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Policies & Criteria

Clinical Policies

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

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

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

Policy NumberPolicy Title

CP.MP.108

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)
CP.BH.104Applied Behavior Analysis (PDF)

CP.MP.26

Articular Cartilage Defect Repairs (PDF)

CP.MP.37

Bariatric Surgery (PDF)
CP.BH.500Behavioral Health Treatment Documentation Requirements (PDF)
CP.MP.168Biofeedback (PDF)
CP.BH.300Biofeedback for Behavioral Health Disorders (PDF)

CP.MP.93

Bone-Anchored Hearing Aid (PDF)
CP.MP.186Burn Surgery (PDF)

CP.MP.94

Clinical Trials (PDF)

CP.MP.14

Cochlear Implant Replacements (PDF)
V1.2025Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)
V1.2025Concert Genetic Testing: Cardiac Disorders (PDF)
V1.2025Concert Genetic Testing: Dermatologic Conditions (PDF)
V1.2025Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)
V1.2025Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)
V1.2025Concert Genetic Testing: Eye Disorders (PDF)
V1.2025Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)
V1.2025Concert Genetic Testing: General Approach to Genetic and Molecular Testing
V1.2025Concert Genetic Testing: Hearing Loss (PDF)
V1.2025Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)
V1.2025Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)
V1.2025Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)
V1.2025Concert Genetic Testing: Kidney Disorders (PDF)
V1.2025Concert Genetic Testing: Lung Disorders (PDF)
V1.2025Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)
V1.2025Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)
V1.2025Concert Genetic Testing: Pharmacogenetics (Version A) (PDF)
V1.2025Concert Genetic Testing: Preimplantation Genetic Testing (PDF)
V1.2025Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
V1.2025Concert Genetic Testing: Prenatal Cell-Free DNA Testing (PDF)
V1.2025Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)
V1.2025Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)
V1.2025Concert Genetics Oncology: Algorithmic Testing (PDF)
V1.2025Concert Genetics Oncology: Cancer Screening (PDF)
V1.2025
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)
V1.2025
Concert Genetics Oncology: Cytogenetic Testing (PDF)
V1.2025
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)

CP.MP.31

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

CP.MP.114

Disc Decompression Procedures (PDF)

CP.MP.101

Donor Lymphocyte Infusion (PDF)

CP.MP.107

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

CP.MP.36

Experimental Technologies (PDF)
CP.MP.248Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)

CP.MP.137

Fecal Incontinence Treatments (PDF)

CP.MP.40

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

OR.CP.MP.95

Gender-Affirming Procedures (PDF)

CP.MP.132

Heart-Lung Transplant (PDF)
CP.MP.184Home Ventilators (PDF)
CP.MP.180Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)

CP.MP.173

Implantable Intrathecal Pain Pump (PDF)

CP.MP.160

Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)

CP.MP.58

Intestinal and Multivisceral Transplant (PDF)

CP.MP.167

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

CP.MP.71

Long Term Care Placement (PDF)
CP.MP.57Lung Transplantation (PDF)

CP.MP.86

Neonatal Abstinence Syndrome Guidelines (PDF)

CP.MP.85

Neonatal Sepsis Management (PDF)

CP.MP.170

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

CP.MP.82

NICU Apnea Bradycardia Guidelines (PDF)

CP.MP.81

NICU Discharge Guidelines (PDF)

CP.MP.141

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

CP.MP.102

Pancreas Transplantation (PDF)

CP.MP.109

Panniculectomy (PDF)

CP.MP.138

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

CP.MP.120

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

CP.MP.133

Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
CP.MP.70Proton and Neutron Beam Therapies (PDF)

CP.MP.51

Reduction Mammoplasty and Gynecomastia Surgery (PDF)

CP.MP.210

Repair of Nasal Valve Compromise (PDF)

CP.MP.126

Sacroiliac Joint Fusion (PDF)

CP.MP.146

Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)
CP.MP.174Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
CP.MP.182Short Inpatient Hospital Stay (PDF)

CP.MP.185

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

CP.MP.22

Stereotactic Body Radiation Therapy (PDF)

CP.MP.162

Tandem Transplant (PDF)
CP.MP.87Therapeutic Utilization of Inhaled Nitric Oxide (PDF)
CP.BH.200Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)
CP.MP.247Transplant Service Documentation Requirements (PDF)

CP.MP.142

Urinary Incontinence Devices and Treatments (PDF)

CP.MP.12

Vagus Nerve Stimulation (PDF)

CP.MP.143

Wireless Motility Capsule (PDF)

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

 

Pharmacy Criteria

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

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

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

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

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

Commercial Pharmacy Criteria

Amebicides

Amnoglycosides

Antifungals

Antihelmintics

Anti-Infective Agents - Misc.

