed malformations

Medical necessity guidelines for performing fetal surgery in utero

September 15, 2020

CP.MP.175 (PDF)

Fixed Wing Air Transportation

Medical necessity guidelines for fixed wing air transportation

May 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

February 16, 2021

CP.MP.43 (PDF)

Functional MRI

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

November 17, 2020

CP.MP.40 (PDF)

Gastric electrical stimulation

Medical necessity guidelines for gastric electrical stimulation

November 17, 2020

CP.MP.95 (PDF)

Gender Affirming Procedures

Medical necessity guidelines for surgery for the treatment of gender dysphoria

November 17, 2020

CP.MP.89 (PDF)

Genetic and Pharmacogenetic Testing

Medical necessity criteria for genetic testing

May 18, 2021

CP.MP.153 (PDF)

H. Pylori serology testing

Medical necessity guidelines for H. pylori serology testing

February 18, 2020

CP.MP.132 (PDF)

Heart-Lung Transplant

Medical necessity guidelines for heart-lung transplantation

September 15, 2020

CP.MP.113 (PDF)

Holter Monitors

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

July 21, 2020

CP.MP.136 (PDF)

Home Birth

Medical necessity guidelines for planned home birth

November 17, 2020

CP.MP.150 (PDF)

Home phototherapy for neonatal hyperbilirubinemia

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

February 18, 2020

CP.MP.121 (PDF)

Homocysteine testing

Medical necessity guidelines for homocysteine testing

September 15, 2020

CP.MP.54 (PDF)

Hospice Services

Medical necessity guidelines for hospice services

July 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)

May 18, 2021

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

March 16, 2021
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 February 16, 2021

CP.MP.173 (PDF)

Implantable Intrathecal Pain Pump

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

March 16, 2021

CP.MP.160 (PDF)

Implantable Wireless Pulmonary Artery Pressure Monitoring

Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring

July 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.

February 18, 2020

CP.MP.87 (PDF)

Inhaled nitric oxide

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

February 16, 2021

CP.MP.69 (PDF)

Intensity-Modulated Radiotherapy

Medical necessity guidelines for intensity-modulated radiotherapy (IMRT)

February 16, 2021

CP.MP.58 (PDF)

Intestinal and multivisceral transplant

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

September 15, 2020

CP.MP.167 (PDF)

Intradiscal Steroid Injections for Pain Management

Medical necessity criteria for intradiscal steroid injections for pain management

November 17, 2020

CP.MP.123 (PDF)

Laser therapy for skin conditions

Medical necessity guidelines for excimer laser based targeted phototherapy

September 15, 2020

CP.MP.71 (PDF)

Long Term Care Placement Criteria

Medical necessity guidelines for long term care (LTC) placement

July 21, 2020

CP.MP.139 (PDF)

Low-frequency ultrasound therapy for wound management

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

November 17, 2020

CP.MP.57 (PDF)

Lung Transplantation

Medical necessity guidelines for review of lung transplantation requests

November 17, 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

November 17, 2020

CP.MP.152 (PDF)

Measurement of serum 1,25-dihydroxyvitamin D

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

February 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.

July 21, 2020

CP.CPC.05 (PDF)

Medical Necessity Criteria

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

July 21, 2020

CP.MP.24 (PDF)

Multiple Sleep Latency Testing

Medical necessity criteria for multiple sleep latency testing (MSLT)

July 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)

November 17, 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

September 15, 2020

CP.MP.170 (PDF)

Nerve Blocks for Pain Management

Medical necessity criteria for nerve blocks for pain management

February 16, 2021

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

September 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.

September 15, 2020
CP.MP.184 (PDF) Non-Invasive Home Ventilators Medical necessity guidelines for non-invasive home ventilators November 17, 2020

CP.MP.141 (PDF)

Non-myeloablative allogeneic stem cell transplants

Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants

May 18, 2021

CP.MP.91 (PDF)

Obstetrical Home Health Care Programs

Medical necessity guidelines for OB home health programs

February 16, 2021

CP.MP.128 (PDF)

Optic nerve decompression surgery

Medical necessity guidelines for optic nerve sheath decompression surgery

November 17, 2020

CP.MP.176 (PDF)

Outpatient Cardiac Rehabilitation

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

September 15, 2020

CP.MP.50 (PDF)

Drugs of Abuse, Definitive Testing

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

May 18, 2021
CP.MP.208 (PDF) Drugs of Abuse, Presumptive Testing Medical Necessity criteria for presumptive drug testing. May 18, 2021
CP.MP.190 (PDF) Oxygen Use and Concentrators Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxemia. February 16, 2021

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.

May 18, 2021

CP.MP.109 (PDF)

Panniculectomy

Medical necessity guidelines for panniculectomy

May 18, 2021

CP.MP.138 (PDF)

Pediatric heart transplant

Medical necessity guidelines for pediatric heart transplant

February 16, 2021

CP.MP.120 (PDF)

Pediatric Liver Transplant

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

March 16, 2021

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.

