Health Net Coverage Criteria
Latest Health Net coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Disc Decompression ProceduresDefines medical necessity criteria and coding stance for open discectomy and microdiscectomy for symptomatic lumbar disc herniation and states which minimally invasive discectomy (MID) procedures are considered not proven superior / not supported.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Liposuction for LipedemaDefines medical necessity criteria and coding guidance for liposuction as a treatment for lipedema for Health Net (Centene-affiliated) health plans and applies to providers requesting coverage for this procedure.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Liposuction for LipedemaDefines medical necessity criteria and coding implications for liposuction as treatment for lipedema for Health Net / Centene-affiliated health plans and specifies when the procedure is not medically necessary.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Pediatric Oral Function TherapyDefines medical necessity criteria and continuation requirements for pediatric oral function therapy (feeding and swallowing treatment) for children, and outlines coding implications. Applies to Health Net/Centene-affiliated health plans.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Pediatric Oral Function TherapyDefines medical necessity criteria for initial and continued pediatric oral function therapy (feeding/swallowing therapy) for children and describes when services are covered by the Health Plan. Applies to pediatric members/enrollees receiving oral/feeding/swallowing treatment.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Implantable Hypoglossal Nerve Stimulation (PDF)Defines medical necessity criteria for implantable hypoglossal (upper airway) nerve stimulation systems (Inspire, Genio) for treatment of moderate to severe obstructive sleep apnea (OSA), device-specific eligibility, contraindications, and requirement that DISE is medically necessary when used to evaluate appropriateness.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Clinical Policy: Burn SurgeryMedical necessity criteria for surgical burn debridement/excision and use/application of skin replacements and skin substitutes in the acute phase of burn care for members/enrollees.All Health Net updates
- Coverage CriteriaEff. 2026-02-01Dental AnesthesiaMedical necessity guidelines for intravenous moderate sedation and deep sedation/general anesthesia for dental procedures in inpatient, ambulatory surgery center, community clinic or dental office settings; describes indications, required documentation, setting requirements, and referenced CPT/Dental codes for billing guidance.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Hyperhidrosis TreatmentsDefines medical necessity criteria for iontophoresis, surgical excision of axillary sweat glands, and endoscopic thoracic sympathectomy (ETS) for primary hyperhidrosis for Health Net/Centene-affiliated health plans and affected members/enrollees and providers.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Implantable Intrathecal or Epidural Pain PumpDefines medical necessity criteria, contraindications, and coding references for preliminary trial and permanent implantation of intrathecal or epidural drug delivery systems for chronic malignant and nonmalignant pain for Health Net members.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-16Asthma Remediation Community Support — Authorization and Coverage CriteriaGoverns authorization and provision of in‑home asthma remediation supplies and physical modifications for Medi‑Cal members in California, describing eligibility, required documentation, limits, and provider requirements for Health Net‑managed services.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Intestinal and Multivisceral TransplantMedical necessity criteria and coding guidance for isolated intestinal, combined intestinal-liver, and multivisceral transplantation for pediatric and adult members/enrollees with irreversible intestinal failure.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Pharmacy and specialty drug formulary — coverage criteria (partial list)Governs coverage, prior authorization (PA), quantity limits (QL), and medical necessity designations for pharmacy and specialty drugs; applies to prescribers and pharmacists processing Health Net member benefits.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-01Avutometinib; Defactinib (Avmapki Fakzynja Co-Pack) coverage criteriaDefines medical necessity criteria, prior authorization, and coverage parameters for the co-packaged combination of avutometinib and defactinib (Avmapki Fakzynja Co-Pack), primarily for KRAS‑mutated recurrent low-grade serous ovarian cancer; affects prescribers and payers reviewing initial and continuation requests.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-25Duobrii (halobetasol propionate/tazarotene) topical lotion — coverage criteriaPolicy governs medical necessity criteria, prior authorization, and coverage limits for Duobrii topical lotion for plaque psoriasis in adults across Health Net lines of business covered by this policy.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Desloratadine (Clarinex) and Desloratadine/Pseudoephedrine (Clarinex-D) prior authorizationThis policy governs prior authorization and coverage criteria for desloratadine (Clarinex) and desloratadine/pseudoephedrine (Clarinex-D 12 Hour) for commercial lines of business under Health Net/Centene Corporation.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-01Osteogenic StimulationMedical necessity criteria and coding guidance for invasive and noninvasive electrical bone growth stimulators and low-intensity pulsed ultrasound (LIPUS) to enhance fracture healing and spinal fusion; applies to Health Net / Centene-affiliated health plans and providers requesting coverage.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-03-01Dupilumab (Dupixent) coverage and medical necessity criteriaClinical policy governing medical necessity, prior authorization, dosing limits, and continuation criteria for dupilumab (Dupixent) for multiple FDA‑approved and selected off‑label indications for Health Net commercial lines of business in NC.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-03-01Eculizumab (Soliris) and biosimilars (Bkemv, Epysqli) — coverage criteriaPolicy governing medical necessity criteria, prior authorization, and continued use for eculizumab (Soliris) and biosimilars (Bkemv, Epijkstra) across covered lines of business; affects providers prescribing these agents for PNH, aHUS, gMG, NMOSD, and other indications for Health Net/Centene products.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-25Bosentan (Tracleer) — Clinical Coverage Criteria for Pulmonary Arterial HypertensionClinical coverage policy describing medical necessity criteria, contraindications, dosing, and authorization requirements for bosentan (Tracleer) for treatment of pulmonary arterial hypertension (PAH) for Health Net lines of business.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Asthma Remediation Community Support — Coverage CriteriaGoverns authorization, covered services, limits, and provider requirements for home-based asthma remediation supplies and physical modifications for Medi-Cal members in California (applies to Health Net/CalViva members).All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Asthma Remediation Community Support — Coverage CriteriaDefines Health Net's coverage, eligibility, and administrative requirements for in-home asthma remediation supplies and home modifications (Community Support) for Medi-Cal members in California, including limits and documentation needed for authorization.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-01Clinical Policy: Axatilimab-csfr (Niktimvo)Defines medical necessity criteria, dosing, and authorization requirements for Niktimvo for treatment of chronic graft-versus-host disease (cGVHD) after failure of prior systemic therapies for members covered by the payer.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-01Clinical Policy: Inavolisib (Itovebi)Defines medical necessity criteria, initial and continuation approval requirements, dosing limits, and coverage limitations for Inavolisib (Itovebi) in combination with palbociclib and fulvestrant for adults with PIK3CA-mutated, HR-positive, HER2-negative locally advanced or metastatic breast cancer; applies to Commercial, HIM, and Medicaid lines of business.All Health Net updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-01Clinical Policy: Lazertinib (Lazcluze)Clinical policy describing medical necessity criteria, dosing, and approval durations for lazertinib (Lazcluze) in combination with amivantamab for first-line treatment of adults with locally advanced or metastatic NSCLC with EGFR exon 19 deletions or exon 21 L858R substitution mutations; includes continuation criteria and references to off-label/non-formulary policies.All Health Net updates
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Tool Description
Search Health Net coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
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