Health Net Medical Policies
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.
Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.
Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.
No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.
No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.
Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.
Policy Limitation: Legal and Regulatory Mandates and Requirements.
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.
Reconstructive Surgery.
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
- To improve function; or
- To create a normal appearance, to the extent possible.
Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.
Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.
Reconstructive Surgery after Mastectomy.
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.
Policy Limitations: Medicare and Medicaid.
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.
A
- Acupuncture (PDF)
- Air Ambulance (PDF)
- Allergy Testing (PDF)
- Allogeneic Hematopoietic Cell Transplant for Sickle Cell Disease (PDF)
- Applied Behavioral Analysis (ABA) (PDF)
- Applied Behavioral Analysis (ABA) Documentation Requirements (PDF)
- Articular Cartilage Defect Repairs (PDF)
- Assisted Reproductive Technology (PDF)
B
- Bariatric Surgery (PDF)
- Behavioral Health Treatment Documentation Requirements (PDF)
- Benign Skin Lesion Removal (PDF)
- Biofeedback (PDF)
- Biofeedback for Behavioral Health Disorders (PDF)
- Bone Anchored Hearing Aids (BAHA) (PDF)
- Bronchial Thermoplasty (PDF)
- Burn Surgery (PDF)
C
- Cardiac Biomarker Testing (PDF)
- Cardiac Rehabilitation, Outpatient (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (PDF)
- Clinical Trials (PDF)
- Cochlear Implant Replacements (PDF)
- Cosmetic and Reconstructive Surgery (PDF)
D
- Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF)
- Dental Anesthesia (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF)
- Digital EEG Spike Analysis (PDF)
- Disc Decompression Procedures - Percutaneous and Laser (PDF)
- Discography (PDF)
- Donor Lymphocyte Infusion (PDF)
- Durable Medical Equipment and Orthotics and Prosthetic Guidelines (PDF)
E
- EEG for Headache (PDF)
- Electric Tumor Treatment Fields (PDF)
- Endometrial Ablation (PDF)
- Enhanced External Counterpulsation (EECP) (PDF)
- Evoked Potential Testing (PDF)
- Experimental Technologies (PDF)
F
- Facet Joint Interventions (PDF)
- Facility-Based Sleep Studies for Obstructive Sleep Apnea (PDF)
- Fecal Incontinence Treatments (PDF)
- Fertility Preservation (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
- Functional MRI (PDF)
G
- Gastric Electrical Stimulation (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
- Gender Affirming Procedures (PDF)
- Genetic Testing for Aortopathies and Connective Tissue Disorders (PDF)
- Genetic Testing for Cardiac Disorders (PDF)
- Genetic Testing for Dermatological Conditions (PDF)
- Genetic Testing for Epilepsy, Neurodegenerative Disorders (PDF)
- Genetic Testing for Exome and Genome Sequencing (PDF)
- Genetic Testing for Eye Disorders (PDF)
- Genetic Testing for GI Disorders (non cancerous) (PDF)
- Genetic Testing for General Approach to Genetic Testing (PDF)
- Genetic Testing for Hearing Loss (PDF)
- Genetic Testing for Hematological Disorders (PDF)
- Genetic Testing for Hereditary Cancer Susceptibility (PDF)
- Genetic Testing for Immune Autoimmune Rheumatoid Disorders (PDF)
- Genetic Testing for Kidney Disorders (PDF)
- Genetic Testing for Lung Disorders (PDF)
- Genetic Testing for Metabolic Endocrine Mitochondrial Disorders (PDF)
- Genetic Testing for Multi system Inherited Disorders (PDF)
- Genetic Testing for Noninvasive Prenatal Screening (PDF)
- Genetic Testing for Oncology Algorithmic Testing (PDF)
- Genetic Testing for Oncology Cancer Screening (PDF)
- Genetic Testing for Oncology Circulating Tumor DNA etc (liquid biospy) (PDF)
