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 |
---|---|---|---|
25-hydroxyvitamin D testing in children and adolescents |
Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents |
November 15, 2022 | |
Acupuncture |
Medical necessity guidelines for acupuncture |
November 15, 2022 | |
ADHD Assessment and Treatment |
Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD) |
May 17, 2022 | |
CP.MP.175 (PDF) | Air Ambulance | Medical necessity guidelines for fixed wing air transportation. | November 15, 2022 |
Allergy Testing and Therapy |
Medical necessity guidelines for allergy testing and treatment |
November 15, 2022 | |
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 |
March 21, 2023 | |
Ambulatory Surgery Center Optimization |
Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services |
November 15, 2022 | |
Articular Cartilage Defect Repairs |
Medical necessity guidelines for articular cartilage defect repairs |
May 17, 2022 | |
Assisted Reproductive Technology |
Medical necessity guidelines for assisted reproductive technology |
March 21, 2023 | |
Bariatric Surgery |
Medical necessity guidelines for bariatric surgery for obesity in adolescents and adults |
November 15, 2022 | |
Biofeedback |
Medical necessity guidelines for biofeedback therapyJuly 20, 2021 |
March 21, 2023 | |
Bone-anchored hearing aid |
Medical necessity guidelines for bone-anchored hearing aid |
November 15, 2022 | |
Bronchial Thermoplasty |
Medical necessity guidelines for bronchial thermoplasty |
July 19, 2022 | |
Burn Surgery |
Medical necessity guidelines for burn surgery, including debridement and application of skin substitutes for burns. |
March 21, 2023 | |
Cardiac biomarker testing |
Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction |
November 15, 2022 | |
Caudal or Interlaminar Epidural Steroid Injections for Pain Management |
Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management |
November 15, 2022 | |
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 |
March 21, 2023 | |
Clinical Trials |
Medical necessity guidelines for routine costs of clinical trials |
November 15, 2022 | |
Cochlear Implant Replacements |
Medical necessity guidelines for the replacement of cochlear implants and/or cochlear implant components. |
September 21, 2021 | |
Cosmetic and Reconstructive Surgery |
Medical necessity guidelines for cosmetic and reconstructive surgery |
March 21, 2023 | |
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures |
Medical necessity guidelines for dental anesthesia |
March 21, 2023 | |
CP.MP.203 (PDF) | Diaphragmatic/Phrenic Nerve Stimulation | Medical necessity guidelines for diaphragmatic/phrenic nerve stimulation | March 21, 2023 |
Digital electroencephalography spike analysis |
Medical necessity guidelines for digital EEG spike analysis |
November 15, 2022 | |
Disc Decompression Procedures |
Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression |
July 19, 2022 | |
Discography |
Medical necessity guidelines for discography |
November 15, 2022 | |
Donor lymphocyte infusion |
Medical necessity guidelines for donor lymphocyte infusion |
March 21, 2023 | |
Drugs of Abuse: Definitive Testing |
Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. |
March 21, 2023 | |
Durable Medical Equipment (DME) |
Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics |
March 21, 2023 | |
Electric Tumor Treating Fields |
Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM) |
March 21, 2023 | |
Electroencephalography in the evaluation of headache |
Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches |
November 15, 2022 | |
Endometrial ablation |
Medical necessity guidelines for endometrial ablation |
November 15, 2022 | |
Evoked Potential Testing |
Medical necessity guidelines for evoked potential testing |
November 15, 2022 | |
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 17, 2022 | |
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 |
November 15, 2022 | |
Fecal incontinence treatments |
Medical necessity guidelines for fecal incontinence treatments |
November 15, 2022 | |
Ferriscan R2-MRI |
Medical necessity guidelines for use of the FerriScan R2-MRI |
March 21, 2023 | |
Fertility preservation |
Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility |
November 15, 2022 | |
Fetal surgery in utero for prenatally diagnosed malformations |
Medical necessity guidelines for performing fetal surgery in utero |
November 15, 2022 | |
Functional MRI |
Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI). |
May 17, 2022 | |
Gastric electrical stimulation |
Medical necessity guidelines for gastric electrical stimulation |
May 17, 2022 | |
Gender Affirming Procedures |
Medical necessity guidelines for surgery for the treatment of gender dysphoria |
March 21, 2023 | |
CP.MP.215 (PDF) | Genetic Testing Aortopathies and Connective Tissue Disorders | Hereditary connective tissue disorders are a group of disorders that affect the connective tissues that support the skin, bones, joints, heart, blood vessels, eyes, and other organs. | May 17, 2022 |
CP.MP.216 (PDF) | Genetic Testing Cardiac Disorders | This document addresses genetic testing for cardiac disorders, focusing on cardiomyopathy, arrhythmia, congenital heart defects, and cholesterol disorders. | May 17, 2022 |
CP.MP.217 (PDF) | Genetic Testing Dermatologic Conditions | This document addresses genetic testing for dermatologic conditions. | May 17, 2022 |
CP.MP.218 (PDF) | Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Disorders | This document addresses genetic testing for neurodegenerative and neuromuscular genetic diseases. | May 17, 2022 |
CP.MP.219 (PDF) | Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders | Rapid exome sequencing (rES) and rapid genome (rGS) sequencing involves sequencing of the exome or genome, respectively, in an accelerated time frame. | May 17, 2022 |
CP.MP.220 (PDF) | Genetic Testing Eye Disorders | Age-related macular degeneration (AMD) is an eye condition that causes damage to the central portion of the retina (the macula), affecting the ability to see objects straight ahead. | May 17, 2022 |
CP.MP.221 (PDF) | Genetic Testing Gastroenterologic Disorders (non-cancerous) | This document addresses genetic testing for common gastroenterologic (non-cancerous) conditions. | May 17, 2022 |
CP.MP.222 (PDF) | Genetic Testing General Approach to Genetic Testing | Genetic testing refers to the use of technologies that identify genetic variation, which include genomic, transcriptional, proteomic, and epigenetic alterations, for the prevention, diagnosis, and treatment of disease. | May 17, 2022 |
CP.MP.223 (PDF) | Genetic Testing Hearing Loss | This policy primarily focuses on the use of genetic testing to identify a cause of suspected hereditary hearing loss. | May 17, 2022 |
CP.MP.224 (PDF) | Genetic Testing Hematologic Condition (non-cancerous) | This document addresses genetic testing for common hematologic (non-cancerous) conditions | May 17, 2022 |
CP.MP.225 (PDF) | Genetic Testing Hereditary Cancer Susceptibility | Genetic testing for hereditary cancer susceptibility is a germline test and can be performed on individual genes (e.g., BRCA1) or on many genes simultaneously (i.e., multi-gene panels). | May 17, 2022 |
CP.MP.226 (PDF) | Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders | Immunodeficiency disorders impair the immune system’s ability to defend the body against foreign substances, such as bacteria, viruses, and cancer cells. | May 17, 2022 |
CP.MP.227 (PDF) | Genetic Testing Kidney Disorders | Inherited kidney disorders and inherited disorders that indirectly affect the kidneys can be more common, such as autosomal dominant polycystic kidney disease, or more rare, such as Lowe syndrome and Fabry disease. | May 17, 2022 |
CP.MP.228 (PDF) | Genetic Testing Lung Disorders | One of the most common forms of inherited lung disorders is alpha-1 antitrypsin deficiency (AATD) is an autosomal recessive genetic disorder that results in decreased production of the alpha-1 antitrypsin (AAT) protein, or production of abnormal types of the protein that are functionally deficient. | May 17, 2022 |
CP.MP.229 (PDF) | Genetic Testing Metabolic Endocrine and Mitochondrial Disorders | Genetic testing for metabolic, endocrine, and mitochondrial disorders aids in identifying the specific disorder that is present, so that proper treatment (if any) can be initiated, and at-risk family member/enrollee can be identified. | May 17, 2022 |
CP.MP.230 (PDF) | Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay | This document addresses genetic testing for rare genetic conditions that impact multiple body systems. | May 17, 2022 |
