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Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.

The policies do not mean approval or guarantee of coverage for any specific procedure, drug, service, or supply. Members and providers should refer to the member contract for specific information. They can find out if any exclusions, limitations or dollar limits apply to a particular procedure, drug, service, or supply. If there are any conflicts between clinical policy guidelines and applicable contract language, the contract language takes precedence. A clinical policy is not intended to override the policy that defines the member's benefits. Additionally, clinical policies do not dictate to providers how to practice medicine. The health plan reserves the right to amend its clinical policies without notice to providers or members.

Note for Medicaid and Medi-Cal members: When state Medicaid or Medi-Cal coverage provisions conflict with the coverage provisions in a clinical policy, state Medicaid or Medi-Cal coverage provisions take precedence. Please refer to the state Medicaid or Medi-Cal manual for any coverage provisions before applying these clinical policies.

Policies in the California Health & Wellness Clinical Policy Manual may have either a California Health & Wellness or a “Centene” heading.  California Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a California Health & Wellness clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling California Health & Wellness. In addition, California Health & Wellness may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by California Health & Wellness.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-F G-O P-Z
Acupuncture (PDF)
Effective Date: Dec 2013
Gastric Electrical Stimulation (PDF)
Effective Date: Sep 2009
Pancreas Transplantation (PDF)
Effective Date: Feb 2016
ADHD Assessment and Testing (PDF)
Effective Date: Aug 2016
Gender Affirming Procedures (PDF)
Effective Date: Jun 2017
Panniculectomy (PDF)
Effective Date: Apr 2016
Air Ambulance (PDF)
Effective Date: Aug 2020
Genetic Testing and Pharmacogenetic Testing (PDF)
Effective Date: Nov 2013
Pediatric Heart Transplant (PDF)
Effective Date: Dec 2016
Allergy Testing and Therapy (PDF)
Effective Date: Feb 2016
Heart-Lung Transplant (PDF)
Effective Date: Jun 2017
Pediatric Heart Transplant (PDF)
Effective Date: Dec 2016
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and B-Thalassemia (PDF)
Effective Date: Mar 2016
Helicobacter Pylori Serology Testing (PDF)
Effective Date: 9/14/2018
Pediatric Liver Transplant (PDF)
Effective Date: Feb 2018
Ambulatory Electroencephalography (EEG) (PDF)
Effective Date: Sep 2015
Holter Monitor (PDF)
Effective Date: Aug 2016
Pediatric Oral Function Therapy (PDF)
Effective Date: Jun 2020
Ambulatory Surgery Center Optimization (PDF)
Effective Date: Jan 2018
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)
Effective Date: Dec 2017
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
Effective Date: Jun 2017
Antithrombin III (PDF)
Effective Date: Nov 2019
Homocysteine Testing (PDF)
Effective Date: Jul 2016
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
Effective Date: Sep 2020
Applied Behavioral Analysis for Autism (PDF)
Effective Date: Aug 2009
Hospice Care (PDF)
Effective Care: Jul 2014

Posterior Nerve Stimulation for Voiding Dysfunction (PDF)
Effective Date: Oct 2016

Articular Cartilage Defect Repairs (PDF)
Effective Date: Oct 2008
Hyperemesis Gravidarum Treatment (PDF)
Effective Date: Mar 2009
Proton and Neutron Beam Therapy (PDF)
Effective Date: Mar 2014
Autism Diagnosis and Treatment (PDF)
Effecitive: November 2018
Hyperhidrosis Treatments (PDF)
Effective Date: Apr 2013
Radial Head Implant (PDF)
Effective Date: Jul 2017
Assisted Reproductive Technology (PDF)
Effective Date: Mar 2014
Implantable Hypoglossal Nerve Stimulation (PDF)
Effective Date: Nov 2019
Radiofrequency Ablation of Uterine Fibroids (PDF)
Effective Date: May 2020

Balloon Sinus Ostial Dilation (PDF)
Effective Date: Nov 2016

Implantable Intrathecal Pain Pump (PDF)
Effective Date: Feb 2019
Reduction Mammoplasty & Gynecomastia Surgery (PDF)
Effective Date: Aug 2012
Bariatric Surgery (PDF)
Effective Date: June 2009
Implantable Wireless PAP Monitoring (PDF)
Effective Date: Apr 2018

Sacroiliac Joint Fusion (PDF)
Effective Date: Sep 2016

Biofeedback (PDF)
Effective Date: Jun 2019
Inhaled Nitric Oxide (PDF)
Effective Date: Apr 2013

Sacroiliac Joint Interventions for Pain Management (PDF)
Effective Date: Aug 2018

Bone Anchored Hearing Aids (PDF)
Effective Date: Dec 2015

Intensity- Modulated Radiography (PDF)
Effective Date: Feb 2014

Sclerotherapy for Varicose Veins (PDF)
Effective Date: May 2017

Bronchial Thermoplasty (PDF)
Effective Date: Apr 2016

Intestinal and Multivisceral Transplant (PDF)
Effective Date: Feb 2014

Selective Dorsal Rhizotomy for Spasticity in Cerberal Palsy (PDF)