Antimalarials

Antimycobacterial Agents

Antivirals

Fluoroqunolones

Passive Immunizing and Treatment Agents

Tetracyclines

Alkylating Agents

Antimetabolites

Antineoplastic – Angiogenesis Inhibitors

Antineoplastic – Anti-HER2 Agents

Antineoplastic – Antibodies

Antineoplastic – BCL-2 Inhibitors

Antineoplastic – Cellular Immunotherapy

Antineoplastic – Hedgehog Pathway Inhibitors

Antineoplastic – Hormonal and Related Agents

Antineoplastic – Hypoxia-Inducible Factor Inhibitors

Antineoplastic – Immunomodulators

Antineoplastic - Menin Inhibitors

Antineoplastic – Kinase Inhibitor

Antineoplastic Antibiotics

Antineoplastic Combinations

Antineoplastic Enzyme Inhibitors

Antineoplastic Enzymes

Antineoplastic Radiopharmaceuticals

Antineoplastics Misc.

Chemotherapy Rescue/Antidote Agents

Antineoplastic XPO1 Inhibitors

Mitotic Inhibitors

Oncolytic Viral Agents

Topoisomerase I Inhibitors

 

Adrenal Steroid Inhibitors

Aldosterone Receptor Antagonists

Androgens/Anabolic

Antidiabetics

Bone Density Regulators

Corticosteroids

Corticotropin

Corticotropin-Releasing Factor Receptor Antagonists

Fertility Regulators

GNRH/LHRH Antagonists

Growth Hormone Receptor Antagonists

Growth Hormone Releasing Hormones (GHRH)

Growth Hormones

Hormone Receptor Modulators

Insulin-Like Growth Factors (Somatomedins)

Insulin-Like Growth Factor Receptor Inhibitors

Menopausal Symptoms Suppressants

Metabolic Modifiers

Natriuretic Peptides

Posterior Pituitary Hormones

Progesterone Receptor Antagonists

Progestins

Somatostatic Agents

Vasopressin Receptor Antagonists

Anti-Diarrheal/Probiotic Agents

Antiemetics

Digestive Aids

Diuretics

Gastrointestinal Agents – Misc.

Genitourinary Agents – Misc.

Gout Agents

Impotence Agents

Laxatives

Ulcer Drugs/Anti-Spasmodies/Anticholinergies 

Urinary Antispasmotics

Vaginal Products

Anticoagulants

Hematological Agents – Misc.

Hematopoietic Agents

 

Anesthetics - Misc.

Antidotes and Specific Antagonists

Chelating Agents

Diabetic Supplies

Diagnostic Products

Enzymes

Immunomodulators

Immunosuppressive Agents

Lipids

Potassium Removing Agents

Progeria Treatment Agents

Other Misc. Drugs

Systemic Lupus Erythematosus Agents

Tissue Products

Wound Care Products

ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants

Anticonvulsants

Anti-Depressants

Anti-Myasthenic/Cholinergic Agents

Antiparkinson and Related Therapy Agents

Antipsychotics/Antimanic Agents

Hypnotics/Sedatives/Sleep Disorder Agents

Migraine Products

Psychotherapeutic and Neurological Agents – Misc.