CP.MP.231 (PDF) | Genetic Testing for Non-Invasive Prenatal Screening (NIPS) | Non-invasive prenatal screening (NIPS) is a sequencing test performed on placental cell-free DNA found in maternal serum and is most commonly used to screen for fetal aneuploidy (trisomy 21, trisomy 13, and trisomy 18); sex chromosomes are also screened for fetal sex determination and sex chromosome aneuploidy. | May 17, 2022 |
CP.MP.237 (PDF) | Genetic Testing Oncology Algorithmic Testing | Oncology prognostic and algorithmic tests are developed to aid in determining the likelihood that an individual has cancer, the prognosis for a patient diagnosed with cancer, and/or surveillance for recurrence. | May 17, 2022 |
CP.MP.238 (PDF) | Genetic Testing Oncology Cancer Screening | This policy relates to genetic and biomarker tests that aim to screen for specific cancers in individuals who are at risk to develop them. | May 17, 2022 |
CP.MP.240 (PDF) | Genetic Testing Oncology Cytogenetic Testing | Cytogenetic analysis of solid tumors and hematologic malignancies aims to both classify the type of tumor or cancer present and also to identify somatic oncogenic mutations in cancer. | May 17, 2022 |
CP.MP.241 (PDF) | Genetic Testing Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies | The molecular analysis of solid tumors and hematologic malignancies aims to identify somatic oncogenic mutations in cancer. | May 17, 2022 |
CP.MP.232 (PDF) | Genetic Testing Pharmacogenetics | Pharmacogenetic tests are germline genetic tests that are developed to aid in assessing an individual's response to a drug treatment or to predict the risk of toxicity from a specific drug treatment. | May 17, 2022 |
CP.MP.233 (PDF) | Genetic Testing Preimplantation Genetic Testing | Preimplantation genetic testing involves analysis of biopsied cells from an embryo as a part of an assisted reproductive procedure. | May 17, 2022 |
CP.MP.234 (PDF) | Genetic Testing Prenatal and Preconception Carrier Screening | Carrier screening is performed to identify individuals at risk of having offspring with inherited recessive or X-linked single-gene disorders. | May 17, 2022 |
CP.MP.235 (PDF) | Genetic Testing Prenatal Diagnosis | Prenatal diagnostic testing for genetic disorders is performed on fetal cells derived from amniotic fluid, and/or percutaneous umbilical blood sampling (PUBS) (cordocentesis) or from placental cells via chorionic villus sampling (CVS). | May 17, 2022 |
CP.MP.236 (PDF) | Genetic Testing Skeletal Dysplasia and Rare Bone Disorders | Genetic testing has allowed for gene identification in more than two thirds of the skeletal dysplasias. | May 17, 2022 |
CP.MP.209 (PDF) | GI Pathogen Nucleic Acid Detection Panel Testing | Medical necessity guidelines for GI Pathogen Nucleic Acid Detection Panel Testing | March 21, 2023 |
H. Pylori serology testing |
Medical necessity guidelines for H. pylori |
November 15, 2022 | |
Heart-Lung Transplant |
Medical necessity guidelines for heart-lung transplantation |
July 19, 2022 | |
Holter Monitors |
Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring |
November 15, 2022 | |
Home Birth |
Medical necessity guidelines for planned home birth |
March 21, 2023 | |
Phototherapy for neonatal hyperbilirubinemia |
Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia |
March 21, 2023 | |
Homocysteine testing |
Medical necessity guidelines for homocysteine testing |
May 17, 2022 | |
Hospice Services |
Medical necessity guidelines for hospice services |
March 21, 2023 | |
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 17, 2022 | |
Hyperhidrosis treatments |
Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands |
March 21, 2023 | |
CP.MP.180 (PDF) | Implantable Hypoglossal Nerve Stimulation | Medical necessity criteria for Implantable Hypoglossal Nerve Stimulation (Inspire) for Obstructive Sleep Apnea | March 21, 2023 |
Implantable Intrathecal Pain Pump |
Medical necessity guidelines for preliminary trial and implantation of intrathecal pain pumps |
March 21, 2023 | |
CP.MP.243 (PDF) | Implantable Loop Recorder | Use this policy when processing requests for implantable loop recorders | July 19, 2022 |
Implantable Wireless Pulmonary Artery Pressure Monitoring |
Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring |
July 19, 2022 | |
Inhaled nitric oxide |
Medical necessity guidelines for the use of inhaled nitric oxide (iNO) |
July 19, 2022 | |
Intensity-Modulated Radiotherapy |
Medical necessity guidelines for intensity-modulated radiotherapy (IMRT) |
March 21, 2023 | |
Intestinal and multivisceral transplant |
Medical necessity guidelines for the review of intestinal and multivisceral transplant requests. |
July 19, 2022 | |
Intradiscal Steroid Injections for Pain Management |
Medical necessity criteria for intradiscal steroid injections for pain management |
November 15, 2022 | |
Laser therapy for skin conditions |
Medical necessity guidelines for excimer laser based targeted phototherapy |
May 17, 2022 | |
CP.MP.244 (PDF) | Liposuction for Lipedema | This policy is for use when processing requests for Liposuction for Lipedema | July 19, 2022 |
Long Term Care Placement Criteria |
Medical necessity guidelines for long term care (LTC) placement |
July 19, 2022 | |
Low-frequency ultrasound and noncontact normothermic wound therapy |
Medical necessity guidelines for low-frequency ultrasound therapy for wound management |
May 17, 2022 | |
CP.MP.57 (PDF) | Lung Transplantation | Medical necessity guidelines for review of lung transplantation requests | May 17, 2022 |
Lysis of Epidural Lesions |
Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty |
July 19, 2022 | |
Measurement of serum 1,25-dihydroxyvitamin D |
Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D |
November 15, 2022 | |
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. |
March 21, 2023 | |
Medical Necessity Criteria |
This policy identifies the medical necessity guidelines used by the health plan and related definitions. |
November 15, 2022 | |
Multiple Sleep Latency Testing |
Medical necessity criteria for multiple sleep latency testing (MSLT) |
July 19, 2022 | |
Neonatal abstinence syndrome guidelines |
Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU) |
May 17, 2022 | |
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 |
November 15, 2022 | |
Nerve Blocks for Pain Management |
Medical necessity criteria for nerve blocks for pain management |
November 15, 2022 | |
CP.MP.48 (PDF) | Neuromuscular Electrical Stimulation (NMES) | Medical necessity requirements for the use of neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES) | November 15, 2022 |
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 |
November 15, 2022 | |
NICU discharge guidelines |
Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home. |
November 15, 2022 | |
CP.MP.184 (PDF) | Home Ventilators | Medical necessity guidelines for non-invasive home ventilators | November 15, 2022 |
Non-myeloablative allogeneic stem cell transplants |
Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants |
May 17, 2022 | |
Obstetrical Home Health Care Programs |
Medical necessity guidelines for OB home health programs |
March 21, 2023 | |
CP.MP.239 (PDF) | Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) | Genetic tests performed on cell-free circulating tumor DNA (ctDNA), also referred to as a liquid biopsy, potentially offer a noninvasive alternative to tissue biopsy for detection of “driver mutations”, or acquired genetic mutations that may guide targeted therapy, and may also be used to track progression of disease. | May 17, 2022 |
Optic nerve decompression surgery |
Medical necessity guidelines for optic nerve sheath decompression surgery |
November 15, 2022 | |
CP.MP.202 (PDF) | Orthognathic Surgery | Medical necessity guidelines for Orthognathic Surgery | March 21, 2023 |
Outpatient Cardiac Rehabilitation |
Medical necessity criteria for conventional and intensive outpatient cardiac rehabiliation programs. |
July 19, 2022 | |
CP.MP.190 (PDF) | Outpatient Oxygen Use | 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. | March 21, 2023 |
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 17, 2022 | |
Panniculectomy |
Medical necessity guidelines for panniculectomy |
March 21, 2023 | |
Pediatric heart transplant |
Medical necessity guidelines for pediatric heart transplant |
March 21, 2023 | |
CP.MP.246 (PDF) | Pediatric Kidney Transplant | Use this policy when processing requests for Pediatric Kidney Transplant | November 15, 2022 |
Pediatric Liver Transplant |
Medical necessity guidelines for pediatric liver transplant for end-stage liver disease |
May 17, 2022 | |
Pediatric Oral Function Therapy |
Medical necessity guidelines for pediatric oral function therapy. |