September 15, 2020
CP.MP.181 (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing Medical necessity criteria for multiplex respiratory polymerase chain reac November 17, 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

November 17, 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.

February 16, 2021

CP.MP.70 (PDF)

Proton and neutron beam therapy

Medical necessity guidelines for proton beam and neutron beam radiation therapy

February 16, 2021

CP.MP.148 (PDF)

Radial Head Implant

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

September 15, 2020

CP.MP.51 (PDF)

Reduction mammoplasty and gynecomastia surgery

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

September 15, 2020

CP.MP.126 (PDF)

Sacroiliac joint fusion

Medical necessity guidelines for sacroiliac joint fusion

September 15, 2020

CP.MP.166 (PDF)

Sacroiliac Joint Interventions for Pain Management

Medical necessity criteria for sacroiliac joint interventions for pain management

November 17, 2020

CP.MP.146 (PDF)

Sclerotherapy for Varicose Veins

Medical necessity guidelines for sclerotherapy for treatment of vericose veins

November 17, 2020

CP.MP.174 (PDF)

Selective Dorsal Rhizotomy

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

May 18, 2021

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

November 17, 2020
CP.MP.182 (PDF) Short Inpatient Hospital Stay Medical necessity criteria for inpatient hospital stays of 2 days or less May 18, 2021

CP.MP.88 (PDF)

Sickle cell disease observation

Medical necessity criteria for observation stay for sickle cell disease

September 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

May 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

February 16, 2021

CP.MP.22 (PDF)

Stereotactic Body Radiation Therapy

Medical necessity guidelines for stereotactic body radiation therapy

March 16, 2021

CP.MP.162 (PDF)

Tandem Transplant

Medical necessity guidelines for tandem transplant

September 15, 2020

CP.MP.149 (PDF)

Testing for rupture of fetal membranes

Medical necessity guidelines for testing for rupture of fetal membranes

September 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

March 16, 2021

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.

February 16, 2021
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 July 21, 2020

CP.MP.154 (PDF)

Thyroid hormones and insulin testing in pediatrics

Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics

February 18, 2020

CP.MP.127 (PDF)

Total artificial heart

Medical necessity guidelines for a total artificial heart (TAH)

February 16, 2021

CP.MP.163 (PDF)

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

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

July 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.

February 16, 2021

CP.BH.200 (PDF)

Transcranial magnetic stimulation

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

September 15, 2020

CP.MP.169 (PDF)

Trigger Point Injections for Pain Management

Medical necessity criteria for trigger point injections for pain management

November 17, 2020

CP.MP.38 (PDF)

Ultrasound in Pregnancy

Medical necessity guidelines for ultrasound use in pregnancy. 

November 17, 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

May 18, 2021

CP.MP.98 (PDF)

Urodynamic testing

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

February 16, 2021

CP.MP.12 (PDF)

Vagus Nerve Stimulation

Medical necessity guidelines for vagus nerve stimulation.

November 17, 2020

CP.MP.46 (PDF)

Ventricular Assist Devices

Medical necessity guidelines for ventricular assist devices.

May 18, 2021

CP.MP.56 (PDF)

Ventriculectomy and cardiomyoplasty

Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures

July 21, 2020
CP.MP.177 (PDF) Video Electroencephalographic Monitoring Medical necessity criteria for video electroencephalographic (EEG) monitoring November 17, 2020

CP.MP.99 (PDF)

Wheelchair seating

Medical necessity guidelines for special wheelchair seating and cushions

November 17, 2020

CP.MP.143 (PDF)

Wireless Motility Capsule

Medical necessity guidelines for wireless motility capsule

March 16, 2021
CP.MP.185 (PDF) Skin Substitutes for Chronic Wounds Medical necessity criteria for skin substitutes in the treatment of chronic wounds. September 15, 2020
CP.MP.186 (PDF) Burn Surgery Medical necessity guidelines for burn surgery, including debridement and application of skin substitutes for burns. September 15, 2020
CP.MP.187 (PDF) Radiofrequency Ablation of Uterine Fibroids Medical necessity criteria for radiofrequency ablation of uterine fibroids. September 15, 2020
CP.MP.188 (PDF) Pediatric Oral Function Therapy Medical necessity guidelines for pediatric oral function therapy. September 15, 2020
CP.MP.206 (PDF) Skilled Nursing Facility Leveling Medical necessity criteria for skilled nursing facility levels of care  March 16, 2021
CP.MP.203 (PDF) Diaphragmatic/Phrenic Nerve Stimulation Medical necessity guidelines for diaphragmatic/phrenic nerve stimulation February 16, 2021

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

Anti-Inflammatory Agents

Opioid Agents

 

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

 

Adrenal Steroid 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

Posterior Pituitary Hormones

Progesterone Receptor Antagonists

Progestins

Somatostatic Agents

Vasopressin Receptor Antagonists

Anti-Diarrheal/Probiotic Agents

Antiemetics

Digestive Aids

Diuretics

Gastrointestinal Agents – Misc.