Medicare Pharmacy Criteria

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

Payment Policies

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

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

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

Policy Number

Policy Title

CP.MP.15725-hydroxyvitamin D Testing in Children and Adolescents (PDF)

CC.PP.501

30 Day Readmission (PDF) (Effective February 15, 2022)

CC.PP.500

3-day Payment Window (PDF)

CP.MP.100Allergy Testing and Therapy (PDF)
CP.MP.110Bronchial Thermoplasty (PDF)
CP.MP.156Cardiac Biomarker Testing (PDF)
CP.MP.105Digital EEG Spike Analysis (PDF)
CP.MP.125DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) (Effective April 01, 2021)
CP.MP.155EEG in the Evaluation of Headache (PDF)
CP.MP.106Endometrial Ablation (PDF)
CC.PI.04Equian for Clean Claims Reviews (PDF)
CP.VP.26Extended Ophthalmoscopy (PDF)
OC.UM.CP.0043External Ocular Photography (PDF) (Effective July 01, 2021)
CP.VP.28Fluorescein Angiography (PDF)
CP.VP.29Fundus Photography (PDF)
CP.VP.31Gonioscopy (PDF)
CP.MP.153Helicobacter Pylori Serology Testing (PDF)
CP.MP.113Holter Monitors (PDF)
CP.MP.121Homocysteine Testing (PDF) (Effective April 01, 2021)
CC.PP.007Lab Quantity Limits (PDF) (Effective January 15, 2021)
CP.MP.123Laser Therapy for Skin Conditions (PDF)
CC.PP.053Leveling of ED Services (PDF) (Effective Date: October 01, 2019)
CP.MP.139Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)
CP.MP.152Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
CC.PP.065Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
CC.PP.061Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
CC.MP.50Outpatient Testing for Drugs of Abuse (PDF) (Effective October 01, 2020)
CC.PP.063Place of Service Mismatch (PDF)
CC.PP.067Renal Hemodialysis (PDF) (Effective January 15, 2021)
CP.PP.050Robotic Surgery (PDF) (Effective January 15, 2021)
CP.VP.14Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
CC.PP.073Sepsis Diagnosis (PDF)
CC.PP.145Severe Malnutrition (PDF)
CC.PP.206Skilled Nursing Facility Leveling (PDF)
CC.PP.035Sleep Studies POS (PDF) (Effective January 15, 2021)
CC.PP.049Status "P" Bundled Services (PDF) (Effective Date: October 01, 2019)
CP.MP.149Testing for Rupture of Fetal Membranes (PDF) (Effective April 01, 2021)
CP.MP.97Testing for Select Genitourinary Conditions (PDF)
CP.MP.154Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
CP.MP.38Ultrasound in Pregnancy (PDF)
CC.PP.056Urine Specimen Validity Testing (PDF)
CP.MP.98Urodynamic Testing (PDF)
CP.VP.63Visual Field Testing (PDF)
CC.PP.502Wheelchair Accessories (PDF) (Effective July 01, 2021)
CP.MP.99Wheelchair Seating (PDF)

Policy Number

Policy Title

CC.PP.011 (PDF)Code Editing Overview (Effective February 15, 2020)

CC.PP.501 (PDF)

30 Day Readmission (Effective February 15, 2022)

CC.PP.500 (PDF)

3-day Payment Window

OC.UM.CP.0029 (PDF)Fundus Photography (Effective May 15, 2021)
OC.UM.CP.0063 (PDF)Visual Field Testing (Effective May 15, 2021)

CC.PI.04 (PDF)

Equian for Clean Claims Reviews

CC.PP.053 (PDF)Leveling of ED Services (Effective October 01, 2019)

CC.PP.061 (PDF)

Non-obstetrical Pelvic and Transvaginal Ultrasounds

CC.PP.063 (PDF)

Place of Service Mismatch

CC.PP.007 (PDF)Lab Quantity Limits (Effective Janaury 15, 2021)
CC.PP.067 (PDF)Renal Hemodialysis (Effective January 15, 2021)
CC.PP.065 (PDF)Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (Effective October 01, 2020)
CC.PP.070 (PDF)340B Drug Payment Reduction (Effective July 01, 2021)
CP.MP.208 (PDF) Outpatient Testing for Drugs of Abuse: Presumptive Frequency Edits (Effective July 01, 2021)
CC.PP.035 (PDF)Sleep Studies POS (Effective January 15, 2021)
CC.PP.073 (PDF)Sepsis Diagnosis
Effective: February 17, 2025
CC.PP.145 (PDF)Severe Malnutrition
Effective: February 17, 2025
MC.CP.MP.106 (PDF)Endometrial Ablation
Effective: February 17, 2025