July 19, 2022 | |
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention |
Medical necessity guidelines for left atrial appendage closure devices for stroke prevention. |
July 19, 2022 | |
CP.MP.181 (PDF) | Polymerase Chain Reaction Respiratory Viral Panel Testing | Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing. | May 17, 2022 |
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 15, 2022 | |
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. |
March 21, 2023 | |
Proton and neutron beam therapy |
Medical necessity guidelines for proton beam and neutron beam radiation therapy |
March 21, 2023 | |
CP.MP.242 (PDF) | Pulmonary Function Testing | Use this policy when processing requests for Pulmonary Function Testing | March 21, 2023 |
Radial Head Implant |
Medical necessity guidelines for radial head implant, also known as arthroplasty |
July 19, 2022 | |
Radiofrequency Ablation of Uterine Fibroids |
Medical necessity criteria for radiofrequency ablation of uterine fibroids. |
May 17, 2022 | |
Reduction mammoplasty and gynecomastia surgery |
Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men |
November 15, 2022 | |
Repair of Nasal Valve Compromise |
Medical necessity guidelines for the treatment of Repair of Nasal Valve Compromise |
July 19, 2022 | |
Sacroiliac joint fusion |
Medical necessity guidelines for sacroiliac joint fusion |
November 15, 2022 | |
Sacroiliac Joint Interventions for Pain Management |
Medical necessity criteria for sacroiliac joint interventions for pain management |
November 15, 2022 | |
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins |
Medical necessity guidelines for sclerotherapy for treatment of vericose veins |
July 19, 2022 | |
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy |
Medical necessity criteria for Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy. |
March 21, 2023 | |
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 15, 2022 | |
CP.MP.182 (PDF) | Short Inpatient Hospital Stay | Medical necessity criteria for inpatient hospital stay of 2 days or less | March 21, 2023 |
Skilled Nursing Facility Leveling |
Medical necessity criteria for skilled nursing facility levels of care |
November 15, 2022 | |
Skin Substitutes for Chronic Wounds |
Medical necessity criteria for skin substitutes in the treatment of chronic wounds. |
March 21, 2023 | |
CP.MP.248 (PDF) | Sleep Center Polysomnography and Split-Night Studies for Obstructive Sleep Apnea | Medical necessity guidelines for sleep center polysomnography and split-night studies for obstructive sleep apnea | March 21, 2023 |
Spinal Cord Stimulation |
Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation |
May 17, 2022 | |
State specific clinical policy process |
This policy describes the process for creating, maintaining, and posting state-specific clinical policies |
March 21, 2023 | |
Stereotactic Body Radiation Therapy |
Medical necessity guidelines for stereotactic body radiation therapy |
March 21, 2023 | |
Tandem Transplant |
Medical necessity guidelines for tandem transplant |
March 21, 2023 | |
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 21, 2023 | |
Therapy Services (PT/OT/ST) |
Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment. |
November 15, 2022 | |
Thyroid hormones and insulin testing in pediatrics |
Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics |
November 15, 2022 | |
Total artificial heart |
Medical necessity guidelines for a total artificial heart (TAH) |
March 21, 2023 | |
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition |
Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN) |
July 19, 2022 | |
Transcatheter closure of patent foramen ovale |
Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder. |
March 21, 2023 | |
CP.MP.247 (PDF) | Transplant Service Documentation Requirements | Medical necessity guidelines for transplant service documentation requirements | March 21, 2023 |
Trigger Point Injections for Pain Management |
Medical necessity criteria for trigger point injections for pain management |
November 15, 2022 | |
Ultrasound in Pregnancy |
Medical necessity guidelines for ultrasound use in pregnancy. |
May 17, 2022 | |
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 |
March 21, 2023 | |
Urodynamic testing |
Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction |
May 17, 2022 | |
Vagus Nerve Stimulation |
Medical necessity guidelines for vagus nerve stimulation. |
November 15, 2022 | |
Ventricular Assist Devices |
Medical necessity guidelines for ventricular assist devices. |
May 17, 2022 | |
Wheelchair seating |
Medical necessity guidelines for special wheelchair seating and cushions |
May 17, 2022 | |
Wireless Motility Capsule |
Medical necessity guidelines for wireless motility capsule |
November 15, 2022 | |
CP.MP.194 (PDF) | Osteogenic Stimulation | Electrical osteogenic stimulation can be performed invasively or non-invasively. | November 15, 2022 |
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
- Abatacept (Orencia); CP.CPA.194 (PDF)
- Adalimumab (Humira); CP.CPA.194 (PDF)
- Anakinra (Kineret); CP.CPA.194 (PDF)
- Apremilast (Otezla); CP.CPA.194 (PDF)
- Baricitinib (Oluminant); CP.CPA.194 (PDF)
- Canakinumab (Ilaris); CP.PHAR.246 (PDF)
- Celecoxib (Celebrex, Elyxyb); CP.PMN.122 (PDF)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zorvolex); CP.PCH.28 (PDF)
- Etanercept (Enbrel); CP.CPA.194 (PDF)
- Golimumab (Simponi, Simponi Aria); CP.CPA.194 (PDF)
- Ibuprofen-famotidine (Duexis); CP.PMN.120 (PDF)
- Indomethacin (Tivorbex); CP.CPA.292 (PDF)
- Ketorolac nasal spray (Sprix); CP.PMN.282 (PDF)
- Meloxicam (Vivlodex); CP.CPA.296 (PDF)
- Methotrexate (Otrexup, Rasuvo, Reditrex, Xatmep); CP.PHAR.134 (PDF)
- Naproxen and esomeprazole magnesium (Vimovo); CP.PMN.117 (PDF)
- Rilonacept (Arcalyst); CP.PHAR.266 (PDF)
- Sarilumab (Kevzara); CP.CPA.194 (PDF)
- Tocilizumab (Actemra); CP.CPA.194 (PDF)
- Tofacitinib (Xeljanz, Xeljanz XR); CP.CPA.194 (PDF)
- Upadacitinib (Rinvoq); CP.CPA.194 (PDF)
Opioid Agents
- Age Limit Override (Codeine, Tramadol, Hydrocodone); CP.PMN.138 (PDF)
- Buprenorphine (Sublocade); CP.PHAR.289 (PDF)
- Buprenorphine (Subutex); CP.PMN.82 (PDF)
- Buprenorphine-naloxone (Bunavail, Cassipa, Suboxone, Zubsolve); CP.PMN.81 (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys); CP.PMN.127 (PDF)
- Morphine/Naltrexone (Embeda); CP.CPA.254 (PDF)
- Oxycodone/acetaminophen extended release (Xartemis XR); CP.CPA.118 (PDF)
Amebicides
Amnoglycosides
- Amikacin (Arikayce); CP.PHAR.401 (PDF)
- Tobramycin (Kitabis pack, TOBI podhale, Bethkis, TOBI); CP.PHAR.211 (PDF)
Antifungals
- Efinaconazole (Jublia); CP.PMN.25 (PDF)
- Isavuconazonium sulfate (Cresemba); CP.PMN.154 (PDF)
- Itraconazole (Sporanox, Tolsura); CP.PMN.124 (PDF)
- Luliconazole (Luzu); CP.PMN.166 (PDF)
- Tavaborole (Kerydin); CP.PMN.105 (PDF)
Antihelmintics
- Benznidazole; CP.PMN.90 (PDF)
- Ivermectin (Stromectol, Sklice); CP.PMN.269 (PDF)
- Triclabendazole (Egaten); CP.PMN.207 (PDF)
Anti-Infective Agents - Misc.
- Abametapir (Xeglyze); CP.PMN.253 (PDF)
- Chloramphenicol; CP.PHAR.388 (PDF)
- Ciprofloxacin/Fluocinolone (Otovel); CP.PMN.249 (PDF)
- Daptomycin (Cubicin, Cubicin RF); CP.PHAR.351 (PDF)
- Lefamulin acetate (Xenleta); CP.PMN.219 (PDF)
- Linezolid (Zyvox); CP.PMN.27 (PDF)
- Nifurtimox (Lampit); CP.PMN.256 (PDF)
- Rifamvcin (Aemcolo); CP.PNM.196 (PDF)
- Rifaximin (Xifaxan); CP.PMN.47 (PDF)
- Vancomycin (Firvanq, Vancocin); CP.CPA.166 (PDF)
Antimalarials
Antimycobacterial Agents
Antivirals
- Acyclovir (Sitavig); CP.PMN.210 (PDF)
- Bolaxavir marboxil (Xofluza); CP.PMN.185 (PDF)
- Cabotegravir, Cabotegravir-Rilpivirine (Apretude, Cabenuva); CP.PHAR.573 (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Vikira XR, Viekira Pak); CP.CPA.288 (PDF)
- Elbasvir-Grazoprevir (Zepatier); CP.CPA.284 (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy); CP.PMN.235 (PDF)
- Enfuvirtide (Fuzeon); CP.PHAR.41 (PDF)
- Fostemsavir (Rukobia); CP.PHAR.516 (PDF)
- Glecaprevir-Pibrentasvir (Mavyret); CP.CPA.285 (PDF)
- Ibalizumab-uiyk (Trogarzo); CP. PHAR.378 (PDF)
- Ledipasvir-Sofosbuvir (Harvoni); CP.CPA.175 (PDF)
- Letermovir (Prevymis); CP.PHAR.367 (PDF)
- Maribavir (Livtencity); CP.PMN.271 (PDF)
- Peginterferon alfa-2a (Pegasys, PegIntron); CP.PHAR.89 (PDF)
- Ribavirin (Rebetol, Ribasphere); CP.PHAR.141 (PDF)
- Sofosbuvir (Sovaldi); CP.CPA.176 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa); CP.CPA.286 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi); CP.CPA.290 (PDF)
- Tenofovir alafenamide fumarate (Vemlidy); CP.PMN.268 (PDF)
- Valganciclovir (Valcyte); CP.PCH.06 (PDF)
Fluoroqunolones
Passive Immunizing and Treatment Agents
- Bezlotoxumab (Zinplava); CP.PHAR.300 (PDF)
