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Policies & Criteria

Clinical Policies

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

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

If you have any questions regarding these policies, please contact Provider Services 1-888-802-7001 (Commercial) or 1-888-445-8913 (Medicare) and ask to be directed to the Medical Management department.

Policy NumberPolicy Title

CP.MP.108

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)

CP.MP.26

Articular Cartilage Defect Repairs (PDF)

CP.MP.37

Bariatric Surgery (PDF)
CP.BH.500Behavioral Health Treatment Documentation Requirements (PDF)
CP.BH.300Biofeedback for Behavioral Health Disorders (PDF)

CP.MP.93

Bone-Anchored Hearing Aid (PDF)

CP.MP.94

Clinical Trials (PDF)

CP.MP.14

Cochlear Implant Replacements (PDF)
V2.2024Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)
V2.2024Concert Genetic Testing: Cardiac Disorders (PDF)
V2.2024Concert Genetic Testing: Dermatologic Conditions (PDF)
V2.2024Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)
V2.2024Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)
V2.2024Concert Genetic Testing: Eye Disorders (PDF)
V2.2024Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)
V2.2024Concert Genetic Testing: General Approach to Genetic and Molecular Testing
V2.2024Concert Genetic Testing: Hearing Loss (PDF)
V2.2024Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)
V2.2024Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)
V2.2024Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)
V2.2024Concert Genetic Testing: Kidney Disorders (PDF)
V2.2024Concert Genetic Testing: Lung Disorders (PDF)
V2.2024Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)
V2.2024Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)
V2.2024Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)
V2.2024Concert Genetic Testing: Pharmacogenetics (PDF)
V2.2024Concert Genetic Testing: Preimplantation Genetic Testing (PDF)
V2.2024Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
V2.2024Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)
V2.2024Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)
V2.2024Concert Genetics Oncology: Algorithmic Testing (PDF)
V2.2024Concert Genetics Oncology: Cancer Screening (PDF)
V2.2024Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)
V2.2024Concert Genetics Oncology: Cytogenetic Testing (PDF)
V2.2024Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)

CP.MP.31

Cosmetic and Reconstructive Procedures (PDF)
CP.BH.201Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)
CP.MP.203Diaphragmatic/Phrenic Nerve Stimulation (PDF)

CP.MP.114

Disc Decompression Procedures (PDF)

CP.MP.101

Donor Lymphocyte Infusion (PDF)

CP.MP.107

Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)
CP.MP.145Electric Tumor Treating Fields (Optune) (PDF)

CP.MP.36

Experimental Technologies (PDF)

CP.MP.137

Fecal Incontinence Treatments (PDF)

CP.MP.40

Gastric Electrical Stimulation (PDF)
CP.MP.209Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)

OR.CP.MP.95

Gender-Affirming Procedures (PDF)

CP.MP.132

Heart-Lung Transplant (PDF)
CP.MP.184Home Ventilators (PDF)

CP.MP.62

Hyperhidrosis Treatments (PDF)

CP.MP.173

Implantable Intrathecal Pain Pump (PDF)

CP.MP.160

Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)

CP.MP.58

Intestinal and Multivisceral Transplant (PDF)

CP.MP.167

Intradiscal Steroid Injections for Pain Management (PDF)
CP.MP.250Lantidra (Donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)
CP.MP.244Liposuction for Lipedema (PDF)

CP.MP.71

Long Term Care Placement (PDF)
CP.MP.57Lung Transplantation (PDF)
CP.MP.144Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)

CP.MP.86

Neonatal Abstinence Syndrome Guidelines (PDF)

CP.MP.85

Neonatal Sepsis Management (PDF)

CP.MP.170

Nerve Blocks and Neurolysis for Pain Management (PDF)
CP.MP.48Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)

CP.MP.82

NICU Apnea Bradycardia Guidelines (PDF)

CP.MP.81

NICU Discharge Guidelines (PDF)

CP.MP.141

Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)
CP.MP.249Omisirge (Omidubicel): Nicotinamide-modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)
CP.MP.202Orthognathic Surgery (PDF)
CP.MP.194Osteogenic Stimulation (PDF)

CP.MP.102

Pancreas Transplantation (PDF)

CP.MP.109

Panniculectomy (PDF)

CP.MP.138

Pediatric Heart Transplant (PDF)
CP.MP.246Pediatric Kidney Transplant (PDF)

CP.MP.120

Pediatric Liver Transplant (PDF)

CP.MP.188

Pediatric Oral Function Therapy (PDF)
CP.MP.49Physical, Occupational, and Speech Therapy Services (PDF)
CP.MP.181Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)

CP.MP.133

Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)

CP.MP.51

Reduction Mammoplasty and Gynecomastia Surgery (PDF)

CP.MP.210

Repair of Nasal Valve Compromise (PDF)

CP.MP.126

Sacroiliac Joint Fusion (PDF)

CP.MP.146

Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)
CP.MP.182Short Inpatient Hospital Stay (PDF)

CP.MP.185

Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)
CP.MP.117Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)

CP.MP.22

Stereotactic Body Radiation Therapy (PDF)

CP.MP.162

Tandem Transplant (PDF)

CP.MP.127

Total Artificial Heart (PDF)
CP.BH.200Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)
CP.MP.247Transplant Service Documentation Requirements (PDF)

CP.MP.142

Urinary Incontinence Devices and Treatments (PDF)

CP.MP.12

Vagus Nerve Stimulation (PDF)

CP.MP.143

Wireless Motility Capsule (PDF)

For Medicare information, please visit our Medicare Prior Authorization website.

