20-709 Medical Policies - 2nd Quarter 2020
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Announcement of new and updated medical policies and coding updates approved in Q2 2020 affecting Physicians, Participating Physician Groups, Hospitals, and ancillary providers; includes Medi-Cal county applicability noted for certain Medi-Cal communications.
New and updated medical policies were approved by Centene's Corporate Clinical Policy Committee and/or Health Net's Medical Advisory Council in Q2 2020.
New policies include Burn Surgery, Pediatric Oral Function Therapy, Radiofrequency Ablation of Uterine Fibroids (investigational), and Skin Substitutes for Chronic Wounds.
Multiple existing policies were updated with specific clinical criteria changes and CPT/HCPCS/ICD-10 code revisions (examples listed such as ADHD assessment, ambulatory EEG, and various others).
Inhaled Nitric Oxide (iNO) was added as medically necessary for COVID-19, severe ARDS and refractory hypoxemia, and related ICD-10 codes were added.
Coverage Criteria Summary
Summary coverage actions (see individual policies for full criteria)
This announcement lists new and updated medical policies and summarizes key coverage determinations and changes approved in Q2 2020. See individual policy pages for complete criteria and coding details.
See full policy pages for complete criteria and product lists.
Refer to each individual policy on the provider website for the detailed logic and code lists.
Related ICD-10 codes were added: J80, J96.01, U07.1, U07.2.
Radiofrequency Ablation of Uterine Fibroids is classified as investigational/experimental and is not considered a medically necessary treatment option under this announcement. Providers should refer to the full policy page on the provider website for any details or future updates to clinical indications or coverage rationale.
Several devices and related indications were recategorized to experimental/investigational. Examples called out in the announcement include low-load prolonged-duration stretch (LLPS) when used for indications other than those meeting specified criteria, and the patient-actuated serial stretch (PASS) and static progressive stretch (SPS) devices for certain indications. See the individual policy pages for the specific not‑medically‑necessary or investigational statements that apply to each device and indication.
Coding Updates and Code Lists
| 95700 | CPT code added for ambulatory EEG (2020) |
| 95705 | CPT code added for ambulatory EEG (2020) |
| 95708 | CPT code added for ambulatory EEG (2020) |
| 95717 | CPT code added for ambulatory EEG (2020) |
| 95719 | CPT code added for ambulatory EEG (2020) |
| 95721 | CPT code added for ambulatory EEG (2020) |
| 95723 | CPT code added for ambulatory EEG (2020) |
| 95725 | CPT code added for ambulatory EEG (2020) |
| 90912 | Updated code (previous ambulatory EEG related) |
| 90913 | Updated code (previous ambulatory EEG related) |
| J80 | ICD-10 code added |
| J96.01 | ICD-10 code added |
| U07.1 | ICD-10 code added (COVID-19) |
| U07.2 | ICD-10 code added |
Provider Requirements and Actions
Obtain prior authorization when required
When required by the medical policy, providers must obtain prior authorization before providing services.
Step therapy not specified in this announcement
No step therapy requirements are specified in this announcement; individual policy pages may contain such requirements.
Follow member EOC/COI for benefits and eligibility
Follow the member's Evidence of Coverage (EOC) or Certificate of Insurance (COI) for benefits, eligibility, exclusions and limits; if the benefits contract conflicts with medical policy, the benefits contract applies. Apply Medicare or Medi‑Cal guidance where specified.
- EOC/COI defines member benefits, eligibility, exclusions and limits.
- If conflicts exist between medical policy and member benefits, the benefits contract governs.
- For Medicare Advantage, apply Medicare national/local policies; for Medi‑Cal, apply Medi‑Cal coverage guidelines first.
Prior authorization required when indicated
If prior authorization is required by the applicable medical policy, providers must obtain it before services are rendered.
Background and Scope
This announcement summarizes new and updated medical policies approved in Q2 2020 and provides high-level guidance on medical necessity criteria, indications, and coding changes across multiple clinical topics. New policies announced include Burn Surgery, Pediatric Oral Function Therapy, Radiofrequency Ablation of Uterine Fibroids (investigational), and Skin Substitutes for Chronic Wounds. The update also notes multiple revisions to existing policies with added or revised clinical criteria and coding updates; providers should consult each policy page on the provider website for the complete medical necessity criteria, contraindications, and code lists.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.