- Cytomegalovirus Immune Globulin (CytoGam); CP.PHAR.277
- Immune Globulin (Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF, GamaSTAN SD, Gammagard Liquid, Gammagard S/D; Gammaked; Gammaplex, Gamunex-C, Hizentra, HyQvia, Octagam, Panzyga, Privigen, Xembify); CP.PHAR.103 (PDF)
- Palivizumab (Synagis); CP.PHAR.16 (PDF)
Tetracyclines
Alkylating Agents
- Bendamustine (Bendeka, Bendeka, Treanda); CP.PHAR.307 (PDF)
- Lomustine (Gleostine); CP.PHAR.507 (PDF)
- Lurbinectedin (Zepzelca); CP.PHAR.500 (PDF)
- Melphalan flufenamide (Pepaxto); CP.PHAR.535 (PDF)
- Prednisone delayed-release (Rayos); CP.CPA.273 (PDF)
Antimetabolites
- Azacitidine (Onureg, Vidaza); CP.PHAR.387 (PDF)
- Pralatrexate (Folotyn); CP.PHAR.313 (PDF)
- Mercaptopurine (Purixan); CP.PHAR.447 (PDF)
Antineoplastic – Angiogenesis Inhibitors
- Bevacizumab (Alymsys; Avastin, Mvasi, Zirabev); CP.PHAR.93 (PDF)
- Ramucirumab (Cyramza); CP.PHAR.119 (PDF)
- Ziv-aflibercept (Zaltrap); CP.PHAR.325 (PDF)
Antineoplastic – Anti-HER2 Agents
Antineoplastic – Antibodies
- Ado-Trastuzumab Emtansine (Kadcyla); CP.PHAR.229 (PDF)
- Amivantamab-vmjw (Rybrevant); CP.PHAR.544 (PDF)
- Atezolizumab (Tecentriq); CP.PHAR.235 (PDF)
- Avelumab (Bavencio); CP.PHAR.333 (PDF)
- Belantamab mafodotin (Blenrep); CP.PHAR.469 (PDF)
- Blinatumomab (Blincyto); CP.PHAR.312 (PDF)
- Brentuximab vedotin (Adcetris); CP.PHAR.303 (PDF)
- Cemiplimab-rwlc (Libtayo); CP.PHAR.397 (PDF)
- Cetuximab (Erbitux); CP.PHAR.317 (PDF)
- Daratumumab (Darzalex); CP.PHAR.310 (PDF)
- Dostarlimab-gxly (Jermerli); CP.PHAR.540 (PDF)
- Durvalumab (Imfinzi): CP.PHAR.339 (PDF)
- Elotozumab (Empliciti); CP.PHAR.308 (PDF)
- Fam-trastuzumb deruxtecan-nxki (Enhertu); CP.PHAR.456 (PDF)
- Gemtuzumab ozogamicin (Mylotarg); CP.PHAR.358 (PDF)
- Inotuzumab Ozogamicin (Besponsa); CP.PHAR.359 (PDF)
- Ipilimumab (Yervoy); CP.PHAR.319 (PDF)
- Isatuximab-irfc (Sarclisa); CP.PHAR.482 (PDF)
- Loncastuximab tesirine-Ipyl (Zynlonta); CP.PHAR.539 (PDF)
- Mogamulizumab-kpkc (Poteligeo); CP.PHAR.139 (PDF)
- Moxetumomab pasudotox-tdfk (Lumoxiti); CP.PHAR.398 (PDF)
- Naxitamab-gqgk (Danyelza); CP.PHAR.523 (PDF)
- Nivolumab (Opdivo); CP.PHAR.121 (PDF)
- Olaratumab (Lartruvo); CP.PHAR.326 (PDF)
- Ofatumumab (Arzerra, Kesimpta); CP.PHAR.306 (PDF)
- Panitumumab (Vectibix); CP.PHAR.321 (PDF)
- Pembrolizumab (Keytruda); CP.PHAR.322 (PDF)
- Pertuzumab (Perjeta); CP.PHAR.227 (PDF)
- Polatuzumab vedotin-piiq (Polivy); CP.PHAR.433 (PDF)
- Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela); CP.PHAR.260 (PDF)
- Sacituzumab govitecan (Trodelvy); CP.PHAR.475 (PDF)
- Tafasitamab-cxix (Monjuvi); CP.PHAR.508 (PDF)
- Tebentafusp-tebn (Kimmtrak); CP.PHAR.575 (PDF)
- Teclistamab-cqyv (Tecvayli); CP.PHAR.611 (PDF)
- Tisotumab vedotin-tftv (Tivdak); CP.PHAR.561 (PDF)
- Trastuzumab (Herceptin); Trastuzumab-dkst (Ogivri); Trastuzumab-dttb (Ontruzant); Trastuzumab-qyyp (Trazimera); Trastuzumab-anns (Kanjinti); Trastuzumab-pkrb (Herzuma); CP.PHAR.228 (PDF)
- Tremelimumab-actl (Imjudo); CP.PHAR.612 (PDF)
- Zanubrutinib (Brukinsa); CP.PHAR.467 (PDF)
Antineoplastic – BCL-2 Inhibitors
Antineoplastic – Cellular Immunotherapy
- Axicabtagene ciloleucel (Yescarta); CP.PHAR.362 (PDF)
- Bresucabtagene autoleucel (Tecartus); CP.PHAR.472 (PDF)
- Ciltacabtagene Autoleucel (Carvykti); CP.PHAR.533 (PDF)
- Idecabtagene Vicleucel (Abecma); CP.PHAR.481 (PDF)
- Lisocabtagene maraleucel (Breyanzi); CP.PHAR.483 (PDF)
- Sipuleucel-T (Provenge); CP.PHAR.120 (PDF)
- Tisagenlecleucel (Kymriah); CP.PHAR.361 (PDF)
Antineoplastic – Hedgehog Pathway Inhibitors
- Glasdegib (Daurismo); CP.PHAR.413 (PDF)
- Sonidegib (Odomzo); CP.PHAR.272 (PDF)
- Vismodegib (Erivedge); CP.PHAR.273 (PDF)
Antineoplastic – Hormonal and Related Agents
- Abiraterone (Yonsa, Zytiga); CP.PHAR.84 (PDF)
- Apalutamide (Erleada); CP.PCH.45 (PDF)
- Darolutamide (Nubeqa); CP.PHAR.435 (PDF)
- Degarelix (Firmagon); CP.PHAR.170 (PDF)
- Enzalutamide (Xtandi); CP.PHAR.106 (PDF)
- Fulvestrant (Faslodex); CP.PHAR.424 (PDF)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi, Camcevi); CP.PHAR.173 (PDF)
- Relugolix (Orgovyx)), relugolix-estradiol-norethindrone (Myfembree); CP.PHAR.529 (PDF)
- Triptorelin pamoate (Trelstar, Triptodur); CP.PHAR.175 (PDF)
Antineoplastic – Hypoxia-Inducible Factor Inhibitors
Antineoplastic – Immunomodulators
Antineoplastic – Kinase Inhibitor
Antineoplastic Antibiotics
Antineoplastic Combinations
- Daratumumab-Haluronidase-fihj (Darzalex Faspro); CP.PHAR.310 (PDF)
- Decitabine-Cedazuridine (Inqovi); CP.PHAR.479 (PDF)
- Nivolumab/Relatlimab (Opdualag); CP.PHAR.588 (PDF)
- Pertuzumab-trastuzumab-hyaluronidse-zzxf (Phesgo); CP.PHAR.501 (PDF)
- Rituximab/Hyaluronidase (Rituxan Hycela); CP.PHAR.260 (PDF)
- Trastuzumab/hyaluonidase-oysk (Heceptin Hylecta); CP.PHAR.228 (PDF)
- Trifluridine-tipiracil (Lonsurf); CP.PHAR.383 (PDF)
Antineoplastic Enzyme Inhibitors
- Abemaciclib (Verzenio); CP.PHAR.355 (PDF)
- Acalabrutinib (Calquence); CP.PHAR.366 (PDF)
- Afatinib (Gilotrif); CP.PHAR.298 (PDF)
- Alectinib (Alecensa); CP.PHAR.369 (PDF)
- Alpelisib (Piqray, Vijoice); CP.PHAR.430 (PDF)
- Asciminib (Scemblix); CP.PHAR.565 (PDF)
- Avapritinib (Ayvakit); CP.PHAR.454 (PDF)
- Axitinib (Inlyta); CP.PHAR.100 (PDF)
- Binimetinib (Mektovi); CP.PHAR.50 (PDF)
- Bortezomib (Velcade); CP.PHAR.410 (PDF)
- Brigatinib (Alunbrig); CP.PHAR.342 (PDF)
- Bosutinib (Bosulif); CP.PHAR.105 (PDF)
- Cabozantinib (Cabometyx, Cometriq); CP.PHAR.111 (PDF)
- Capmatinib (Tabrecta); CP.PHAR.494 (PDF)
- Carfilzomib (Kyprolis); CP.PHAR.309 (PDF)
- Ceritinib (Zykadia); CP.PHAR.349 (PDF)
- Cobimetinib (Cotellic); CP.PHAR.380 (PDF)
- Copanlisib (Aliqopa); CP.PHAR.357 (PDF)
- Crizotinib (Xalkori); CP.PHAR.90 (PDF)
- Dabrafenib (Tafinlar); CP.PHAR.239 (PDF)
- Dacomitinib (Vizimpro); CP.PHAR.399 (PDF)
- Dasatinib (Sprycel); CP.PHAR.72 (PDF)
- Duvelisib (Copiktra); CP.PHAR.400 (PDF)
- Enasidenib (Idhifa); CP.PHAR.363 (PDF)
- Encorafenib (Braftovi); CP.PHAR.127 (PDF)
- Entrectinib (Rozlytrek); CP.PHAR.441 (PDF)
- Erdafitinib (Balversa); CP.PHAR.423 (PDF)
- Erlotinib (Tarceva); CP.PHAR.74 (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress); CP.PHAR.63 (PDF)
- Fedratinib (Inrebic); CP.PHAR.442 (PDF)
- Futibatinib (Lytgobi); CP.PHAR.604 (PDF)
- Gefitinib (Iressa); CP.PHAR.68 (PDF)
- Gilteritinib (Xospata); CP.PHAR.412 (PDF)
- Ibrutinib (Imbruvica); CP.PHAR.126 (PDF)
- Idelalisib (Zydelig); CP.PHAR.133 (PDF)
- Imatinib mesylate (Gleevec); CP.PHAR.65 (PDF)
- Infigratinib (Truseltiq); CP.PHAR.547 (PDF)
- Ivosidenib (Tibsovo); CP.PHAR.137 (PDF)
- Ixazomib (Ninlaro); CP.PHAR.302 (PDF)
- Lapatinib (Tykerb); CP.PHAR.79 (PDF)
- Larotrectinib (Vitrakvi); CP.PHAR.414 (PDF)
- Lenvatinib (Lenvima); CP.PHAR.138 (PDF)
- Lorlatinib (Lorbrena); CP.PHAR.406 (PDF)
- Midostaurin (Rydapt); CP.PHAR.344 (PDF)
- Neratinib (Nerlynx); CP.PHAR.365 (PDF)
- Nilotinib (Tasigna); CP.PHAR.76 (PDF)
- Niraparib (Zejula); CP.PHAR.408 (PDF)
- Olaparib (Lynparza); CP.PHAR.360 (PDF)
- Osimertinib (Tagrisso); CP.PHAR.294 (PDF)
- Pacritinib (Vonjo); CP.PHAR.583 (PDF)
- Palbociclib (Ibrance); CP.PHAR.125 (PDF)
- Panobinostat (Farydak); CP.PHAR.382 (PDF)
- Pazopanib (Votrient); CP.PHAR.81 (PDF)
- Pemigatinib (Pemazyre); CP.PHAR.496 (PDF)
- Pexidartinib (Turalio); CP.PHAR.436 (PDF)
- Ponatinib (Iclusig); CP.PHAR.112 (PDF)
- Pralsetinib (Gavreto); CP.PHAR.514 (PDF)
- Regorafenib (Stivarga); CP.PHAR.107 (PDF)
- Ribociclib (Kisqali, Kisqali Femara); CP.PHAR.334 (PDF)
- Ripretinib (Qinlock); CP.PHAR.502 (PDF)
- Romidepsin (Istodax); CP.PHAR.314 (PDF)
- Rucaparib (Rubraca); CP.PHAR.350 (PDF)
- Ruxolitinib (Jakafi, Opzelura); CP.PHAR.98 (PDF)
- Selpercatinib (Retevmo); CP.PHAR.478 (PDF)
- Selumetinib (Koselugo); CP.PHAR.464 (PDF)
- Sirolimus Protein-Bound Particles (Fyarro), Topical Gel, (Hyftor); CP.PHAR.574 (PDF)
- Sorafenib (Nexavar); CP.PHAR.69 (PDF)
- Sotorasib (Lumakras); CP.PHAR.549 (PDF)
- Sunitinib (Sutent); CP.PHAR.73 (PDF)
- Talazoparib (Talzenna); CP.PHAR.409 (PDF)
- Tazemetostat (Tazverik); CP.PHAR.452 (PDF)
- Tepotinib (Tepmetko); CP.PHAR.530 (PDF)
- Tivozanib (Fotivda); CP.PHAR.538 (PDF)
- Trametinib (Mekinist); CP.PHAR.240 (PDF)
- Tucatinib (Tukysa); CP.PHAR.497 (PDF)
- Umbralisib (Ukoniq); CP.PHAR.531 (PDF)
- Vandetanib (Caprelsa); CP.PHAR.80 (PDF)
- Vemurafenib (Zelboraf); CP.PHAR.91 (PDF)
- Vorinostat (Zolinza); CP.PHAR.83 (PDF)
Antineoplastic Enzymes
- Erwinia Asparaginase (Erwinaze, Rylaze); CP.PHAR.301 (PDF)
- Pegaspargase (Oncaspar); Calaspargase pegol-mknl (Asparlas) CP.PHAR.353 (PDF)
Antineoplastic Radiopharmaceuticals
- Iobenguane I 131 (Azedra); CP.PHAR.459 (PDF)
- Lutetium Lu 177 dotatate (Lutathera); CP.PHAR.384 (PDF)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto); CP.PHAR.582 (PDF)
Antineoplastics Misc.