Effective Date: Mar 2019

Burn Surgery (PDF)
Effective Date Jun 2020

Intradiscal Steroid Injections for Paint Management (PDF)
Effective Date: Aug 2018

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
Effective Date: Aug 2018

Cardiac Biomarker Testing for Acute Myocardial Infarction (PDF)

Effective Date: Sep 2018

Laser Therapy for Skin Diseases (PDF)
Effective Date: Jul 2016

Sickle Cell Observation (PDF)
Effective Date: Sep 2013

Cardiac Risk Assessment Lab Tests (PDF)
Effecitve Date: Sep 2018
Long Term Care (PDF)
Effective Date: May 2014

Skin Substitutes for Chronic Wounds (PDF)

Effective Date: May 2020

Carrier Screening in Pregnancy (PDF)
Effective Date: Jul 2013
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)
Effective Date: Jan 2017

Spinal Cord Stimulation (PDF)
Effective Date: Jul 2016

Caudal or Interlaminar Epidural Steroid Injections (PDF)
Effective Date: Aug 2018
Lung Transplantation (PDF)
Effective Date: Jan 2014
Stereotactic Body Radiation Therapy (PDF)
Effective Date: May 2013
Cell-free Fetal DNA Testing (PDF)
Effective Date: Jul 2013
Lysis of Epidural Lesions (PDF)
Effective Date: Jul 2016
Tandem Transplant (PDF)
Effective Date: Jul 2018
Clinical Trials (PDF)
Effective Date: Jan 2014
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: Sep 2018
Testing for Rupture of Membranes (PDF)
Effective Date: Aug 2017
Cochlear Implant Replacements (PDF)
Effective Date: Feb 2009
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
Effective Date: Apr 2017
Testing for Select Genitourinary Conditions (PDF)
Effective Date: Jun 2016
Coverage of Experiemental Technologies (PDF)
Effective Date: Sep 2015
Medical Necessity Criteria (PDF)
Effective Date: Jun 2013
Therapy Services (PT OT ST) (PDF)
Effective Date: Apr 2011
Cystic Fibrosis Carrier Screening (PDF)
Effective Date: Jul 2013
Multiple Sleep Latency Testing (PDF)
Effective Date: Oct 2008
Thymus Transplantation (PDF)
Effective Date: Jun 2020
Dental Anesthesia (PDF)
Effective Date: Sep 2013
Neonatal Abstinence Syndrome Guidelines (PDF)
Effective Date: Oct 2013
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: Sep 2018
Digital EEG Spike Analysis (PDF)
Effective Date: Jan 2016
Neonatal Intensive Care Unit (NICU) Guidelines (PDF)
Effective Date: Jun 2013
Total Artificial Heart (PDF)
Effective Date: Sep 2016
Disc Decompression Procedures (PDF)
Effective Date: Jul 2016
Neonatal Sepsis Management (PDF)
Effective Date: Aug 2013
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Effective Date: May 2016
Discography (PDF)
Effective Date: Aug 2016
Nerve Blocks for Pain Management (PDF)
Effective: Aug 2018
Transcatheter Closure of Patent Foramen Ovale (PDF)
Effective Date: Dec 2018
Durable Medical Equipment (PDF)
Effective Date: Jun 2009
Neurofeedback (PDF)
Effective Date: Jan 2019
Transcranial Magnetic Stimulation (PDF)
Effective Date: Aug 2020
DNA Analysis of Stool (PDF)
Effective Date: Sep 2016
NICU Apnea Bradycardia Guidelines (PDF)
Effective Date: Jun 2013
Trigger Point Injections for Pain Management (PDF)
Effective Date: Aug 2018
Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Stem Cell Transplantation (PDF)
Effective Date: Nov 2015
Non-Invasive Home Ventilator (PDF)
Effetive Date: May 20
Ultrasound in Pregnancy Medi-Cal (PDF)
Effective Date: Apr 2017
EEG in the Evaluation of Headache
Effective Date: Sep 2018
Non-Myeoablative Allogeneic Stem Cell Transplants (PDF)
Effective Date: Mar 2017
Urinary Incontinence Devices and Treatments (PDF)
Effective Date: Apr 2017
Electric Tumor Treating Fields (PDF)
Effective Date: Apr 2017
Obstetrical Home Health Programs (PDF)
Effective Date: Jan 2014
Urodynamic Testing (PDF)
Effective Date: Oct 2015
Endometrial Ablation (PDF)
Effective Date: Feb 2016
Optic Nerve Decompression Surgery (PDF)
Effective Date: Sep 2016
Vagus Nerve Stimulation (PDF)
Effective Date: Sep 2013
Essure Removal (PDF) 
Effective Date: Nov 2016
Outpatient Cardiac Rehabilitation (PDF)
Effective Date: May 2019
Ventricular Assist Devices (VAD) (PDF)
Effective Date: Dec 2009
Evoked Potential Testing (PDF)
Effective Date: Jan 2017
Outpatient Tresting for Drugs of Abuse (PDF)
Effective Date: Sep 2012
Ventriculectomy & Cardiomyplasty (PDF) 
Effective Date: May 2013
Facet Joint Interventions (PDF)
Effective Date: Sept 2018
Oxygen Use and Concentrators (PDF)
Effective Date: Sep 2020
Video EEG (PDF)
Effective Date: Nov 2018
Fecal Incontinence Treatments (PDF)
Effective Date: Dec 2016
  Wheelchair Seating (PDF)
Effective Date: Oct 2015
Ferriscan (PDF)
Effective Date: Jan 2019
  Wireless Motility Capsule (PDF)
Effective Date: Apr 2017
Fetal Surgery in Utero for Prenatally Diagnosed Malformation (PDF)
Effective Date: Nov 2018
  25-hydroxyvitamin D Testing in Children and Adolescents (PDF)
Effective Date: Sept 2018
Fertility Preservation (PDF)
Effective Date: Sep 2016
   
