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Medical Policies

Medical Policies


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A

Abdominoplasty/Panniculectomy/Suction-Assisted Lipectomy/Ventral Hernia Repair
Ablation of Liver Tumors
Accommodating Intraocular Lens (Crystalens, ReStore, Synchrony)
Acne Treatments
Acupuncture
Acute Inpatient Rehabilitation
Adaptive Servo-Ventilation
Adoptive Immunotherapy for Cancer
Air Fluidized Beds and Other Pressure Reducing Mattresses
Airway Clearance Devices
Allergy Testing
Ambulance Transportation, Non-Emergent
Ambulatory EEG
Amyvid for Use with PET Scans
ANCA for Crohn's Disease and Ulcerative Colitis
Antibody Screening Tests for Neurological Diseases
Arthroscopic Lavage and Debridement for Osteoarthritis of the Knee
Artificial Intervertebral Disc
Artificial Retina
Autism Spectrum Disorder
Autologous Chondrocyte Implantation (ACI)
Automated Ambulatory Blood Pressure Monitoring
Axial Lumbar Interbody Fusion (AxiaLIF)




B

Balloon Sinuplasty for Treatment of Chronic Sinusitis
Bariatric Surgery
Benign Skin Lesion Removal
Biofeedback
Bioimpedance for Assessment of Lymphedema
Biomagnetic Therapy, Bioelectromagnetic Therapy
Biventricular Pacemakers-Cardiac Resynchronization-Defibrillation Devices for the Treatment of Congestive Heart Failure
Blepharoplasty
Blood-Brain Barrier Disruption for the Treatment Of Malignant Brain Tumors
Blood Product Injections for Tendonopathies
Bone Anchored Hearing Aids (BAHA)
Bone Growth Stimulators, Electrical and Ultrasonic
Bone Mineral Density Measurement
Bone Morphogenetic Protein
Brachytherapy for Breast Cancer
Brachytherapy for Gynecological Cancer
Breast Elastography
Breast Reconstruction
Breast Tomosynthesis
Bronchial Thermoplasty
Buprenorphine Treatment




C

Canaloplasty (Transluminal Dilation of Aqueous Outflow Canal) for Glaucoma
Capsular Tension Rings
Cardiac Defibrillators - External, Automatic
Cardiac Defibrillator (AICD), Automatic Implantable
Cardiac Rehabilitation, Outpatient
Cardiac Risk Assesment-Laboratory Tests
Carotid Angioplasty and Stenting
Carotid Artery Intimal-Medial Thickness (IMT)
Catheter Ablation for Atrial Fibrillation
Celiac Disease Laboratory Testing
Central Auditory Processing Disorder
Cervical Traction Devices
Chelation Therapy
Chemotherapy Sensitivity and Resistance Assays
Circulating Tumor Cells
Circumferential Endoscopic Radiofrequency Ablation of Barrett's Esophagus (e.g., HALO Ablation Technology)
Circumcision
Cleft Palate and other Craniofacial Disorders
Coccygectomy for Coccygodynia
Cochlear Implantation
Cognitive Rehabilitation Post Traumatic Brain Injury (TBI)
Collagen Meniscal Implant (e.g. Meneflex)
Colonoscopy
Comparative Genomic Hybridization
Complementary and Alternative Medicine
Computed Tomography Angiography (CTA) of the Coronary Arteries
Computed Tomography Perfusion Imaging of the Brain
Computer-Aided Detection of Chest Radiographs and CT Scanning for Lung Cancer Screening
Computer Assisted Orthopedic Surgery
Computerized Dynamic Posturography
Computerized Gait Analysis
Computerized Lower Limb Prosthesis (Otto Bock C-Leg)
Continuous Glucose Monitoring Devices
Continuous Passive Motion (CPM) Devices
Corneal Pachymetry
Corneal Topography
Cosmetic and Reconstructive Surgery
Cryosurgical Ablation of Renal Tumors
CT Scan of the Heart Prior and Post Cardiac Ablation




D

Deep Brain Stimulation for Intractable Pain
Deep Brain Stimulation for Movement Disorders
Dental Anesthesia
Diabetic Neuropathy, Surgical Decompression
Diaphragmatic Phrenic Nerve Stimulation
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
Dorsal Column Stimulators
Double Balloon Enteroscopy
Ductal Lavage of the Breast
Dynamic Spinal Visualization




E

Electric Tumor Treatment Fields
Electrocardiographic Body Surface Mapping
Electromagnetic Navigational Bronchoscopy
Electron Beam Computed Tomography
Electronic Brachytherapy
Endometrial Ablation
Endoscopic Anterior Spinal Surgery
Endoscopic Cyclophotocoagulation (ECP) with Glaucoma Surgery and Cataract Extraction
Endothelial Keratoplasty
Endovascular Repair of Thoracic Aortic Aneurysms
Enhanced External Counterpulsation (EECP)
Epidural Analgesia, Continuous
Epidural Steroid Injections for Treatment of Low Back and Cervical Pain
Excimer Laser for Psoriasis
Extended Opthalmoscopy
Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions




F

Facet Joint Denervation
Facet Joint Injections
Facial Lipodystrophy Treatments (i.e. Sculptra and Radiesse)
Fecal Bacteriotherapy
Fecal Calprotectin Assay
Fecal Incontinence Treatments
Femoro-Acetabular Surgery for Hip Impingement Syndrome (FAI)
Fertility Preservation for Cancer Patients
Fetal Surgery in Utero for Prenatally Diagnosed Malformations
FIBROSpect, HCV-FIBROSURE, Acti Test
Frequency Related Electromagnetic Stimulation (FREMS)




G

Gastric Pacing, Enterra Therapy
Gastroesophogeal Reflux Disease (GERD) Transendoscopic Therapies for
Gender Reassignment Surgery
Gene Expression Profiling for Cancers of Unknown Origin
Genetic Counseling
Genetic Testing for BRCA1 and BRCA2
Genetic Testing for Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
Genetic Testing for Cystic Fibrosis
Genetic Testing for Familial Adenomatous Polyposis
Genetic Testing for Hereditary Nonpolyposis Colorectal Cancer (HNPCC)
Genetic Testing for Huntington's Disease
Genetic Testing Indications
Genetic Testing for Long QT Syndrome
Genetic Testing for Multiple Endocrine Neoplasia Type I (MEN1) Syndrome
Genetic Testing for Tay-Sachs Disease
Genetic Testing for Von Hippel-Lindau Disease
Glaucoma Surgery
Growing Rods Spinal Surgery
Guided Imagery, Hypnosis, Relaxation Therapy




H

Heart Transplant (Adult or Adolescent)
Heart Transplantation Rejection Monitoring (AlloMap Gene-Expression Testing, Heartsbreath Test)
Heart-Lung Transplant
Heparin Bonded Graft using Propaten Vascular Graft for Treatment of Peripheral Vascular Disease
Her-2 neu (formerly Her2-nue Herceptin)
High Intensity Focused Ultrasound (HIFU) for Treatment of Prostate Cancer
Hip Resurfacing
Histamine Desensitization Therapy
HIV Antiretroviral (ART) Drug Resistence Testing
HIV Seropositivity and Solid Organ Transplantation
HIV Testing and Counseling
Home Apnea Monitoring for Infants
Home Births
Home Uterine Activity Monitoring (HUAM)
Hospice Care
Hospital Beds and Accessories
Human Papillomavirus Vaccine (Gardasil, Cervarix)
Humanitarian Use Devices
Humate-P (Antihemophilic Factor-von Willebrand Factor Complex - Human)
Hyperbaric Oxygen Therapy
Hyperhidrosis Treatments
Hyperthermia as Treatment for Breast Cancer




I

Ilizarov Method of Distraction Osteosynthesis
Image Guided (computer assisted) Endoscopic Sinus Surgery
ImmuKnow (Transplantation Immune Cell Function Assay)
Immunochemical Fecal Occult Blood Testing
Implantable Cardiac Event Monitors
Implantable Hormone Pellets
Implantable Miniature Telescope Screening for Age Related Macular Degeneration
Inferential Therapy
Infertility, Diagnosis and Treatment
Infusion Pumps, External Portable and Implantable
Infusion Pumps, Intrathecal
Inhaled Nitric Oxide Therapy
Insulin Infusion Pumps
Intensity Modulated Radiation Therapy (IMRT)
Intercostal Nerve Blocks Neurolysis
Interferential Current Therapy Inferential Stimulation
Interleukin-2 (Aldesleukin, Proleukin, IL-2)
Interspinonous Process Decompression System
Intra-oral Appliance for Migraine
Intradialytic Parenteral Nutrition/Intrperitoneal Amino Acid (IPAA Supplementation)
Intradiscal Electrothermal Therapy (IDET) Percutaneous Intradiscal Radiofrequncy Thermocoagulation
Intradiscal Steroid Injections
Intraepidermal Nerve Fiber Density Testing in the Diagnosis of Small Fiber Neuropathy
Intraoperative Radiation Therapy (IORT)
Intraoperative Neurophysiologic Monitoring
Intraperitoneal Hyperthermic Chemotherapy for Abdominopelvic Cancers
Intraperitoneal Chemotherapy for Ovarian Cancer
Intrastromal Corneal Rings for Keratoconus
Investigational Category B Devices
Investigational Procedure List
Islet Cell Transplantation
Isolated Limb Perfusion for Malignant Melanoma