- Bexarotene (Targretin Capsules, Gel); CP.PHAR.75 (PDF)
- Interferon Gamma- 1b (Actimmune); CP.PHAR.52 (PDF)
- Nadofaragene firadenovec (Instiladrin); CP.PHAR.461 (PDF)
- Omacetaxine (Synribo); CP.PHAR.108 (PDF)
- Ropeginterferon alfa-2b-njft (BESREMi); CP.PHAR.570 (PDF)
Chemotherapy Rescue/Antidote Agents
- Dextazoxane (Zinecard, Totect); CP.PHAR.418 (PDF)
- Levoleucovorin (Fusilev; Khapzorv); CP.PHAR.151 (PDF)
- Leucovorin Injection; CP.PHAR.393 (PDF)
- Sodium thiosulfate (Pedmark); CP.PHAR.610 (PDF)
Antineoplastic XPO1 Inhibitors
Mitotic Inhibitors
- Eribulin Mesylate (Halaven); CP.PHAR.318 (PDF)
- Paclitaxel Protein-Bound Particles (Abraxane); CP.PHAR.176 (PDF)
- Vincristine sulfate liposome injection (Marqibo); CP.PHAR.315 (PDF)
Oncolytic Viral Agents
Topoisomerase I Inhibitors
Antianginal Agents
Antihyperlipidemics
- Alirocumab (Praluent); CP.PHAR.124 (PDF)
- Bempedoic acid (Nexletol); bempedoic acid-ezetimibe (Nexlizet); CP.PMN.237 (PDF)
- Evinacumab-dgnb (Evkeeza); CP.PHAR.511 (PDF)
- Evolocumab (Repatha); CP.CPA.269 (PDF)
- Icosapent ethyl (Vascepa); CP.CPA.357 (PDF)
- Inclisiran (Leqvio); CP.PHAR.568 (PDF)
- Lomitapide (Juxtapid); CP.PHAR.283 (PDF)
Antihypertensives
Cardiovascular Agents – Misc.
- Ambrisentan (Letairis); CP.PHAR.190 (PDF)
- Amlodipine-Atorvastatin (Caduet); CP.PMN.176 (PDF)
- Bosentan (Tracleer); CP.PHAR.191 (PDF)
- Epoprostenol (Flolan, Veletri); CP.PHAR.192 (PDF)
- Iloprost (Ventavis); CP.PHAR.193 (PDF)
- Ivabradine (Corlanor); CP.PMN.70 (PDF)
- Macitentan (Opsumit); CP.PHAR.194 (PDF)
- Mavacamten (Camzyos); CP.PMN.272 (PDF)
- Riociguat (Adempas); CP.PHAR.195 (PDF)
- Sacubitril/valsartan (Entresto); CP.PMN.67 (PDF)
- Selexipag (Uptravi); CP.PHAR.196 (PDF)
- Sildenafil (Revatio); CP.PHAR.197 (PDF)
- Tadalafil (Adcirca, Alyq, Tadliq); CP.PHAR.198 (PDF)
- Tafamidis (Vyndaquel, Vyndamax); CP.PHAR.432 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso); CP.PHAR.199 (PDF)
Vasopressors
Allergenic Extracts/Biologicals Misc.
- Dust mite mixed allergen extracat (Odactra); CP.PMN.111 (PDF)
- Mixed pollens allergen extract (Oralair); CP.PMN.85 (PDF)
- Peanut allergen powder (Palforzia); CP.PMN.220 (PDF)
- Ragweed pollen (Ragwitek); CP.PMN.83 (PDF)
- Timothy grass pollen (Grastek); CP.PMN.84 (PDF)
Antihistamines – Non-Sedating
Cough/Cold/Allergy Combinations
Nasal Steroids
- Abrocitinib (Cibinqo); CP.PHAR.578 (PDF)
- Adapalene/Benzoyl peroxide (Epiduo Forte); CP.CPA.337 (PDF)
- Afamelanotide (Scenesse); CP.PHAR.444 (PDF)
- Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft); CP.PHAR.562 (PDF)
- Betamethasone dipropionate (Sernivo); CP.PMN.182 (PDF)
- Brodalumab (Siliq); CP.CPA.194 (PDF)
- Calcipotriene/betamethasone (Enstilar); CP.PMN.181 (PDF)
- Ciclopirox (Penlac); CP.PMN.24 (PDF)
- Clascoterone (Winlevi); CP.PMN.257 (PDF)
- Clindamycin/benzoyl peroxide (Acanya, Onexton); CP.CPA.133 (PDF)
- Crisaborole (Eucrisa); CP.PMN.110 (PDF)
- Dapsone (Aczone); CP.PCH.32 (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea); CP.PMN.79 (PDF)
- Dupilumab (Dupixent); CP.PHAR.336 (PDF)
- Fluorouracil (Tolak); CP.PMN.165 (PDF)
- Glycopyrronium Tosylate (Qbrexza); CP.PMN.177 (PDF)
- Guselkumab (Tremfya); CP.CPA.194 (PDF)
- Halobetasol Propionate Lotion (Bryhali, Lexette, Ultravate); CP.PMN.180 (PDF)
- Halobetasol-Tazarotene (Duobrii); CP.PMN.208 (PDF)
- Isotretinoin (Claravi, Absorica, Absorica LD, Myorisan, Zenatane, Amnesteem); CP.PMN.143 (PDF)
- Ivermectin (Soolantra); CP.CPA.155 (PDF)
- Ixekizumab (Taltz); CP.CPA.194 (PDF)
- Lidocaine Transdermal (Lidoderm); ZTlido; CP.PMN.08 (PDF)
- Mechlorethamine (Valchlor); CP.PHAR.381 (PDF)
- Minocycline Micronized Foam (Amzeeq); CP.PMN.242 (PDF)
- Neomycin/Fluocinolone (Neo-Synalar Kit); CP.PMN.167 (PDF)
- Oxymetazoline (Rhofade, Upneeq); CP.PMN.86 (PDF)
- Ozenoxacin (Xepi); CP.PMN.119 (PDF)
- Pimecrolimus (Elidel); CP.PMN.107 (PDF)
- Risankizumab-rzaa (Skyrizi); CP.CPA.194 (PDF)
- Secukinumab (Cosentyx); CP.CPA.194 (PDF)
- Spesolimab-sbzo (Spevigo); CP.PHAR.606 (PDF)
- Tacrolimus (Protopic); CP.PMN.107 (PDF)
- Tapinarof (Vtama); CP.PMN.283 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac); CP.PMN.244 (PDF)
- Tildrakizumab-asmn (Ilumya); CP.CPA.194 (PDF)
- Tralokinumab-ldrm (Adbry); CP.PHAR.577 (PDF)
- Trifarotene (Aklief); CP.PMN.225 (PDF)
- Ustekinumab (Stelara); CP.CPA.194 (PDF)
Adrenal Steroid Inhibitors
Aldosterone Receptor Antagonists
Androgens/Anabolic
- Testosterone (testosterone undecanoate capsule (Jatenzo®), testosterone transdermal gel (Vogelxo®, Testim®), testosterone nasal gel (Natesto®), testosterone pellet (Testopel®), testosterone enanthate injection (Xyosted®) testosterone cypionate (Depo®-testosterone), and testosterone undecanoate (Aveed®); CP.CPA.291 (PDF)
Antidiabetics
- Albiglutide (Tanzeum); CP.CPA.16 (PDF)
- Alogliptin (Nesina), Alogliptin-Metformin (Kazano), Alogliptin-Pioglitazone (Oseni); CP.CPA.343 (PDF)
- Canafliflozin (Invokana), Canafliflozin-Metformin (Invokamet, Invokamet XR); CP.CPA.347 (PDF)
- Dapagliflozin/Saxagliptin (Qtern), Dapagliflozin-Sazagliptin-Metformin (Qternmet XR); CP.CPA.347 (PDF)
- Dulaglutide (Trulicity); CP.CPA.16 (PDF)
- Empagliflozin-Linagliptin (Glyxambi), Empagliflozin-Linagliptin-Metformin (Trijardy XR); CP.CPA.347 (PDF)
- Ertugliflozin (Steglatro); Ertugliflozin-Sitagliptin (Steglujan), Ertugliflozin-Metformin (Sgluromet); CP.CPA.347 (PDF)
- Exenatide ER (Bydureon, Bydureon BCise); CP.CPA.16 (PDF)
- Exenatide IR (Byetta); CP.CPA.16 (PDF)
- Insulin glargine (Basaglar, Rezvoglar, Semglee); CP.CPA.228 (PDF)
- Insulin glulisine (Apidra); CP.CPA.224 (PDF)
- Linagliptin (Tradjenta); Linagliptin-Metformin (Jentadueto, Jentadueto XR); CP.CPA.343 (PDF)
- Liraglutide (Victoza); CP.CPA.16 (PDF)
- Liraglutide/insulin degludec (Xultophy); CP.CPA.16 (PDF)
- Lixisenatide (Adlyxin); CP.CPA.16 (PDF)
