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Medical Policies

Medical Policies

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Accommodating Intraocular Lens (Crystalens, ReStore, Synchrony)
ADHD Assessment and Testing
Allergy Testing
Allogeneic Hematopoietic Cell Transplant for Sickle Cell Disease
Ambulance Transportation, Non-Emergent
Ambulatory EEG
Ambulatory Surgery Center Optimization
Applied Behavioral Analysis (ABA)
Assisted Reproductive Technologies and Infertility
Articular Cartilage Defect Repairs
Artificial Retina
Autism Diagnosis and Treatment
Automated Ambulatory Blood Pressure Monitoring


Balloon Sinuplasty for Treatment of Chronic Sinusitis
Bariatric Surgery
Benign Skin Lesion Removal
Bone Anchored Hearing Aids (BAHA)
Breast Tomosynthesis
Bronchial Thermoplasty


Cardiac Biomarker Testing in Acute MI
Cardiac Risk Assesment-Laboratory Tests
Carrier Screening in Pregnancy
Celiac Disease Testing
Cell-free Fetal DNA Testing
Central Auditory Processing Disorder
Chelation Therapy
Clinical Trials
Cochlear Implant Replacements
Cosmetic and Reconstructive Surgery


Dental Anesthesia
Digital EEG Analysis
Disc Decompression Procedures - Percutaneous and Laser
DNA Analysis of Stool to Screen for Colorectal Cancer
Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Stem Cell Transplantation
Double Balloon Enteroscopy


Early Elective Deliveries Before 39 Weeks Gestation
EEG for Headache
Electric Tumor Treatment Fields
Endometrial Ablation
Enhanced External Counterpulsation (EECP)
EpiFix Wound Treatment
Essure Removal
Evoked Potentials


Facial Lipodystrophy Treatments (i.e. Sculptra and Radiesse)
Fecal Bacteriotherapy
Fecal Calprotectin Assay
Fecal Incontinence Treatments
Fertility Preservation
Fetal Surgery in Utero for Prenatally Diagnosed Malformations
Functional MRI


Gastric Electrical Stimulation
Gender Reassignment Surgery
Genetic Testing
Genetic Testing for Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
Growing Rods Spinal Surgery


H. Pylori Serology Testing
Heart-Lung Transplant
Her-2 neu (formerly Her2-nue Herceptin)
Holter Monitor
Home Phototherapy for Neonatal Hyperbilirubinemia
Homocysteine Testing
Hospice Care
Hyperbaric Oxygen Therapy
Hyperhidrosis Treatments
Hyperemesis Gravidarum Treatment


Implantable Cardiac Event Monitors
Implantable Hormone Pellets
Implantable Wireless Pulmonary Artery Pressure Monitoring
Implantable Miniature Telescope Screening for Age Related Macular Degeneration
Inhaled Nitric Oxide Therapy
Injections for Pain Management
Interferential Current Therapy Inferential Stimulation
Intestinal and Multiviseral Transplant
Intradialytic Parenteral Nutrition/Intrperitoneal Amino Acid (IPAA Supplementation)
Intradiscal Electrothermal Therapy (IDET) Percutaneous Intradiscal Radiofrequncy Thermocoagulation
Intraperitoneal Hyperthermic Chemotherapy for Abdominopelvic Cancers
Investigational Procedure List




Laser Therapy for Skin Conditions
Leuprolide for Breast Cancer
Levonorgestrel Intrauterine Device (Mirena) Noncontraceptive Use
Long Term Care Placement
Low-Frequency Ultrasound Therapy for Wound
Lung Transplantation
Lymphedema and Venous Stasis Ulcer Treatments
Lysis of Epidural Adhesions


Mechanical Stretching Devices for Joint Stiffness and Contracture
Microvolt T-Wave Alternans Testing
Monitored Anesthesia Care
Multiple Sleep Latency Testing


Neonatal Abstinence Syndrome Guideline
Neonatal Sepsis Management Guidelines
Neovascular (Wet) Macular Degeneration Treatment
NICU Apnea Brachycardia Discharge Guidelines
NICU Discharge Guidelines
Nonmyeoablative Allogenic Transplant


Obstetrical Home Health Programs
Occipital Nerve Stimulation for Headache
Optic Nerve Decompression Surgery
Oxygen Therapy in the Home


Pancreas Transplan
Pediatric Heart Transplantation
Pediatric Liver Transplant
Percutaneous Left Atrial Appendage (Watchman)
Photophoresis (Extracorporeal Photochemotherapy)
Phototherapy and Photochemotherapy for Dermatological Conditions
Physical, Occupational and Speech Therapy
Plasmapheresis/Plasma Exchange/Therapeutic Apheresis
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
Prostatic Urethral Lift (PUL)




Radial Head Implant
Reduction Mammoplasty and Gynecomastia Surgery
Refractive Surgery (LASIK, LESEK, PRK, PARK and PRK-A)
Robotic Surgery


Sacroiliac Joint Fusion
Sclerotherapy for Varicose Veins
Sickle Cell Disease Observation
Specialty Care Ground Transport
Spinal Cord Stimulation


Testing for Drugs of Abuse
Testing for Rupture of Fetal Membranes
Testing Select GU Conditions
Thyroid and Insulin Testing in Pediatrics
Total Artificial Heart
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition
Transcranial Magnetic Stimulation (TMS)
Transcatheter Closure of Patent Foramen Ovale


Ultrafiltration for Heart Failure
Ultrasound in Pregnancy
Umbilical Cord Blood Storage
Urinary Incontinence Devices and Treatments
Urodynamic Testing


Vagus Nerve Stimulation
Ventricular Assist Devices
Ventriculectomy and Cardiomypoplasty
Vitamin D, Measurement of Serum
Vitamin D Testing in Pediatric Population
Voice Therapy


Wheelchair Seating
Wireless Motility Capsule




Zika Virus Testing

Preventive Health Guidelines

2018 Adult Female Preventive Health Guidelines
2018 Adult Immunization Schedule
2018 Adult Male Preventive Health Guidelines
2018 Childhood and Adolescent Immunizations
2017 Pediatric Preventive Guidelines
Most Recent Vaccinations Updates from the CDC

Medi-Cal Disease Management Program Clinical Practice Guidelines

Medi-Cal DM Clinical Practice Guideline for Adult Diabetes
Medi-Cal DM Clinical Practice Guideline for Asthma
Medi-Cal DM Clinical Practice Guideline for Children Adolescents with Type 2 Diabetes
Medi-Cal DM Clinical Practice Guideline for Children with Type 1 Diabetes
Medi-Cal DM Clinical Practice Guideline for Heart Failure

Clinical Practice Guidelines

ADHD in Children
American Academy of Family Physicians: Low Back Pain
Annals of Internal Medicine: Diagnosis and Treatment of Low Back Pain
Clinical Practice Guidelines
Substance Use Disorder Practice Guideline

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Important Notice

General Purpose
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:

1. To improve function; or
2. 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.


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