 

Pharmacy Criteria

Health Net’s goal is to offer the right drug coverage to our members. Health Net covers prescription and some over the counter drugs when they are ordered by a licensed prescriber. 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 doctors and pharmacists. Together we work to offer drugs used to treat many conditions and illnesses. All clinical policies are reviewed annually by the P&T Committee, which meets quarterly. Approved criteria and revisions made by the P&T Committee go into effect the first day of the month the start of the following quarter. All medications newly approved by the FDA (Food and Drug Administration) require prior approval until reviewed by our P&T Committee.

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

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

Commercial Pharmacy Criteria

Amebicides

Amnoglycosides

Antifungals

Antihelmintics

Anti-Infective Agents - Misc.

Antimalarials

Antimycobacterial Agents

Antivirals

Fluoroqunolones

Passive Immunizing and Treatment Agents

Tetracyclines

Alkylating Agents

Antimetabolites

Antineoplastic – Angiogenesis Inhibitors

Antineoplastic – Anti-HER2 Agents

Antineoplastic – Antibodies

Antineoplastic – BCL-2 Inhibitors

Antineoplastic – Cellular Immunotherapy

Antineoplastic – Hedgehog Pathway Inhibitors

Antineoplastic – Hormonal and Related Agents

Antineoplastic – Hypoxia-Inducible Factor Inhibitors

Antineoplastic – Immunomodulators

Antineoplastic – Kinase Inhibitor

Antineoplastic Antibiotics

Antineoplastic Combinations

Antineoplastic Enzyme Inhibitors

Antineoplastic Enzymes

Antineoplastic Radiopharmaceuticals

Antineoplastics Misc.

Chemotherapy Rescue/Antidote Agents

Antineoplastic XPO1 Inhibitors

Mitotic Inhibitors

Oncolytic Viral Agents

Topoisomerase I Inhibitors

 

Adrenal Steroid Inhibitors

Aldosterone Receptor Antagonists

Androgens/Anabolic

Antidiabetics

Bone Density Regulators

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 Factor Receptor Inhibitors

Menopausal Symptoms Suppressants

Metabolic Modifiers

Natriuretic Peptides

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

 

Anesthetics - Misc.

Antidotes and Specific Antagonists

Chelating Agents

Diabetic Supplies

Diagnostic Products

Enzymes

Immunomodulators

Immunosuppressive Agents

Lipids

Potassium Removing Agents

Progeria Treatment Agents

Other Misc. Drugs

Systemic Lupus Erythematosus Agents

Tissue Products

Wound Care Products

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.501 (PDF)

30 Day Readmission (Effective February 15, 2022)

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.105 (PDF)Digital EEG Spike AnalysisElectroencephalography (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 ConditionsTargeted 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.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.
CP.VP.14 (PDF)Scanning Computerized Ophthalmic Diagnostic ImagingScanning 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 PhotographyFundus 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 TestingA 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.

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.

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 

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 Genitourinary Conditions 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

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

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.155 (PDF)EEG in the Evaluation of Headache (Effective June 24, 2022)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.
CP.VP.26 (PDF)Extended OphthalmoscopyExtended 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.VP.28 (PDF)Fluorescein AngiographyIntravenous 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.
CP.VP.31 (PDF)GonioscopyGonioscopy 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.145 (PDF)Severe Malnutrition (Last review October 2023)Acute care hospitalizations for severe malnutrition require the most appropriate and most specific level of diagnosis coding.
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.
CC.PP.073 (PDF)Sepsis Diagnosis (Last review date January 2024)The policy describes the process for pre- and post-pay review to validate correct coding on claims billed with a sepsis diagnosis but is not applicable to sepsis screening.  
CC.PP.206 (PDF)Skilled Nursing Facility Leveling (Effective November 19, 2024)The purpose of this policy is to ensure that the level of skilled nursing facility care reported by the provider reflects the services performed.

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 (Effective February 15, 2022)

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.VP.14 (PDF)Scanning Computerized Ophthalmic Diagnostic ImagingScanning 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.
OC.UM.CP.0029 (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.
OC.UM.CP.0063 (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.

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.

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.

MC.CP.MP.106 (PDF)

Endometrial Ablation (Effective January 01, 2024)

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.
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.VP.31 (PDF)GonioscopyGonioscopy 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.PP.145 (PDF)Severe Malnutrition (Last review October 2023)Acute care hospitalizations for severe malnutrition require the most appropriate and most specific level of diagnosis coding.
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.
CC.PP.073 (PDF)Sepsis Diagnosis (Last review date January 2024)The policy describes the process for pre- and post-pay review to validate correct coding on claims billed with a sepsis diagnosis but is not applicable to sepsis screening.