CommercialCoverageHigh impact
20-435 Medical Policies - 1st Quarter 2020
Health Net·CA · Orthopedics, Neurology, Pain Management +6 more·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health Net updated multiple medical policies for Q1 2020, including new COVID-19 testing guidelines, changes to prior authorization requirements for various procedures, and updates to coverage criteria for DME, nerve blocks, transplants, and other services. Most notably, several procedures were reclassified as not medically necessary or investigational, affecting billing and coverage.
Action Required
Immediately: Billing teams must update prior authorization requirements and coverage criteria for multiple procedures. Key changes include: 1) Stop billing E1399 for gait trainers and update criteria for wheelchair repairs using E1399, K0108, K0739; 2) Update coverage for cold pad pumps to 'not medically necessary'; 3) Mark CPT codes 0587T, 0588T, 0589T, 0590T as investigational for tibial nerve stimulation; 4) Flag CPT 64625 and 64451 as not medically necessary for sacroiliac joint interventions; 5) Remove CPT 38206 from transplant billing. Update billing system rules and train staff on new coverage criteria to prevent claim denials.