Fractional Exhaled Nitric Oxide (PDF)
Effective Date: Dec 2015
   
Functional MRI (PDF)
Effective Date: Sep 2009
   

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the California Health & Wellness Payment Policy Manual apply with respect to California Health & Wellness members. Policies in the California Health & Wellness Payment Policy Manual may have either a California Health & Wellness or a “Centene” heading.  In addition, California Health & Wellness may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by California Health & Wellness.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-L M-Q R-Z
3 Day Payment Window (PDF)
Effective Date: 3/1/18
Maximum Units (PDF)
Effective Date: 6/14/19
Robotic Surgery (PDF)
Effective Date: 4/21/17
30 Day Readmission (PDF)
Effective Date: 11/1/19
Maximum Units of Service (PDF)
Effective Date: 7/5/19
Same Day Visit as Surgery (PDF)
Effective Date: 3/1/18
Add on Code Billed Without Primary Code (PDF)
Effective Date: 2/24/18
Moderate Conscious Sedation (PDF)
Effective Date: 3/5/18
Sleep Studies Place of Service (PDF)
Effective Date: 5/1/17
Assistant Surgeon (PDF)
Effective Date: 3/1/18
Modifier -25 Clinical Validation (PDF) 
Effective Date: 2/24/18
Status "B" Bundle Services (PDF)
Effective Date: 3/10/18
Bilateral Procedures (PDF)
Effective Date: 5/11/18
Modifier -59 Clinical Validation (PDF)
Effective Date: 2/24/18
Status P Bundle Services (PDF)
Effective Date: 4/27/17
CA-Digital Breast Tomosynthesis (PDF)  Effective Date: 6/1/2017 Modifier DOS Validation (PDF)
Effective Date: 2/24/18
Supplies Billed on Same Day Surgery (PDF)
Effective Date: 2/28/18
Cerumen Removal (PDF)
Effective Date: 2/28/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 2/23/18
Transgender Related Services (PDF)
Effective Date: 2/15/18
Clean Claims (PDF)
Effective Date: 6/9/18
Multiple CPT Code Replacement (PDF)
Effective Date: 2/28/18
Unbundled Professional Services (PDF)
Effective Date: 3/1/18
Coding Overview (PDF)
Effective Date: 6/9/18
NCCI Unbundling (PDF)
Effective Date: 9/9/16
Unbundled Surgical Procedures (PDF)
Effective Date: 3/1/18
Cosmetic Procedures (PDF)
Effective Date: 6/20/18
Never Paid Events (PDF)
Effective Date: 3/5/18
Unlisted Procedure Codes (PDF)
Effective Date: 2/24/18
Distinct Procedural Modifers (PDF)
Effective Date: 3/10/18
New Patient (PDF)
Effective Date: 3/10/18
Urine Specimen Validity Testing  (PDF)
Effective Date: 12/27/18
Duplicate Primary Code Billing (PDF)
Effective Date: 3/10/18
Outpatient Consultation (PDF)
Effective Date: 3/13/18
Wheelchair Accessories (PDF)
Effective Date: 3/1/18
E&M Medical Decision-Making (PDF)
Effective Date: 8/7/17
Physician's Consultation Services (PDF)
Effective Date: 5/16/18
 
EM Bundling: Labs & Radiology (PDF)
Effective Date: 2/24/18
Physician's Office Lab Testing (PDF)
Effective Date: 7/5/19
 
Global Maternity Billing (PDF)
Effective Date: 3/1/18
Place of Service Mismatch (PDF)
Effective Date: 12/27/18
 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 6/20/18
Post-Operative Visits (PDF)
Effective Date: 3/1/18
 
Inpatient Consultation (PDF)
Effective Date: 3/10/18
Pre-Operative Visits (PDF)
Effective Date: 3/1/18
 
Inpatient Only Procedures (PDF)
Effective Date: 1/1/18
Professional Component (PDF)
Effective Date: 6/28/18
 
IV Hydration (PDF)
Effective Date: 2/25/18
Pulse Oximetry (PDF)
Effective Date: 2/13/18
 
Leveling of Emergency Room Services (PDF)
Effective Date: 7/1/19
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 3/13/18