J





K

K-RAS Mutation Analysis of Colon Cancer
Kidney Transplantation
KTP Laser for Acne, Rosacea and Facial Telangiectasias
Kyphoplasty




L

Lactate Pro Meter for Glycogen Storage Disease (GSD)
Laparoscopic Ultrasound Guided RFA of Uterine Fibroids
Laser Ablation (Interstitial Laser Coagulation) for Treatment of Localized Breast Cancer
Laser Photocoagulation of Macular Drusen
Left Atrial Appendage Devices
Leuprolide for Breast Cancer
Levonorgestrel Intrauterine Device (Mirena) Noncontraceptive Use
Linx Reflux Management System
Liver Transplantation
Low Level Laser Therapy
Low Pressure Pulse Generator for Ear (Meniett Pressure Therapy)
Lumbar Laminectomy
Lumbar Spinal Fusion
Lung Transplantation
Lung Volume Reduction Surgery (LVRS)
Lymphedema and Venous Stasis Ulcer Treatments
Lysis of Epidural Adhesions




M

Magnetic Resonance Spectroscopy for Various Diagnoses
Magnetoencephalography Magnetic Source Imaging
MammaPrint, Prosigna, and Other Gene Expression Tests for Breast Cancer
Mechanical Stretching Devices for Joint Stiffness and Contracture
Melaris Genetic Testing for Malignant Melanoma and Pancreatic Cancer
Microsurgical Anterior Foraminotomy
MicroVas
Microvolt T-Wave Alternans Testing
Mini Transplants (Non-Myloablative Allogenic Stem Cell Transplants)
Mobile Outpatient Cardiac Telemetry (e.g. CardioNet)
Mohs Micrographic Surgery
Molecular Topographic Genotypting (PathFinder TG)
Molecular Tumor Markers for Non-Small Cell Lung Cancer
MRI Guided Ablation of Uterine Fibroids
MRI of the Breast
Myoelectric Prosthesis




N

Natural Orifice Transluminal Endoscopic Surgery
Naturopathy for Pain Management
Neovascular (Wet) Macular Degeneration Treatment
Nerve Conduction Studies
Neuromuscular Electrical Stimulation (NMES) and Functional Stimulation (FES)
Neuropsychological Testing
Neutralizing Antibody Testing in Multiple Sclerosis
Non-invasive Cell-Free Fetal DNA-Based Prenatal Screening (e.g., MaterniT21, Harmony, Verifi, Panorama)
Non Medically Indicated Induction of Labor Prior to 39 Week Gestation
Nuchal Translucency
Nucleoplasty
Nutritional Therapy, Oral and Enteral




O

Obstructive Sleep Apnea Diagnosis and Medical Treatments
Obstructive Sleep Apnea in Children
Obstructive Sleep Apnea Surgical Treatments
Occipital Nerve Block
Occipital Nerve Stimulation for Headache
Oncotype DX for Cancer
Optic Nerve Decompression Surgery
Orthognathic Surgery
Ostrochondral Allograft Transplants of the Lower Extremity (OAG)
Osteochondral Autograft Transfer System (OATS) & Mosaicplasty
Outpatient Joint Replacement
Oxygen Therapy for Treatment of Cluster Headaches
Oxygen Therapy in the Home




P

Pain Pumps (Intra-lesional, Intra-incisionsal)
Pancreas Transplants
Particle Repositioning Maneuvers for Benign Paroxysmal Positional Vertigo (BRRV)
Patient Initiated Spirometric Recording
Patient Lift and Seat Lift Mechanism
Pedicle Screws for Spinal Fixation Intervertebral Body Fusion Devices
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
Percutaneous Sacroplasty
Percutaneous Vertebroplasty
Pharmacogenetic Testing
Photodynamic Therapy for Cancer
Photophoresis (Extracorporeal Photochemotherapy)
Phototherapy and Photochemotherapy (PUVA) for Dermatological Conditions
Phototherapy for Psoriasis Treatment
Phototherapy for Seasonal Affective Disorder
Physical and Occupational Therapy
Plagiocephaly Treatments, Dynamic Orthotic Cranioplasty and Soft Helmets
Plasmapheresis/Plasma Exchange/Therapeutic Apheresis
Pneumatic Compression Device
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
Preimplantation Genetic Diagnosis in Assisted Reproduction
Prolotherapy
Prophylactic Bilateral Oopherectomy
Prophylactic Mastectomy
ProstaScint (Indium In 111 Capromab Pendetide)
Prostatic Urethral Lift (PUL)
Proteomic-based Testing - Detection of Ovarian CA
Proton Beam Radiotherapy
Pulmonary Artery Pressure Monitoring (CardioMEMS)
Pulmonary Rehabilitation
Pulse Oximetry for Adults and Children