- Lixisenatide/insulin glargine (Soliqua); CP.CPA.16 (PDF)
- Metformin ER (Glumetza, Fortamet); CP.PMN.72 (PDF)
- Pramlintide (Symlin); CP.PMN.129 (PDF)
- Saxagliptin (Onglyza), Saxagliptin-Metformin (Kombiglyze XR); CP.CPC.343 (PDF)
- Semaglutide (Ozempic); CP.CPA.16 (PDF)
- Teplizumab-mzwv (Tzield); CP.PHAR.492 (PDF)
Bone Density Regulators
- Abaloparatide (Tymlos); CP.PHAR.345 (PDF)
- Alendronate (Binosto, Fosamax plus D); CP.PMN.88 (PDF)
- Denosumab (Prolia, Xgeva); CP.PHAR.58 (PDF)
- Ibandronate injection (Boniva); CP.PHAR.189 (PDF)
- Parathyroid hormone (Natpara); CP.PHAR.282 (PDF)
- Risedronate (Actonel, Atelvia); CP.PMN.100 (PDF)
- Romosozumab-aqqg (Evenity); CP.PHAR.428 (PDF)
- Teriparatide (Forteo); CP.PHAR.188 (PDF)
- Zoledronic Acid (Reclast, Zometa); CP.PHAR.59 (PDF)
Corticosteroids
- Budesonide (Tarpeyo); CP.PHAR.572 (PDF)
- Budesonide (Uceris); CP.PCH.11 (PDF)
- Deflazacort (Emflaza); CP.PHAR.331 (PDF)
- Triamcinolone ER Injection (Zilretta); CP.PHAR.371 (PDF)
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
Metabolic Modifiers
- Agalsidase beta (Fabrazyme); CP.PHAR.158 (PDF)
- Alglucosidase alfa (Lumizyme); CP.PHAR.160 (PDF)
- Asfotase alfa (Strensiq); CP.PHAR.328 (PDF)
- Avalglucosidase Alfa-ngpt (Nexviazyme); CP.PHAR.521 (PDF)
- Betaine (Cystadane); CP.PHAR.143 (PDF)
- Burosumab-twza (Crysvita); CP.PHAR.11 (PDF)
- Calcifediol (Rayaldee); CP.PMN.76 (PDF)
- Carglumic acid (Carbaglu); CP.PHAR.206 (PDF)
- Cerliponase alfa (Brineura); CP.PHAR.338 (PDF)
- Cinacalcet (Sensipar); CP.PHAR.61 (PDF)
- Elapegademse-lvlr (Revcovi); CP.PHAR.419 (PDF)
- Elosulfase alfa (Vimizim); CP.PHAR.162 (PDF)
- Fosdenopterin (Nulibry); CP.PHAR.471 (PDF)
- Galsulfase (Naglazyme); CP.PHAR.161 (PDF)
- Glycerol phenylbutyrate (Ravicti); CP.PHAR.207 (PDF)
- Idursulfase (Elaprase); CP.PHAR.156 (PDF)
- Laronidase (Aldurazyme); CP.PHAR.152 (PDF)
- Metreleptin (Myalept); CP.PHAR.425 (PDF)
- Migalastat (Galafold); CP.PHAR.394 (PDF)
- Nitisinone (Orfadin, Nityr); CP.PHAR.132 (PDF)
- Pegvaliase-pqpz (Palynziq); CP.PHAR.140 (PDF)
- Paricalcitol (Zemplar); CP.PHAR.270 (PDF)
- Sapropterin (Kuvan); CP.PHAR.43 (PDF)
- Sebelipase alfa (Kanuma); CP.PHAR.159 (PDF)
- Sodium phenylbutyrate (Buphenyl, Pheburane); CP.PHAR.208 (PDF)
- Vestronidase alfa-vjbk (Mepsevii); CP.PHAR.374 (PDF)
Natriuretic Peptides
Posterior Pituitary Hormones
Progesterone Receptor Antagonists
Progestins
- Hydroxyprogesterone caproate (Makena); CP.PHAR.14 (PDF)
- Progesterone (Crinone, Endometrin, Milprosa); CP.PMN.243 (PDF)
Somatostatic Agents
- Lanreotide (Somatuline Depot); CP.PHAR.391 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR, Bynfezia, Mycapssa); CP.PHAR.40 (PDF)
- Pasireotide (Signifor LAR, Singifor); CP.PHAR.332 (PDF)
Vasopressin Receptor Antagonists
Anti-Diarrheal/Probiotic Agents
Antiemetics
- Amisulpride (Barhemsys); CP.PMN.236 (PDF)
- Dolasetron (Anzemet); CP.PMN.141 (PDF)
- Dronabinol (Marinol, Syndros); CP.PMN.159 (PDF)
- Granisetron (Sancuso, Sustol); CP.PMN.74 (PDF)
- Ondansetron (Zuplenz); CP.PMN.45 (PDF)
Digestive Aids
Diuretics
Gastrointestinal Agents – Misc.
- Alosetron (Lotronex); CP.PMN.153 (PDF)
- Certolizumab (Cimzia); CP.CPA.194 (PDF)
- Chenodiol (Chenodal); CP.PMN.239 (PDF)
- Cholic Acid (Cholbam); CP.PHAR.390 (PDF)
- Dalfampridine (Ampyra); CP.PHAR.248 (PDF)
- Eluxadoline (Viberzi); CP.PMN.170 (PDF)
- Ferric citrate (Auryxia); CP.PMN.04 (PDF)
- Infliximab (Remicade); Infliximab-axxq (Avsola); Infliximab-dyyb (Inflectra); Infliximab-abda (Renflexis); CP.CPA.194 (PDF)
- Lanthanum carbonate (Fosrenol); CP.PMN.04 (PDF)
- Linaclotide (Linzess); CP.PMN.71 (PDF)
- Lubiprostone (Amitiza); CP.PMN.142 (PDF)
- Maralixibar (Livmarli); CP.PHAR.543 (PDF)
- Methylnaltrexone (Relistor); CP.CPA.274 (PDF)
- Metoclopramide (Gimoti); CP.PMN.252 (PDF)
- Naldemedine (Symproic); CP.PMN.112 (PDF)
- Obeticholic acid (Ocaliva); CP.PHAR.287 (PDF)
- Odevixibat (Bylvay); CP.PHAR.528 (PDF)
- Plecanatide (Trulance); CP.PMN.87 (PDF)
- Prucalopride (Motegrity): CP.PMN.194 (PDF)
- Sevelamer carbonate (Renvela); CP.PMN.04 (PDF)
- Sevelamer hydrochloride (Renagel); CP.PMN.04 (PDF)
- Sodium zirconium cyclosilicate (Lokelma); CP.PMN.163 (PDF)
- Sucroferric oxyhydroxide (Velphoro); CP.PMN.04 (PDF)
- Teduglutide (Gattex); CP.PHAR.114 (PDF)
- Tegaserod maleate (Zelnorm); CP.PMN.206 (PDF)
- Telotristat ethyl (Xermelo); CP.PHAR.337 (PDF)
- Tenapanor (Ibsrela); CP.PMN.224 (PDF)
- Vedolizumab (Entyvio); CP.CPA.194 (PDF)
Genitourinary Agents – Misc.
- Cysteamine oral (Cystagon, Procysbi); CP.PHAR.155 (PDF)
- Dutasteride (Avodart); CP.PMN.128 (PDF)
- Dutasteride/tamsulosin (Jalyn); CP.PMN.128 (PDF)
- Lumasiran (Oxlumo); CP.PHAR.473 (PDF)
- Pentosan polysulfate sodium (Elmiron); CP.PMN.276 (PDF)
Gout Agents
Impotence Agents
- Alprostadil (Caverject, Edex, Muse); CP.CPA.02 (PDF)
- Avanafil (Stendra); CP.CPA.323 (PDF)
- Sildenafil for ED (Viagra); CP.PCH.07 (PDF)
- Tadalafil (Cialis); CP.PMN.132 (PDF)
- Vardenafil (Levitra, Staxyn); CP.CPA.324 (PDF)
Laxatives
- Lactitol (Pizensy); CP.PMN.241 (PDF)
- Colonoscopy Preparation Products (GoLytely, Colyte, MoviPrep, OsmoPrep, Plenvu, Preopik, Clenpiq, Nulytely, Suprep); CP.PCH.43 (PDF)
Ulcer Drugs/Anti-Spasmodies/Anticholinergies
- Proton Pump Inhibitors (rabeprazole (AcipHex®, AcipHex® Sprinkle), dexlansoprazole (Dexilant®), esomeprazole strontium (ES), esomeprazole (Nexium®, Nexium® 24HR, Nexium® 24HR ClearMinisTM), omeprazole (Prilosec® Packets), lansoprazole (Prevacid® SoluTabsTM), omeprazole/sodium bicarbonate (Zegerid®, Zegerid® OTC)); CP.CPA.209 (PDF)
- Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia, Voquezna Triple/Dual Pak); CP.CPA.277 (PDF)
Urinary Antispasmotics
Vaginal Products
Anticoagulants
- Dalteparin (Fragmin); CP.PHAR.225 (PDF)
- Enoxaparin (Lovenox); CP.PHAR.224 (PDF)
- Fondaparinux (Arixtra); CP.PHAR.226 (PDF)
Hematological Agents – Misc.