Genitourinary Agents – Misc.

Gout Agents

Impotence Agents

Laxatives

 

Ulcer Drugs/Anti-Spasmodies/Anticholinergies 

Urinary Antispasmotics

Vaginal Products

Anticoagulants

Hematological Agents – Misc.

 

Hematopoietic Agents

 

ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants

Anticonvulsants

Anti-Depressants

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.011 (PDF) Code Editing Overview (Effective February 15, 2020) The purpose of this policy is to serve as a reference guide for general coding and claims editing information.

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 May 15, 2021)

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.105 (PDF) Digital EEG Spike Analysis (Effective May 15, 2021) Electroencephalography (EEG) is a significant component of epilepsy diagnosis, along with a thorough medical history and neurological workup. Most EEGs today are performed on digital machines which record data and automatically detect spikes that may indicate seizures (ACNS, 2008). For the purpose of this policy, digital EEG spike analysis, which also is known as 3D dipole localization or dipole source imaging, refers to additional analysis of digitally recorded EEG spikes by a technician and a physician. Digital EEG spike analysis is also called 3D dipole localization or dipole source imaging.
CP.MP.110 (PDF) Bronchial Thermoplasty (Effective May 15, 2021) This policy describes the medical necessity requirements for bronchial thermoplasty (BT). BT is a bronchoscopic procedure that utilizes radiofrequency ablation to reduce airway smooth muscle cells. It is designed to serve as a therapeutic option to reduce severe bronchoconstriction for severe persistent asthma.
CP.MP.123 (PDF) Laser Therapy for Skin Conditions (Effective May 15, 2021) Targeted phototherapy utilizes non-ionizing ultraviolet radiation with therapeutic benefit. Phototherapy is an efficacious local therapy that provides several advantages to traditional and biologic systemic therapies. Excimer lasers are monochromatic 308 nm xenon chloride lasers that are approved to treat certain inflammatory skin diseases. This policy describes the medical necessity requirements for excimer laser based targeted phototherapy.
CP.MP.156 (PDF) Cardiac Biomarker Testing (Effective May 15, 2021) The release of cardiac biomarkers is among the cascade of events that occur during acute coronary syndromes and cardiac ischemia. This policy discusses the medical necessity requirements for testing of these cardiac biomarkers.
CP.MP.96 (PDF) Ambulatory EEG (Effective May 15, 2021) Ambulatory electroencephalogram (EEG) testing in the outpatient setting (e.g., at home) is a diagnostic test used to evaluate an individual in whom a seizure disorder or possibly nonepileptic attacks are suspected but not conclusively confirmed by the person's medical history, physical examination, and a previous routine or standard (awake and asleep) EEG. Ambulatory EEG monitoring allows extended interictal EEG recording outside of a clinic or a hospital and can allow patients to “mark” events experienced on the EEG recording. 
CP.MP.99 (PDF) Wheelchair Seating (Effective May 15, 2021) The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. 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.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.
OC.UM.CP.0014 (PDF) Scanning Computerized Ophthalmic Diagnostic Imaging (Effective May 15, 2021) Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) is a non-invasive, non-contact imaging technique that produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of anterior segment and posterior segment diseases. This policy describes the medical necessity indications for SCODI.
CP.VP.29 (PDF) Fundus Photography (Effective May 15, 2021) Fundus photography involves the use of a retinal camera to photograph regions of the vitreous, retina, choroid, and optic nerve. The resultant images may be either photographic or digital and become part of the patient’s permanent record. Fundus photographs are usually taken through a dilated pupil in order to enhance the quality of the photographic record, unless unnecessary for image acquisition or clinically contraindicated. This policy describes the medical necessity guidelines for fundus photography.
CP.VP.63 (PDF) Visual Field Testing (Effective May 15, 2021) A visual field acuity test is a painless test that determine a patient’s visible field of view. The test maps central and peripheral vision. This policy describes the medical necessity requirements for visual field testing.
CP.MP.140 (PDF) EpiFix Wound Treatment (Effective October 01, 2019) 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: October 01, 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.049 (PDF) Status "P" Bundled Services (Effective Date: October 01, 2019)