- Genetic Testing for Oncology Cytogentic Testing (PDF)
- Genetic Testing for Oncology Molecular Analysis of Solid Tumor and Hematologic Malignancies (PDF)
- Genetic Testing for Pharmacogenetics (PDF)
- Genetic Testing for Preimplantation Genetic Testing (PDF)
- Genetic Testing for Prenatal and Preconception Carrier Screening (PDF)
- Genetic Testing for Prenatal Diagnosis and Pregnancy Loss (PDF)
- Genetic Testing for Skeletal Dysplasia and Rare Bone Disorders (PDF)
H
- H. Pylori Serology Testing (PDF)
- Heart-Lung Transplant (PDF)
- Holter Monitor (PDF)
- Home Birth (PDF)
- Home Ventilators (PDF)
- Homocysteine Testing (PDF)
- Hospice Services (PDF)
- Hyperhidrosis Treatments (PDF)
I
- Implantable Hypoglossal Nerve Stimulation (PDF)
- Implantable Intrathecal or Epidural Pain Pump (PDF)
- implantable Loop Recorder (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
- Intensity Modulated Radiotherapy (PDF)
- Intestinal and Multivisceral Transplant (PDF)
- Intradialytic Parenteral Nutrition/Intraperitoneal Amino Acid (IPAA Supplementation) (PDF)
- Intradiscal Steroid Injections for Pain Management (PDF)
- Investigational Procedure List (PDF)
J
K
L
- Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy (PDF)
- Laser Therapy for Skin Conditions (PDF)
- Liposuction for Lipedema (PDF)
- Long Term Care Placement Criteria (PDF)
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)
- Lung Transplantation (PDF)
- Lysis of Epidural Adhesions (PDF)
M
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
- Multiple Sleep Latency Testing (PDF)
N
- Neonatal Abstinence Syndrome Guideline (PDF)
- Neonatal Sepsis Management Guidelines (PDF)
- Nerve Blocks and Neurolysis for Pain Management (PDF)
- Neurofeedback (PDF)
- Neuromuscular Electrical Stimulation (PDF)
- NICU Apnea Bradycardia Guidelines (PDF)
- NICU Discharge Guidelines (PDF)
- Non-Emergency Ambulance Transportation (PDF)
- Non-myeoablative Allogenic Transplant (PDF
O
- Obstetrical Home Care Programs (PDF)
- Omisirge (omidubicel) (PDF)
- Orthognathic Surgery (PDF)
- Osteogenic Stimulation (PDF)
- Outpatient Oxygen Use (PDF)
P
- Palliative Care Eligibility Criteria (PDF)
- Pancreas Transplant (PDF)
- Panniculectomy (PDF)
- Pediatric Heart Transplantation (PDF)
- Pediatric Kidney Transplant (PDF)
- Pediatric Liver Transplant (PDF)
- Pediatric Oral Function Therapy (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (PDF)
- Physical, Occupational and Speech Therapy (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
- Proton and Neutron Beam Therapy (PDF)
- Pulmonary Function Testing (PDF)
Q
R
- Reduction Mammoplasty and Gynecomastia Surgery (PDF)
- Refractive Surgery (LASIK, LESEK, PRK, PARK and PRK-A) (PDF)
- Repair of Nasal Valve Compromise (PDF)
S
- Sacroiliac Joint Fusion (PDF)
- Sacroiliac Joint Interventions for Pain Management (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF)
- Skilled Nursing Facility Leveling (PDF)
- Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)
- Sleep Studies, Adult (PDF)
- Sleep Studies, Pediatric (PDF)
- Spinal Cord, Peripheral Nerve and Percutaneous Electrical Stimulation (PDF)
- Stereotactic Body Radiation Therapy (PDF)
T
- Tandem Transplant (PDF)
- Testing for Select Genitourinary Conditions (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide Therapy (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
- Total Artificial Heart (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
- Transcatheter Closure of Patent Foramen Ovale (PDF)
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)
- Transplant Service Documentation Requirements (PDF)
- Trigger Point Injections for Pain Management (PDF)
U
- Ultrasound in Pregnancy (PDF)
- Urinary Incontinence Devices and Treatments (PDF)
- Urodynamic Testing (PDF)
V
- Vagus Nerve Stimulation (PDF)
- Ventricular Assist Devices (PDF)
- Vitamin D, Measurement of Serum (PDF)
- Vitamin D Testing in Pediatric Population (PDF)
- Voice Therapy (PDF)