- Anti-inhibitor Coagulant Complex, Human; (Feiba); CP.PHAR.217 (PDF)
- Antithrombin III (ATryn, Thrombate III); CP.PHAR.564 (PDF)
- Avacopan (Tavneos); CP.PHAR.515 (PDF)
- Berotralstat (Orladeyo); CP.PHAR.485 (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest); CP.PHAR.202 (PDF)
- Caplacizumab-yhdp (Cablivi); CP.PHAR.416 (PDF)
- Ecallantide (Kalbitor); CP.PHAR.177 (PDF)
- Eculizumab (Soliris); CP.PHAR.97 (PDF)
- Emicizumab-kxwh (Hemlibra); CP.PHAR.370 (PDF)
- Etranacogene Dezaparvovec (Hemgenix); CP.PHAR.580 (PDF)
- Factor IX Complex, Human (Profilnine); CP.PHAR.219 (PDF)
- Factor IX Human (AlphaNine SD, Mononine); Recombinant (Alprolix, BeneFIX, Idelvion, Ixinity, Rebinyn, Rixubis); CP.PHAR.218 (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact); CP.PHAR.220 (PDF)
- Factor VIII - Human, recombinant; (Hemofil M, Koate-DVI, Advate, Adynovate, Afstyla, Eloctate, Esperoct, Helixate FS, Jivi, Kogenate FS, Kovaltry, NovoEight, Nuwiq, Obizur, Recombinate, ReFacto, Xyntha, Xyntha Solofuse); CP.PHAR.215 (PDF)
- Factor VIII- von Willebrand (Alphanate, Humate-P, Vonvendi, Wilate); CP.PHAR.216 (PDF)
- Factor XIII, Human; (Corifact); CP.PHAR.221 (PDF)
- Factor XIII A-Subunit, Recombinant (Tretten); CP.PHAR.222 (PDF)
- Fibrinogen concentrate (human) (Fibryga, RiaSTAP); CP.PHAR.526 (PDF)
- Fostamatinib (Tavalisse); CP.PHAR.24 (PDF)
- Givosiran (Givlaari); CP.PHAR.457 (PDF)
- Hemin (Panhematin); CP.PHAR.181 (PDF)
- Icatibant (Firazyr); CP.PHAR.178 (PDF)
- Lanadelumab-fylo (Takhzyro); CP.PHAR.396 (PDF)
- Mitapivat (Pyrukynd); CP.PHAR.558 (PDF)
- Plasminogen, human-tvmh (Ryplazim); CP.PHAR.513 (PDF)
- Pegcetacoplan (Empaveli); CP.PHAR.524 (PDF)
- Protein C Concentrate Human (Ceprotin); CP.PHAR.330 (PDF)
- Ravulizumab-cwvz (Ultomiris); CP.PHAR.415 (PDF)
- Sutimlimab-jome (Enjaymo); CP.PHAR.503 (PDF)
Hematopoietic Agents
- Avatrombopag (Doptelet); CP.PHAR.130 (PDF)
- Betibeglogene autotemcel (Zynteglo); CP.PHAR.545 (PDF)
- Crizanlizumab-tmca (Adakveo); CP.PHAR.449 (PDF)
- Darbepoetin alfa (Aranesp); CP.PHAR.236 (PDF)
- Eliglustat (Cerdelga); CP.PHAR.153 (PDF)
- Eltrombopag (Promacta); CP.PHAR.180 (PDF)
- Epoetin Alfa (Epogen, Procrit); Epoetin alfa-ebpx (Retacrit); CP.PHAR.237 (PDF)
- Ferric Derisomaltose (Monoferric); CP.PHAR.480 (PDF)
- Ferric maltol (Accrufer); CP.PMN.213 (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastm-aafi (Nivestym), Filgrastim-ayow (Releuko); CP.PHAR.297 (PDF)
- Hydroxyurea (Siklos); CP.PMN.193 (PDF)
- Imiglucerase (Cerezyme); CP.PHAR.154 (PDF)
- L-glutamine (Endari); CP.PMN.116 (PDF)
- Luspatercept-aamt (Reblozyl); CP.PHAR.450 (PDF)
- Lusutrombopag (Mulpleta); CP.PHAR.407 (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera); CP.PHAR.238 (PDF)
- Miglustat (Zavesca); CP.PHAR.164 (PDF)
- Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastim-apgf (Nyvepria), Pegfilgrastim-pbbk (Fylnetra); CP.PHAR.296 (PDF)
- Plerixafor (Mozobil); CP.PHAR.323 (PDF)
- Romiplostim (Nplate); CP.PHAR.179 (PDF)
- Sargramostim (Leukine); CP.PHAR.295 (PDF)
- Taliglucerase alfa (Elelyso); CP.PHAR.157 (PDF)
- Velaglucerase alfa (VPRIV); CP.PHAR.163 (PDF)
- Voxelotor (Oxbyta); CP.PHAR.451 (PDF)
Antidotes and Specific Antagonists
- Deferasirox (Exjade, Jadenu); CP.PHAR.145 (PDF)
- Deferiprone (Ferriprox); CP.PHAR.147 (PDF)
- Deferoxamine (Desferal); CP.PHAR.146 (PDF)
- Naloxone (Evzio); CP.PMN.139 (PDF)
- Naltrxone (Vivotrol); CP.PHAR.96 (PDF)
Chelating Agents
Diabetic Supplies
- Continuous Glucose Monitors; CP.CPA.355 (PDF)
- Insulin Delivery Systems (V-Go, Omnipod); CP.PHAR.534 (PDF)
Diagnostic Products
Enzymes
Immunomodulators
Immunosuppressive Agents
- Antithymocyte Globulin (Atgam, Thymoglobulin); CP.PHAR.506 (PDF)
- Belatacept (Nulojix); CP.PHAR.201 (PDF)
- Belumosudil (Rezurock); CP.PHAR.552 (PDF)
- Emapalumab-lzsg (Gamifant); CP.PHAR.402 (PDF)
- Inebilizumb-cdon (Uplinza); CP.PHAR.458 (PDF)
- Satralizaumab-mwge (Enspryng); CP.PHAR.463 (PDF)
- Voclosporin (Lupkynis); CP.PHAR.504 (PDF)
Lipids
Potassium Removing Agents
- Patiromer sorbitex calcium (Veltassa); CP.PMN.205 (PDF)
- Sodium zirconium cyclosilicate (Lokelma); CP.PMN.163 (PDF)
Progeria Treatment Agents
Other Misc. Drugs
Systemic Lupus Erythematosus Agents
Tissue Products
Wound Care Products
- Baclofen (Fleqsuvy, Galofen, Lioresal, Lyvispah, Ozobax); CP.PHAR.149 (PDF)
- Hyaluronate derivatives (sodium hyaluronate (Euflexxa®, Gelsyn-3™, GenVisc®850, Hyalgan®, Supartz™, Supartz FX™, Synojoynt™, Triluron™, TriVisc™, VISCO-3™), hyaluronic acid (Durolane®), cross-linked hyaluronate (GelOne®), hyaluronan (Hymovis®, Orthovisc®, Monovisc®), and hylan polymers A and B (Synvisc®, Synvisc One®); CP.PHAR.05 (PDF)
ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants
- Amphetamine-dextroamphetamine extended-release (Mydayis); CP.PMN.92 (PDF)
- Amphetamine extended-release oral suspension (Adzenys ER, Dyanavel XR); CP.PMN.92 (PDF)
- Amphetamine extended-release orally disintegrating tablets (Adzenys XR-ODT); CP.PMN.92 (PDF)
- Amphetamine orally disintegrating tablets (Evekeo ODT); CP.PMN.92 (PDF)
- Armodafinil (Nuvigil); CP.PMN.35 (PDF)
- Benzphetamine; CP.CPA.326 (PDF)
- Bupropion-Naltrexone (Contrave); CP.PCH.12 (PDF)
- Dexmethylphenidate HCI (Foralin XR); CP.PMN.92 (PDF)
- Diethylpropion (Tenuate, Tenuate Dospan); CP.CPA.328 (PDF)
- Liraglutide (Saxenda); CP.CPA.332 (PDF)
- Methylphenidate extended-release orally disintegrating tablets (Cotempla XR-ODT); CP.PMN.92 (PDF)
- Methylphenidate extended-release oral suspension (Quillivant XR); CP.PMN.92 (PDF)
- Methylphnidate extended-release chewable tablets (Quillichew ER); CP.PMN.92 (PDF)
- Methylphenidate transdermal system (Daytrana); CP.PMN.92 (PDF)
- Methylphenidate extended-release (Adhansia XR, Aptensio XR, Jornay PM); CP.PMN.92 (PDF)
- Orlistat (Alli, Xenical); CP.CPA.335 (PDF)
- Phentermine (Adipex-P, Lomaira); CP.PCH.13 (PDF)
- Phentermine-Topiramate (Qsymia); CP.CPA.336 (PDF)
- Pitolisant (Wakix); CP.PMN.221 (PDF)
- Semaglutide (Wegovy); CP.CPA.352 (PDF)
- Setmelanotide (Imcivree); CP.PHAR.491 (PDF)
- Solriamfetol (Sunosi); CP.PMN.209 (PDF)
- Viloxazine (Oelbree); CP.PMN.264 (PDF)
Anticonvulsants
- Brivaracetam (Briviact); CP.PCH.26 (PDF)
- Cannabidiol (Epidiolex); CP.PMN.164 (PDF)
- Cenobamate (Xcopri); CP.PMN.231 (PDF)
- Clobazam (Onfi, Sympazan); CP.PMN.54 (PDF)
- Diazepam nasal spray (Valtoco); CP.PMN.216 (PDF)
- Fenfluramine (Fintepla); CP.PMN.246 (PDF)
- Ganaxolone (Ztalmy); CP.PMN.278 (PDF)
- Lamotrigine (Lamictal ODT, Lamictal XR); CP.CPA.97 (PDF)
- Midazolam (Nayzilam); CP.PMN.211 (PDF)
- Perampanel (Fycompa); CP.PMN.156 (PDF)
- Pregabalin (Lyrica); CP.PMN.33 (PDF)
- Topiramate ER (Qudexy XR, Trokendi XR); CP.PMN.281 (PDF)
- Valproate (Depacon); CP.PHAR.429 (PDF)
Anti-Depressants
- Brexanolone (Zulresso); CP.PHAR.417 (PDF)
- Dextromethorphan-bupropion (Auvelity); CP.PMN.285 (PDF)
- Esketamine (Spravato); CP.PMN.199 (PDF)
Anti-Myasthenic/Cholinergic Agents
Antiparkinson and Related Therapy Agents
- Amantadine EER (Gocovri, Osmolex ER); CP.PMN.89 (PDF)
- Apomorphine (Apokyn, Kynmobi); CP.PHAR.488 (PDF)
- Carbidopa-Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy); CP.PMN.238 (PDF)
- Istradefylline (Nourianz); CP.PMN.217 (PDF)
- Levodopa Inhalation Powder (Inbrija); CP.PMN.267 (PDF)
- Opicapone (Ongentys); CP.PMN.245 (PDF)
- Safinamide (Xadago); CP.PMN.113 (PDF)
Antipsychotics/Antimanic Agents
- Aripiprazole (Aripiprazole ODT, Abilify ODT); CP.PCH.37 (PDF)
- Asenapine (Saphris, Secuado); CP.PMN.15 (PDF)
- Brexpiprazole (Rexulti); CP.PMN.68 (PDF)
- Carbarnazepine ER (Equetro); CP.PMN.137 (PDF)
- Cariprazine (Vraylar); CP.PMN.91 (PDF)
- Iloperidone (Fanapt); CP.PMN.32 (PDF)
- Lumateperone (Caplyta); CP.PMN.232 (PDF)
- Lurasidone (Latuda); CP.PMN.50 (PDF)
- Olanzapine-samidorpham (Lybalyi); CP.PMN.265 (PDF)
- Paliperidone (Invega Hafyera, Invega Sustenna, Invega Trinza); CP.PHAR.291 (PDF)
- Pimavanserin (Nuplazid); CP.PMN.140 (PDF)
- Quetiapine ER (Seroquel XR); CP.PMN.64 (PDF)
- Risperidone (perseris, Risperdal Consta); CP.PHAR.293 (PDF)
Hypnotics/Sedatives/Sleep Disorder Agents
- Doxepin (Silenor); CP.PMN.175 (PDF)
- Ramelteon (Rozerem); CP.PMN.173 (PDF)
- Suvorexant (Belsomra); CP.CPA.200 (PDF)
- Tasimelteon (Hetlioz); CP.PMN.104 (PDF)
- Zolpidem (Edluar, Intermezzo, Zolpimist); CP.PMN.172 (PDF)
Migraine Products
- Atogepant (Qulipta); CP.PHAR.566 (PDF)
- Triptans (naratriptan (Amerge®), almotriptan (Axert®), frovatriptan (Frova®), sumatriptan (Imitrex®, Tosymra™), rizatriptan (Maxalt®/Maxalt-MLT®), eletriptan (Relpax®), sumatriptan/naproxen (Treximet®), zolmitriptan (Zomig®/Zomig® ZMT), Imitrex® injection, Onzetra™ Xsail™, Sumavel™ Dosepro™, and Zembrace™ SymTouch™)); CP.CPA.217 (PDF)
- Diclofenac potassium (Cambia); CP.PCH.28 (PDF)
- Erenumab-aaoe (Aimovig); CP.CPA.349 (PDF)
- Eptinezumab-jjmr (Vyepti); CP.CPA.345 (PDF)
- Fremanezumab-vfrm (Ajovy); CP.CPA.346 (PDF)
- Galcanezumba-gnln (Emgality); CP.CPA.344 (PDF)
- Lasmiditan (Reyvow); CP.PMN.218 (PDF)
- Rimegepant (Nurtec ODT); CP.PHAR.490 (PDF)
- Ubrogepant (Ubrelvy); CP.PHAR.476 (PDF)
Psychotherapeutic and Neurological Agents – Misc.