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 October 01, 020) 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 October 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. 
CC.PP.035 (PDF) Sleep Studies POS (Effective January 15, 2021) Sleep Studies/Polysomnogram (PSG) procedures refer to continuous and simultaneous monitoring and recording observational physiological parameters of sleep for a period of at least six hours. Attended sleep studies are typically performed in a sleep laboratory or facility and attended by a technologist or qualified healthcare professional. Unattended sleep studies may be performed in the home.
CP.PP.050 (PDF) Robotic Surgery (Effective January 15, 2021) A Robotic Surgical Device is a type of surgical technique or approach that is not medically necessary to ensure the successful outcome of the procedure. Therefore, separate reimbursement for surgeries that are performed using a robotic technique will not be considered for additional reimbursement. The type of instruments, technique or approach used in a procedure is a matter of choice of the surgeon.
CC.PP.500 (PDF) 3-Day Payment Window (Effective January 15, 2021) The Health Plan covers certain services, procedures or devices provided to members in accordance with the member’s coverage documents, when rendered by participating providers and, in certain circumstances, by non-participating provides, all in accordance with the treating provider’s scope of practice and this policy. While this policy serves as a guideline and general reference regarding reimbursement for the “3-day payment rule,” it is not intended to address every reimbursement situation. In instances that are not specifically addressed by this policy or addressed by another policy or contract, The Health Plan retains the right to use reasonable discretion in interpreting this policy and applying it (or not applying it) to the reimbursement of services provided to all or certain of The Health Plans members.
CC.PP.007 (PDF) Lab Quantity Limits (Effective January 15, 2021) Frequent billing errors are made when assigning the number of units to a procedure code. For example, the units for a drug may be mistakenly billed as the number of milligrams, e.g., 50, where the actual unit of service may be 1 (1 unit = 50mg), or the descriptor for a CPT code may specify “bilateral” meaning the code includes both sides of the body, and the maximum units that may be billed is 1, not 2. Maximum units edits are unit-of-service claim edits applied to medical claims against a procedure code for medical services rendered by 1 provider/supplier to 1 patient for a period of time, usually 1 day. These claim edits compare different values on medical claims to a set of defined criteria to check for irregularities. Maximum units edits are designed to limit fraud or coding errors. They represent an upper limit that unquestionably requires further documentation to support. The Maximum Units of Service policy is derived from several sources: CMS, AMA CPT (American Medical Association Current Procedural Terminology), knowledge of anatomy, standards of medical practice, FDA (U.S. Food and Drug Administration) and other nationally recognized drug references, and outlier claims data from provider billing patterns.
CC.PP.067 (PDF) Renal Hemodialysis (Effective January 15, 2021) Chronic kidney disease (CKD) is a worsening condition that without treatment can progress quickly. It describes the gradual loss of kidney function resulting in physical complications that include fluid retention and a rise in electrolyte levels such as potassium, which consequently can lead to heart failure and sudden death. When left untreated, CKD can evolve into irreversible kidney damage and ultimately failure. When the kidneys are unable to function, dialysis or a kidney transplant is necessary to sustain life.

CP.MP.38 (PDF)

Ultrasound in Pregnancy (Effective April 01, 2021)

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today. Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location; and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented. 

CP.MP.97 (PDF)

Testing for Select GU Conditions (Effective April 01, 2021)

Various diagnostic methods are available to identify the etiology of the signs and symptoms of vaginitis. The purpose of this policy is to define medical necessity criteria for the diagnostic evaluation of vaginitis in members ≥ 13 years of age. This policy also defines unnecessary amplified DNA-(deoxyribonucleic acid) probe testing for genitourinary conditions.

CP.MP.106 (PDF)

Endometrial Ablation (Effective April 01, 2021)

This policy describes the medical necessity guidelines for an endometrial ablation. Endometrial ablation is a minimally invasive surgical procedure used to treat premenopausal abnormal uterine bleeding. Although this procedure preserves the uterus, endometrial ablation is indicated for those who have no desire for future fertility. The two major classifications of endometrial ablation procedures are first generation resectoscopic techniques and second generation non-resectoscopic methods. Quality of life may improve following endometrial ablation procedures.

CP.MP.113 (PDF)

Holter Monitors (Effective April 01, 2021)

Ambulatory electrocardiogram (ECG) monitoring provides a view of cardiac activity over an extended period of time. Holter monitoring, or continuous ambulatory ECG monitoring, for 24 to 48 hours is most practical as the initial monitor for members with daily or near daily symptoms, as well as for assessing the efficacy of medication and other treatments for cardiac arrhythmias.

CP.MP.125 (PDF)

DNA Analysis of Stool to Screen for Colorectal Cancer (Effective April 01, 2021)

Cologuard is a noninvasive screening test for colon cancer. This test comprises a multi-target screen for several aberrant DNA markers of colon cancer, as well as a hemoglobin immunoassay. This policy describes the medical necessity requirements for DNA analysis of stool with Cologuard.

CP.MP.149 (PDF)

Testing for Rupture of Fetal Membranes (Effective April 01, 2021)

Premature rupture of membranes is a complication in pregnancy that can lead to preterm delivery. The purpose of this policy is to define medical necessity criteria for testing for rupture of fetal membranes using AmniSure®, Actim® PROM and the ROM Plus Fetal Membranes Rupture Test for the diagnostic evaluation for premature rupture of membranes.

