List of Investigational Procedures
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A payer-maintained list identifying procedures, devices, tests and therapies considered experimental or investigational and therefore generally not covered; applies to Health Net National members unless overridden by member contract, Medicaid state provisions, or Medicare NCD/LCDs.
No material clinical or coverage changes in this revision.
Coverage Criteria and Policy Scope
Definition of Investigational
General coverage stance for items on this list
Defines how items are categorized as investigational.
Coverage decision logic
Coverage determination process
Policy provides guidance but does not override member contract; medical necessity and contract terms govern coverage.
For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions on this list, state Medicaid coverage provisions take precedence. Refer to the applicable state Medicaid manual for specific coverage provisions that may supersede the policies in this document.
Coverage for any procedure, drug, service, or supply listed in this document is determined on the basis of the individual clinical case and the terms and conditions of the member's contract (also called the benefit contract or evidence of coverage). The member's contract contains specific provisions such as pre‑existing condition clauses, limitations, exclusions, benefit maximums, and eligibility rules; if the member contract conflicts with these Policies, the member's contract governs and controls the final coverage determination.
All coverage determinations must comply with applicable legal and regulatory mandates and requirements. If there is a discrepancy between these Policies and a legal or regulatory requirement, the requirements of law and regulation govern the coverage decision.
Policies developed to assist in administering Medicare or Medicaid benefits for Medicare or Medicaid members shall not be construed to apply to other Health Net plans and members. These Policies must not be interpreted to limit benefits afforded to Medicare and Medicaid members by law and regulation, and they do not automatically apply to non‑Medicare/Medicaid Health Net plans or members.
Examples of procedures and products specifically called out in this document include surgical and device interventions listed as investigational or not medically necessary — for example, Surgical Decompression for treatment of diabetic neuropathy (not medically necessary), and device or supply items such as TenoGlide tendon protector sheet and Trufuse Facet Fusion for Spinal Instability (not medically necessary). This list is illustrative and not exhaustive; see the full listing for other named procedures and codes.
Codes and Coding Status
| T codes | T codes unless otherwise specified |
| TenoGlide | TenoGlide tendon protector sheet (Tendon Wrap tendon protector) |
Provider Responsibilities and Prior Authorization
Prior notification, policy amendments, and state rules
Policies are subject to applicable legal and regulatory mandates and may be amended without notice; in some states new or revised policies require prior notice or website posting before they are effective. Contact your provider representative for state-specific prior-notification requirements and effective date information.
- Health Net reserves the right to amend Policies without notice; some states require prior notice or website posting for amendments to be effective [[16]].
- All policies are subject to legal and regulatory mandates and requirements for prior notification; contact your provider representative for effective date details [[15]].
Listing is not authorization or coverage guarantee
Inclusion of a procedure, drug, service, or supply on these Policies does not constitute authorization or guarantee of coverage; providers and members must obtain any required authorizations per the member's contract and plan rules.
- The Policies do not constitute authorization or guarantee of coverage of a particular procedure, drug, service, or supply; refer to the Member contract for applicability of exclusions, limitations, and dollar caps [[18]].
Coverage depends on individual case and member contract
Coverage determinations are made case‑by‑case and are governed by the facts of the individual clinical case and the terms, conditions, limitations, and exclusions of the member's benefit contract; medical necessity requirements must be met.
- Coverage is subject to the member's contract, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and medical necessity requirements; the contract governs if it conflicts with the Policies [[14],[19]].
- Health Net uses Policies as clinical guidance, but final benefit determinations are based on applicable contract language and individual case facts [[14],[19]].
Provider action: use policy as guidance and confirm definitions/effective dates
Providers should refer to the Policies for clinical guidance but must rely on the member's contract and applicable laws when seeking coverage; contact your provider representative for clarification on definitions and policy effective dates as needed.
- Medical policy is intended as guidance and does not override the member's benefits contract or dictate clinical practice; the contract language prevails where there is conflict [[14]].
- For information about policy effective dates and definitions of terms, contact your provider representative [[15]].
Confirm policy effective date and term definitions with provider representative
The date a policy is posted is not necessarily its effective date; providers should contact their provider representative to confirm the effective date and to obtain definitions used in the Policies.
- The Policy is effective as of the date determined by Health Net, not the posting date; contact your provider representative for effective date information [[15]].
- The Policies do not include definitions within the document; all terms are defined by Health Net and provider representatives can supply those definitions [[15]].
Check Member contract for exclusions, limitations, and dollar caps
Providers and members must consult the Member contract to determine if exclusions, limitations, or dollar caps apply to a requested procedure, drug, service, or supply.
- The member's contract defines which items are covered, excluded, limited, or subject to dollar caps and governs if it conflicts with the Policies [[14],[19]].
- Members and providers should refer to the Member contract to determine applicability of exclusions, limitations, and dollar caps [[18]].
Denial risk: investigational services are generally not covered
Procedures listed as investigational are generally not covered and coverage determinations are made on a case‑by‑case basis subject to the member's contract terms, limitations, and exclusions—risk of denial is elevated for investigational services.
- Coverage determinations are subject to all terms, conditions, limitations, and exclusions of the member's contract; items considered experimental/investigational are generally not covered [[14]].
State Medicaid provisions supersede policy where applicable
For Medicaid members, state Medicaid coverage provisions take precedence over these Policies; when state provisions conflict with the list, follow the state Medicaid manual and state rules.
- When state Medicaid coverage provisions conflict with this list, state Medicaid coverage provisions take precedence; refer to the state Medicaid manual for details [[3]].
No automatic authorization or coverage guarantee
Inclusion on the Policies does not authorize or guarantee coverage; providers and members must obtain authorization as required by the member's contract and plan rules.
- The Policies do not constitute authorization or guarantee of coverage; refer to the Member contract for authorization requirements and applicability of exclusions or caps [[18]].
Coverage decisions follow clinical facts and the member's contract
Coverage decisions are based on the individual clinical facts of the case and the member's benefit contract; if the contract conflicts with the Policies, the contract governs the coverage determination.
- The contract contains specific terms and conditions (pre-existing conditions, limits, exclusions, benefit maximums, eligibility) that determine coverage [[19]].
- If there is a discrepancy between the Policies and the Member's contract, the Member's contract shall govern [[19]].
Legal and regulatory requirements override policy conflicts
If a Policy conflicts with applicable legal or regulatory mandates, the requirements of law and regulation govern coverage decisions; providers must follow legal/regulatory requirements over the Policy.
- All policies are subject to applicable legal and regulatory mandates and requirements for prior notification; where discrepancies exist, law and regulation govern [[15],[20]].
- If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern [[20]].
Background and Scope
A technology is considered experimental or investigational when it is under active, credible evaluation (for example, in clinical trials) to determine clinical efficacy or therapeutic value, or when peer‑reviewed studies do not conclude safety and effectiveness for the requested indication. Items meeting this definition are generally listed as investigational and are not covered under these Policies unless otherwise specified.
Definitions
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