- Aducanumab (Aduhelm); CP.PHAR.468 (PDF)
- Alemtuzumab (Lemtrada); CP.PHAR.243 (PDF)
- Bremelanotide (Vyleesi); CP.PHAR.434 (PDF)
- Cladribine (Mavenclad); CP.PHAR.422 (PDF)
- Deutetrabenazine (Austedo); CP.PCH.42 (PDF)
- Dextromethorphan-Quinidine (Nuedexta); CP.PMN.93 (PDF)
- Dimethyl fumarate (Tecfidera); Diroximel fumarate (Vumerity); CP.PCH.41 (PDF)
- Elivaldogene Autotemcel (Skysona); CP.PHAR.556 (PDF)
- Fingolimod (Gilenya); CP.PCH.38 (PDF)
- Flibanserin (Addyi); CP.PHAR.446 (PDF)
- Gabapentin ER (Gralise, Horizant); CP.PMN.240 (PDF)
- Glatiramer (Copaxone, Glatopa); CP.CPA.252 (PDF)
- Interferon beta-1a (Avonex, Rebif); CP.PHAR.255 (PDF)
- Interferon beta-1b (Betaseron, Extavia); CP.PCH.46 (PDF)
- Inotersen (Tegsedi); CP.PHAR.405 (PDF)
- Lecanemab-irmb (Leqembi); CP.PHAR.596 (PDF)
- Lofexidine (Lucemyra); CP.PMN.152 (PDF)
- Memantine (Namenda XR, Namzaric); CP.PCH.30 (PDF)
- Milnacipran (Savella); CP.PMN.125 (PDF)
- Monomethyl fumarate (Bifiertam); CP.PCH.41 (PDF)
- Natalizumab (Tysabri); CP.PHAR.259 (PDF)
- Ocrelizumab (Ocrevus); CP.PHAR.335 (PDF)
- Ozanimod (Zeposia); CP.PHAR.462 (PDF)
- Patisiran (Onpatrro); CP.PHAR.395 (PDF)
- Peginterferon beta-1a (Plegridy); CP.PHAR.271 (PDF)
- Ponesimod (Ponvoy); CP.PHAR.537 (PDF)
- Satralizumab-mwge (Enspryng); CP.PHAR.463 (PDF)
- Siponimod fumarate (Mayzent); CP.PHAR.427 (PDF)
- Sodium Oxybate (Xyrem) and Calcium,. Magnesium, Potassium, Sodium Oxybate (Xywav); CP.PMN.42 (PDF)
- Stiripentol (Diacomit); CP.PMN.184 (PDF)
- Teriflunomide (Aubagio); CP.PCH.40 (PDF)
- Tetrabenazine (Xenazine); CP.PHAR.92
- Valbenazine (Ingrezza); CP.CPA.351 (PDF)
- Vutrisiran (Amvuttra); CP.PHAR.550 (PDF)
- AbobotulinumtoxinA (Dysport); CP.PHAR.230 (PDF)
- Casimersen (Amondys 45); CP.PHAR.470 (PDF)
- Edaravone (Radicava); CP.PHAR.343 (PDF)
- Eteplirsen (Exondys 51); CP.PHAR.288 (PDF)
- Golodirsen (Vyondys 53); CP.PHAR.453 (PDF)
- IncobotulinumtoxinA (Xeomin); CP.PHAR.231 (PDF)
- OnabotulinumtoxinA (Botox); CP.PHAR.232 (PDF)
- Onasemnogene abeparvovec-xioi (Zolgensma); CP.PHAR.421 (PDF)
- Nusinersen (Spinraza); CP.PHAR.327 (PDF)
- RimabotulinumtoxinB (Myobloc); CP.PHAR.233 (PDF)
- Risdiplam; CP.PHAR.477 (PDF)
- Sodium Phenylbutyrate-Taurursodiol (Relyvrio); CP.PHAR.584 (PDF)
- Viltolarsen (Viltepson): CP.PHAR.484 (PDF)
- Aflibercept (Eylea); CP.PHAR.184 (PDF)
- Bimatoprost (Durysta); CP.PHAR.486 (PDF)
- Brimonidine (Mirvaso); CP.PMN.192 (PDF)
- Brolucizumab (Beovu); CP.PHAR.445 (PDF)
- Cenegermin-bkbj (Oxervate); CP.PMN.186 (PDF)
- Corticosteroids for ophthalmic injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq); CP.PHAR.385 (PDF)
- Cyclosporine ophthalmic emulsion (Cequa, Restasis, Verkazia); CP.PMN.48 (PDF)
- Cysteamine ophthalmic (Cystaran, Cystadrops); CP.PMN.130 (PDF)
- Faricimab (Vabysmo); CP.PHAR.581 (PDF)
- Glaucoma Agents (Omlonti, Rhopressa, Rocklatan, Vyzulta); CP.PMN.286 (PDF)
- Lifitegrast (Xiidra); CP.CPA.297 (PDF)
- Loteprednol etabonate (Eysuvis); CP.PMN.260 (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous); CP.PHAR.536 (PDF)
- Oxymetazoline (Rhofade, Upneeq); CP.PMN.86 (PDF)
- Pilocarpine (Vuity); CP.PMN.270 (PDF)
- Ranibizumab (Byooviz, Lucentis, Susvimo); CP.PHAR.186 (PDF)
- Varenicline (Tyrvaya); CP.CPA.354 (PDF)
- Verteporfin (Visudyne); CP.PHAR.187 (PDF)
- Voretigene neparvovec-rzyl (Luxturna); CP.PHAR.372 (PDF)
Antiasthmatic and Bronchodilator Agents
- Aclidinium bromide (Tudorza Pressair); CP.CPA.350 (PDF)
- Aclidnium-Formoterol (Duaklir Pressair); CP.CPA.350 (PDF)
- Albuterol (ProAir Digihaler); CP.CPA.350 (PDF)
- Arformoterol (Brovana); CP.CPA.350 (PDF)
- Benralizumab (Fasenra); CP.PHAR.373 (PDF)
- Budesonide-Formoterol (Symbicort); CP.CPA.350 (PDF)
- Ciclesonide (Alvesco); CP.CPA.350 (PDF)
- Fluticasone (Armonair Digihaler); CP.CPA.350 (PDF)
- Fluticasone-Salmeterol (Advair Diskus, AirDuo Digihaler, AirDuo RespiClick); CP.CPA.350 (PDF)
- Formoterol (Perforormist); CP.CPA.350 (PDF)
- Glycopyrrolate (Seebri Neohaler, Lonhala Magnair); CP.CPA.350 (PDF)
- Glycopyrrolate-Formoterol (Bevespi Aerosphere); CP.CPA.350 (PDF)
- Indacaterol (Arcapta Neohaler); CP.CPA.350 (PDF)
- Indacaterol-Glycopyrrolate (Utibron Neohaler); CP.CPA.350 (PDF)
- Mepolizumab (Nucala); CP.PHAR.200 (PDF)
- Mometasone (Asmanex HFA, Asmanex Twisthaler); CP.CPA.350 (PDF)
- Mometasone-Formoterol (Dulera); CP.CPA.350 (PDF)
- Omalizumab (Xolair); CP.PCH.49 (PDF)
- Reslizumab (Cinqair); CP.PHAR.223 (PDF)
- Revefenacin (Yupelri); CP.CPA.350 (PDF)
- Roflumilast (Daliresp, Zoryve); CP.PMN.46 (PDF)
- Tezepelumab (Tezspire); CP.PHAR.576 (PDF)
Respiratory Agents – Misc.
- Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira); CP.PHAR.94 (PDF)
- Dornase alfa (pulmozymn); CP.PHAR.212 (PDF)
- Elexacaftor-ivacaaftor-tezacaftor (Trikafta); CP.PHAR.440 (PDF)
- Ivacaftor (Kalydeco); CP.PHAR.210 (PDF)
- Lumacaftor-ivacaftor (Orkambi); CP.PHAR.213 (PDF)
- Mannitol (Bronchitol); CP.PHAR.518 (PDF)
- Nintedanib esylate (Ofev); CP.PHAR.285 (PDF)
- Pirfenidone (Esbriet); CP.PHAR.286 (PDF)
- Tezacaftlor-Ivacaflor (Symdeko); CP.PHAR.377 (PDF)
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 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. |
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. |
|
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.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. |
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. |
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. |
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. |
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. |
|
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. |
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. |
|
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. |
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. | |
Testing for Select GU Conditions (Effective April 01, 2021-June 23, 2022) |
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.97 (PDF) | Testing for Select GU Conditions (Effective June 24, 2022) | 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. |
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. | |
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. | |
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. | |
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. | |
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. | |
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. | |
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. | |
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. | |
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-June 23, 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.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. |
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. |
CC.PP.073 (PDF) | Sepsis Diagnosis (Last review date March 2022) | 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. |
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. |
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. |
|
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.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. |
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. |
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. |
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. |
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. |
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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. |
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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. |
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. | |
Testing for Select GU Conditions (Effective April 01, 2021-June 23, 2022) |
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.97 (PDF) | Testing for Select GU Conditions (Effective June 24, 2022) | 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. |
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. | |
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. | |
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. | |
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. | |
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. | |
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-June 23, 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.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.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.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. |
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 March 2022) | 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. |