CP.MP.152 (PDF)

Measurement of Serum 1,25-dihydroxyvitamin D (Effective April 01, 2021)

Vitamin D is metabolized in the liver to 25-hydroxyvitamin D [25(OH)D], (also known as calcidiol), and then in the kidney to 1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol. 25(OH)D is the major circulating form of vitamin D while 1,25(OH)2D is the active form of vitamin D. In individuals at risk for vitamin D deficiency, the best method for determining a person's vitamin D status is to measure a 25(OH)D concentration. Measurement of 1,25(OH)2D is not useful for monitoring the vitamin D status, as it does not reflect vitamin D reserves. This policy addresses when measurement of 1,25(OH)2D is appropriate and medically necessary.

CP.MP.153 (PDF)

H Pylori Serology Testing (Effective April 01, 2021)

Helicobacter pylori (H. pylori) is the most prevalent chronic bacterial infection and is associated with peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, and gastric mucosa associated lymphoid tissue (MALT) lymphoma. Noninvasive tests for the diagnosis of H. pylori include urea breath testing (UBT), stool antigen testing, and serology.

CP.MP.154 (PDF)

Thyroid Hormones and Insulin Testing in Pediatrics (Effective April 01, 2021)

Numerous essential metabolic functions are mitigated by hormones produced by, and affecting the thyroid, e.g., thyroid stimulating hormone [TSH] and thyroxine [T4], as well as by insulin. This policy discusses the medical necessity requirements for the testing of these hormones.

CP.MP.156 (PDF)

Cardiac Biomarker Testing for Acute Myocardial Infarction (Effective April 01, 2021)

The release of cardiac biomarkers is among the cascade of events that occur during acute coronary syndromes and cardiac ischemia. This policy discusses the medical necessity requirements for testing of these cardiac biomarkers.

CP.MP.157 (PDF)

25-hydroxyvitamin D Testing in Children and Adolescents (Effective April 01, 2021)

A global consensus statement recommends against universal screening for vitamin D deficiency in healthy children as there is insufficient evidence that the potential benefits of testing outweigh the potential harms.
CP.MP.121 (PDF) Homocysteine Testing (Effective April 01, 2021) Homocysteine is a nonproteinogenic amino acid that is generated during the conversion of methionine to cysteine. Mutations of the enzymes within the biochemical pathways that regulate homeostatic homocysteine levels are associated with risk factors for various diseases, including venous thromboembolism. Supplementation of folic acid, vitamin B6, and vitamin B12 are known to modulate homocysteine levels, given the interplay between the folate cycle and metabolism. This policy describes the medical necessity requirements for testing levels of homocysteine.
CP.MP.208 (PDF)  Outpatient Testing for Drugs of Abuse: Presumptive Frequency Edits (Effective July 01, 2021) 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 non-cancer pain) and to identify drug misuse or addiction prior to starting or during treatment with controlled substances.
CP.MP.155 (PDF) EEG in the Evaluation of Headache (Effective July 01, 2021) function. EEG measures the electrical activity that is recorded from many different standard sites on the scalp according to the international (10 to 20) electrode placement system. It is a useful diagnostic test in evaluating epilepsy. This policy addresses the use of EEG in the diagnostic evaluation of headache.
OC.UM.CP.0026 (PDF) Extended Ophthalmoscopy (Effective July 01, 2021) Extended ophthalmoscopy is a method of examining the posterior portion of the eye when the level of examination requires a complete view of the back of the eye and documentation is greater than that required during routine ophthalmoscopy. This policy describes the medical necessity guidelines for extended ophthalmoscopy.
OC.UM.CP.0043 (PDF) External Ocular Photography (Effective July 01, 2021) External ocular photography documents the external eye, lids and ocular adnexa. Photographs can record the eye and its motion more accurately than physician chart notes or drawings. This policy describes the medical necessity requirements for external ocular photography.
CP.MP.103 (PDF) FeNO Testing (Effective July 01, 2021) Fractional exhaled nitric oxide (FeNO) measurement is a noninvasive and simple test thought to reflect eosinophilic airway inflammation. While measurement of FeNO is standardized, there are currently no reference guidelines available to aid practitioners in appropriately applying test results in practice.
OC.UM.CP.0028 (PDF) Flourescein Angiography (Effective July 01, 2021) Intravenous Fluorescein Angiography (IVFA) or fluorescent angiography is a technique for examining the circulation of the retina and choroid using a fluorescent dye and a specialized camera. It involves injection of sodium fluorescein into the systemic circulation, and then an angiogram is obtained by photographing the fluorescence emitted after illumination of the retina with blue light at a wavelength of 490 nanometers. This policy describes the medical necessity guidelines for fluorescein angiography.
OC.UM.CP.0031 (PDF)  Gonioscopy (Effective July 01, 2021) Gonioscopy involves using a concave contact lens in conjunction with oblique mirrors to view the iridocorneal angle. This policy describes the medical necessity requirements for gonioscopy.
CP.MP.139 (PDF) Low-Frequency Ultrasound Wound Therapy (Effective July 01, 2021) Low-frequency ultrasound debridement is a noncontact debridement method that provides simultaneous cleansing and debridement of wounds. It is generally performed at a 5 mm -15 mm distance from the wound surface. A device uses ultrasound technology to atomize saline, delivering a continuous mist to the treatment site. Multiple passes over the wound are made with the treatment head of the device for a predetermined treatment session. This can accelerate the wound healing process by removing the necrotic tissue, fibrosis, exudate, and bacteria with minimum bleeding and pain.
CC.PP.056 (PDF) Urine Specimen Validity Testing (Effective July 01, 2021) Urine specimen testing is necessary to treat patients for specific medical problems. Providers use the results to detect and monitor drug levels for medical treatment purposes.
CC.PP.502 (PDF) Wheelchair Accessories (Effective July 01, 2021) Options and accessories for wheelchairs may be covered if the member has a wheelchair that meets coverage criteria and the option/accessory itself is medically necessary. General coverage and payment information for specific items are described below. This policy is adapted from CMS’s 4 DME MAC Local Coverage Determinations and Local Coverage Articles for wheelchairs and accessories.

