Medicare AdvantagePrior AuthHigh impact
21-141 Medical Policies - 4th Quarter 2020
Health Net·CA · Pulmonology, Allergy & Immunology, General Surgery +8 more·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, and wound care. Most changes involve revised medical necessity criteria and updated CPT/ICD-10 codes that require immediate attention for proper billing and authorization processes.
Action Required
Immediately: Billing team must review and update authorization workflows for oxygen therapy, allergy testing, bariatric surgery, wound care, and other affected services. Update billing system to reflect new CPT code requirements for ambulatory surgery center redirection. Remove HCPCS code Q4111 from wound care billing as it's now covered under different policy. Providers must update documentation requirements for oxygen concentrator reauthorizations to include 90-day physician evaluations or medical necessity letters. Update encounter forms and EMR templates to reflect new ICD-10 code additions and removals.