Q

Quantitative Electroencephalography




R

Radial Head Implant
Radiofrequency Ablation of Lung Tumors
Radiofrequency Ablation for Renal Cell Cancer
Radiofrequency Lesioning for Plantar Fasciitis
Reduction Mammoplasty for Male Gynecomastia
Reduction Mammoplasty Macromastia in the Female
Refractive Surgery (LASIK, LESEK, PRK, PARK and PRK-A)
Retisert (Fluocinolone acetonide implant)
Robotic Surgery




S

Sacroiliac Joint Fusion
Sacroiliac Joint Injection
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Scintimammography and Breast-Specific Gamma Imaging
Septoplasty, Turbinoplasty and Rhinoplasty
Selective Internal Radiation Therapy
Shoulder Arthroplasty
Signal Averaged Electrocardiography
SilverHawk Plaque Excision System
Single Nucleotide Polymorphism (SNP) Chromosomal Microarray Analysis
Small Bowel Transplant
SmartPill GI Monitoring System
Specialty Care Ground Transport
SPECT Scan for Evaluation of Spondylolysis, Spondylolisthesis
Speech Generating Devices
Speech Therapy
Spinal Endoscopy
Spinal Manipulation Under Anesthesia for Chronic Pain
Spinal Unloading and Home Lumbar Traction Devices
Standing and Flexion MRI
Stealth System for Neurosurgery
Stem Cell Therapy for Heart Failure and Acute Myocardial Infarction
Stem Cell Transplant Glossary
Stem Cell Transplantation in Adult Patients
Stem Cell Transplantation in Pediatric Patients
Stem Cell Treatment for Spinal Fusion
Stereotactic Radiosurgery
Subtalar Implant for Treatment for Pes Planus (Flatfeet)
Suit Therapy for Cerebral Palsy
Sural Nerve Graft with Radical Prostatectomy
Surgical Treatment of Esophageal Cancer
Swallowing-Feeding Therapy
Sympathetic Nerve Blocks
Sympathetic Therapy




T

Tandem Stem Cell Transplants in the Adult Patient
Terbutaline Infusion Pump in the Home for Preterm Labor
Testing for Drugs of Abuse
Thermal Assisted Anterior Capsulorrhaphy, Shoulder
Thermography
Thoracic Electrical Bioimpedance - Outpatient Setting
Three Dimensional (3D) Cardiac Echocardiography
Three Dimensional Obstetric Ultrasound
Three Dimensional Reconstruction of CT Scan or MRI
Topoisomerase II alpha Gene Testing (TOP2A) for Breast Cancer
Total Ankle Replacement
Total Artificial Heart
Transanal Endoscopic Microsurgery (TEM) for Rectal Cancer (TEMS)
Transcatheter Aortic Valve Replacement
Transcatheter Arterial Chemoembolization for Liver Cancer
Transcatheter Closure of Septal Defects, Fenestrated Fontan Procedure and Patent Ductus Arteriorosis
Transcatheter Placement of Intracranial Stent
Transcendental Meditation
Transcutaneous Electric Nerve Stimulation (TENS), Conductive Garments, Electrostimulation
Transcranial Magnetic Stimulation (TMS)
Transmyocardial Laser Revascularization
Trigeminal Neuralgia, Interventional Treatments
Trigger Point Injections
TruFUSE Facet Fusion for Minor Spinal Instability
Tumor Markers for Cancer




U

Ultrafiltration for Heart Failure
Ultrasound Guidance for Joint Injections
Unicompartmental Knee Arthroplasty
Umbilical Cord Blood Storage
Unicondylar Interpositional Spacer
Urinary Incontinence Devices and Treatments




V

Vagus Nerve Stimulation
Varicose Vein Surgical Interventions
Ventilator Care
Ventricular Assist Devices
Vertebral Axial Decompression (VAX D)
Vestibular Function Testing
Video EEG
Video-Assisted Thoracoscopic Surgery (VATS)
Virtual Colonoscopy
Viscosupplementation of Shoulder
Vitamin D Screening
Vitiligo Treatment
Voice Therapy




W

Wheelchairs and other Mobility Assistive Devices
Whole-Body CT Screening
Wireless Capsule Endoscopy
Wireless Esophageal pH Monitoring
Wound Care




X





Y





Z

Zostavax (Herpes Zoster Vaccine for Adults)




Clinical Practice Guidelines

ADHD in Children
Major Depression Clinical Practice Guideline
Substance Use Disorder Practice Guideline




Preventive Health Guidelines

2016 Adult Female Preventive Health Guidelines
2016 Adult Immunization Schedule
2016 Adult Male Preventive Health Guidelines
2016 Childhood and Adolescent Immunizations
2016 Maternity Health Guidelines
2016 Pediatric Preventive Guidelines
Most Recent Vaccinations Updates from the CDC

MedSolutions and eviCore

Evidence-based clinical guidelines for procedures prior authorized by MedSolutions and eviCore

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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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