Policy Reference Number

Policy Name

Description

CC.PP.011 (PDF) Code Editing Overview (Effective February 15, 2020) The purpose of this policy is to serve as a reference guide for general coding and claims editing information.

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 May 15, 2021)

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.105 (PDF)
Digital EEG Spike Analysis (Effective May 15, 2021) Electroencephalography (EEG) is a significant component of epilepsy diagnosis, along with a thorough medical history and neurological workup. Most EEGs today are performed on digital machines which record data and automatically detect spikes that may indicate seizures (ACNS, 2008). For the purpose of this policy, digital EEG spike analysis, which also is known as 3D dipole localization or dipole source imaging, refers to additional analysis of digitally recorded EEG spikes by a technician and a physician. Digital EEG spike analysis is also called 3D dipole localization or dipole source imaging.
CP.MP.110 (PDF) Bronchial Thermoplasty (Effective May 15, 2021) This policy describes the medical necessity requirements for bronchial thermoplasty (BT). BT is a bronchoscopic procedure that utilizes radiofrequency ablation to reduce airway smooth muscle cells. It is designed to serve as a therapeutic option to reduce severe bronchoconstriction for severe persistent asthma.
CP.MP.123 (PDF) Laser Therapy for Skin Conditions (Effective May 15, 2021) Targeted phototherapy utilizes non-ionizing ultraviolet radiation with therapeutic benefit. Phototherapy is an efficacious local therapy that provides several advantages to traditional and biologic systemic therapies. Excimer lasers are monochromatic 308 nm xenon chloride lasers that are approved to treat certain inflammatory skin diseases. This policy describes the medical necessity requirements for excimer laser based targeted phototherapy.
CP.MP.156 (PDF) Cardiac Biomarker Testing (Effective May 15, 2021) The release of cardiac biomarkers is among the cascade of events that occur during acute coronary syndromes and cardiac ischemia. This policy discusses the medical necessity requirements for testing of these cardiac biomarkers.
CP.MP.96 (PDF) Ambulatory EEG (Effective May 15, 2021) Ambulatory electroencephalogram (EEG) testing in the outpatient setting (e.g., at home) is a diagnostic test used to evaluate an individual in whom a seizure disorder or possibly nonepileptic attacks are suspected but not conclusively confirmed by the person's medical history, physical examination, and a previous routine or standard (awake and asleep) EEG. Ambulatory EEG monitoring allows extended interictal EEG recording outside of a clinic or a hospital and can allow patients to “mark” events experienced on the EEG recording. 
CP.MP.99 (PDF) Wheelchair Seating (Effective May 15, 2021) The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. 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.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.
OC.UM.CP.0014 (PDF) Scanning Computerized Ophthalmic Diagnostic Imaging (Effective May 15,2021) Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) is a non-invasive, non-contact imaging technique that produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of anterior segment and posterior segment diseases. This policy describes the medical necessity indications for SCODI.
CP.VP.29 (PDF) Fundus Photography (Effective May 15, 2021) Fundus photography involves the use of a retinal camera to photograph regions of the vitreous, retina, choroid, and optic nerve. The resultant images may be either photographic or digital and become part of the patient’s permanent record. Fundus photographs are usually taken through a dilated pupil in order to enhance the quality of the photographic record, unless unnecessary for image acquisition or clinically contraindicated. This policy describes the medical necessity guidelines for fundus photography.
CP.VP.63 (PDF) Visual Field Testing (Effective May 15, 2021) A visual field acuity test is a painless test that determine a patient’s visible field of view. The test maps central and peripheral vision. This policy describes the medical necessity requirements for visual field testing.
CP.MP.140 (PDF) EpiFix Wound Treatment (Effective October 01, 2019) 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 October 01, 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.007 (PDF) Lab Quantity Limits (Effective Janaury 15, 2021) Frequent billing errors are made when assigning the number of units to a procedure code. For example, the units for a drug may be mistakenly billed as the number of milligrams, e.g., 50, where the actual unit of service may be 1 (1 unit = 50mg), or the descriptor for a CPT code may specify “bilateral” meaning the code includes both sides of the body, and the maximum units that may be billed is 1, not 2. Maximum units edits are unit-of-service claim edits applied to medical claims against a procedure code for medical services rendered by 1 provider/supplier to 1 patient for a period of time, usually 1 day. These claim edits compare different values on medical claims to a set of defined criteria to check for irregularities. Maximum units edits are designed to limit fraud or coding errors. They represent an upper limit that unquestionably requires further documentation to support. The Maximum Units of Service policy is derived from several sources: CMS, AMA CPT (American Medical Association Current Procedural Terminology), knowledge of anatomy, standards of medical practice, FDA (U.S. Food and Drug Administration) and other nationally recognized drug references, and outlier claims data from provider billing patterns.
CC.PP.067 (PDF) Renal Hemodialysis (Effective January 15, 2021) Chronic kidney disease (CKD) is a worsening condition that without treatment can progress quickly. It describes the gradual loss of kidney function resulting in physical complications that include fluid retention and a rise in electrolyte levels such as potassium, which consequently can lead to heart failure and sudden death. When left untreated, CKD can evolve into irreversible kidney damage and ultimately failure. When the kidneys are unable to function, dialysis or a kidney transplant is necessary to sustain life.

CP.MP.38 (PDF)

Ultrasound in Pregnancy (Effective April 01, 2021)

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today. Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location; and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented. 

CP.MP.97 (PDF)

Testing for Select GU Conditions (Effective April 01, 2021)

Various diagnostic methods are available to identify the etiology of the signs and symptoms of vaginitis. The purpose of this policy is to define medical necessity criteria for the diagnostic evaluation of vaginitis in members ≥ 13 years of age. This policy also defines unnecessary amplified DNA-(deoxyribonucleic acid) probe testing for genitourinary conditions.

CP.MP.106 (PDF)

Endometrial Ablation (Effective April 01, 2021)

This policy describes the medical necessity guidelines for an endometrial ablation. Endometrial ablation is a minimally invasive surgical procedure used to treat premenopausal abnormal uterine bleeding. Although this procedure preserves the uterus, endometrial ablation is indicated for those who have no desire for future fertility. The two major classifications of endometrial ablation procedures are first generation resectoscopic techniques and second generation non-resectoscopic methods. Quality of life may improve following endometrial ablation procedures.

CP.MP.113 (PDF)

Holter Monitors (Effective April 01, 2021)

Ambulatory electrocardiogram (ECG) monitoring provides a view of cardiac activity over an extended period of time. Holter monitoring, or continuous ambulatory ECG monitoring, for 24 to 48 hours is most practical as the initial monitor for members with daily or near daily symptoms, as well as for assessing the efficacy of medication and other treatments for cardiac arrhythmias.

CP.MP.125 (PDF)

DNA Analysis of Stool to Screen for Colorectal Cancer (Effective April 01, 2021)

Cologuard is a noninvasive screening test for colon cancer. This test comprises a multi-target screen for several aberrant DNA markers of colon cancer, as well as a hemoglobin immunoassay. This policy describes the medical necessity requirements for DNA analysis of stool with Cologuard.

CP.MP.149 (PDF)

Testing for Rupture of Fetal Membranes (Effective April 01, 2021)

Premature rupture of membranes is a complication in pregnancy that can lead to preterm delivery. The purpose of this policy is to define medical necessity criteria for testing for rupture of fetal membranes using AmniSure®, Actim® PROM and the ROM Plus Fetal Membranes Rupture Test for the diagnostic evaluation for premature rupture of membranes.

CP.MP.152 (PDF)

Measurement of Serum 1,25-dihydroxyvitamin D (Effective April 01, 2021)

Vitamin D is metabolized in the liver to 25-hydroxyvitamin D [25(OH)D], (also known as calcidiol), and then in the kidney to 1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol. 25(OH)D is the major circulating form of vitamin D while 1,25(OH)2D is the active form of vitamin D. In individuals at risk for vitamin D deficiency, the best method for determining a person's vitamin D status is to measure a 25(OH)D concentration. Measurement of 1,25(OH)2D is not useful for monitoring the vitamin D status, as it does not reflect vitamin D reserves. This policy addresses when measurement of 1,25(OH)2D is appropriate and medically necessary.

CP.MP.153 (PDF)

H Pylori Serology Testing (Effective April 01, 2021)

Helicobacter pylori (H. pylori) is the most prevalent chronic bacterial infection and is associated with peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, and gastric mucosa associated lymphoid tissue (MALT) lymphoma. Noninvasive tests for the diagnosis of H. pylori include urea breath testing (UBT), stool antigen testing, and serology.

CP.MP.154 (PDF)

Thyroid Hormones and Insulin Testing in Pediatrics (Effective April 01,2021)

Numerous essential metabolic functions are mitigated by hormones produced by, and affecting the thyroid, e.g., thyroid stimulating hormone [TSH] and thyroxine [T4], as well as by insulin. This policy discusses the medical necessity requirements for the testing of these hormones.

CP.MP.156 (PDF)

Cardiac Biomarker Testing for Acute Myocardial Infarction (Effective April 01, 2021)

The release of cardiac biomarkers is among the cascade of events that occur during acute coronary syndromes and cardiac ischemia. This policy discusses the medical necessity requirements for testing of these cardiac biomarkers.

CP.MP.157 (PDF)

25-hydroxyvitamin D Testing in Children and Adolescents (Effective April 01, 2021)

A global consensus statement recommends against universal screening for vitamin D deficiency in healthy children as there is insufficient evidence that the potential benefits of testing outweigh the potential harms.
CC.PP.065 (PDF) Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (Effective October 01, 2020) This policy is based on CMS reimbursement methodologies for MPPR and applies a multiple diagnostic cardiovascular procedure reimbursement reduction (MDCR) to procedures assigned a multiple procedure indicator (MPI) of 6 on the CMS National Physician Fee Schedule (NPFS). When this occurs, only the highest-valued procedure is reimbursed at the full payment allowance (100%) and payment for subsequent procedures/units is reimbursed at 75% of the allowance.
CC.PP.070 (PDF) 340B Drug Payment Reduction (Effective July 01, 2021) In 1992, Congress enacted Section 340B of the Public Health Service Act requiring pharmaceutical manufacturers to enter into a pharmaceutical pricing agreement (PPA) with the Health and Human Services (HHS) secretary in exchange for having their drugs covered by Medicaid and Medicare Part B. As part of this agreement, pharmaceutical companies provide up front discounts directly to outpatient eligible providers that deliver health care services to a large number of underserved, underinsured, and vulnerable populations (safety-net providers). The program is administered by the Office of Pharmacy Affairs (OPA), a division within the Health Resources and Services Administration (HRSA).
CP.MP.208 (PDF)  Outpatient Testing for Drugs of Abuse: Presumptive Frequency Edits (Effective July 01, 2021) 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 non-cancer pain) and to identify drug misuse or addiction prior to starting or during treatment with controlled substances.
CP.MP.155 (PDF) EEG in the Evaluation of Headache (Effective July 01, 2021) function. EEG measures the electrical activity that is recorded from many different standard sites on the scalp according to the international (10 to 20) electrode placement system. It is a useful diagnostic test in evaluating epilepsy. This policy addresses the use of EEG in the diagnostic evaluation of headache.
OC.UM.CP.0026 (PDF) Extended Ophthalmoscopy (Effective July 01, 2021) Extended ophthalmoscopy is a method of examining the posterior portion of the eye when the level of examination requires a complete view of the back of the eye and documentation is greater than that required during routine ophthalmoscopy. This policy describes the medical necessity guidelines for extended ophthalmoscopy.
OC.UM.CP.0043 (PDF) External Ocular Photography (Effective July 01, 2021) External ocular photography documents the external eye, lids and ocular adnexa. Photographs can record the eye and its motion more accurately than physician chart notes or drawings. This policy describes the medical necessity requirements for external ocular photography.
CP.MP.103 (PDF) FeNO Testing (Effective July 01,2021) Fractional exhaled nitric oxide (FeNO) measurement is a noninvasive and simple test thought to reflect eosinophilic airway inflammation. While measurement of FeNO is standardized, there are currently no reference guidelines available to aid practitioners in appropriately applying test results in practice.
OC.UM.CP.0028 (PDF) Flourescein Angiography (Effective July 01, 2021) Intravenous Fluorescein Angiography (IVFA) or fluorescent angiography is a technique for examining the circulation of the retina and choroid using a fluorescent dye and a specialized camera. It involves injection of sodium fluorescein into the systemic circulation, and then an angiogram is obtained by photographing the fluorescence emitted after illumination of the retina with blue light at a wavelength of 490 nanometers. This policy describes the medical necessity guidelines for fluorescein angiography.
OC.UM.CP.0031 (PDF)  Gonioscopy (Effective July 01, 2021) Gonioscopy involves using a concave contact lens in conjunction with oblique mirrors to view the iridocorneal angle. This policy describes the medical necessity requirements for gonioscopy.
CP.MP.139 (PDF) Low-Frequency Ultrasound Wound Therapy (Effective July 01, 2021) Low-frequency ultrasound debridement is a noncontact debridement method that provides simultaneous cleansing and debridement of wounds. It is generally performed at a 5 mm -15 mm distance from the wound surface. A device uses ultrasound technology to atomize saline, delivering a continuous mist to the treatment site. Multiple passes over the wound are made with the treatment head of the device for a predetermined treatment session. This can accelerate the wound healing process by removing the necrotic tissue, fibrosis, exudate, and bacteria with minimum bleeding and pain.