National Medical Policy

Subject:

Post Traumatic Stress Disorder (PTSD)

Clinical Practice Guideline

Policy Number:

NMP473

Effective Date*: February 2007

Updated:

February 2009, February 2011, February 2013

This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE
at the end of this document

DIAGNOSTIC CONSIDERATIONS1
It has long been recognized that some individuals who are exposed to traumatic events will
go on to develop emotional and behavioral problems. However, while it is estimated that
the majority of the population are exposed to traumatic events during their lifetimes, most
do not develop PTSD, which has an estimated lifetime prevalence of 7.8% (roughly 5% for
men, 4% for boys, 10% for women, 7% for girls)2,10. It is not known why most people who
develop an Acute Stress Disorder (ASD), a self-limited condition lasting no longer than 30
days immediately following the event, do not go on to have PTSD. Nor is it known why
people who do not develop ASD go on to develop PTSD. PTSD is defined by a duration of
symptoms beyond 30 days and the onset is 30 or more days after the trauma. It is known
that those more likely to develop PTSD have often experienced one of the following:
Childhood neglect
Assault, abuse, or catastrophe at a young age
Being younger than 10 years old at the time of a parental divorce
Lack of social support system
Strong family history of mental illness
In addition, we know that there is a strong genetic pre-disposition from twin studies and
from genetic mapping studies13.
The patient with PTSD can present to the clinician at any time from a month to several
years after the event. The patient may present to a behavioral health clinician complaining
of classical symptoms of PTSD or symptoms of another psychiatric disorder. Co morbidity is
the rule rather than the exception.10 The patient may present to any health care setting.
The chief complaint is as likely to be a physical as it is to be emotional. Some patients may
openly discuss the traumatic event at the first visit. Others, possibly due to survivor guilt or
emotional numbing, may never mention the trauma unless an effort is made to elicit it.

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Given the wide variation of patient presentations and therapeutic settings, as well as the
high lifetime prevalence of this disorder, it is important that all health care professionals
keep PTSD in mind even when the initial diagnosis appears to be something else.
Types

of Extreme Stressors That Cause PTSD3

Motor Vehicle accident
Occupational accident
Natural disaster
Terrorist attack
Criminal assault, including domestic violence
Serving in an active military combat theater
Sexual assault
Child physical/sexual abuse or severe neglect
Hostage/imprisonment/torture
Witnessing a traumatic event
Living through a close friend or family members serious injury or medical illness
On occasion, even just hearing about severe traumatic events may precipitate PTSD
symptoms; this method of PTSD development may be more commonly associated
with impaired ego boundaries

Description of the Stressor 1,3

The disorder develops after the individual is involved in or hears about a stressor
that is overwhelming enough to impact almost anyone. The stressor must be
perceived as extreme, such as
Actual or threatened death of self or others
Actual or threatened serious injury of self or others
Actual or threatened rape of self or others
Other threat to the physical integrity of self or others
Diagnosis of PTSD 1,4
The individual was exposed to a traumatic event as described above
The individuals response involved a sense of
Intense fear
Helplessness
Horror
Disorganized or agitated behavior (especially in children)
The traumatic event is re-experienced in one or more of the following ways
Recurrent, intrusive and distressing recollections of the event
o In young children, this may be reflected by repetitive play in which
themes or aspects of the trauma are expressed
Recurrent distressing dreams of the event
o Nonspecific recurring nightmares in children
Acting or feeling as if the event were recurring, which can include dissociative
flashbacks, hallucinations or a sense of reliving the experience
o In young children, trauma-specific reenactment may occur
Exaggerated emotional and physical reactions to triggers that remind the
person of the trauma
Persistent avoidance of stimuli and/or numbing associated with the trauma in 3 of
the following ways (Note that many feel that these criteria may be too restrictive for

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the diagnosis in children; because of this, some have suggested a loosening of the
following requirements in children):
Efforts to avoid thoughts, feelings or conversations related to the trauma
Efforts to avoid activities, places or people that cause recollections of the
trauma
Inability to recall important aspects of the trauma (dissociative amnesia)
Numbing of general responsiveness that was not present before the trauma
Feeling detached or estranged from others
Markedly diminished interest or participation in significant activities
Restricted emotions, such as inability to experience loving feelings
Sense of a foreshortened or empty future

Persistent increased arousal that was not present before the trauma as
demonstrated by 2 of the following:
Difficulty sleeping
Irritability or angry outbursts
Difficulty concentrating
Hypervigilance
Exaggerated startle response

Children are likely to demonstrate some of the following symptoms:

Social withdrawal and/or want to be alone
Loss of interest
Return to babyish behavior
Attention/concentration problems
Clinging, dependent behavior
Fearfulness, esp. at night
Distressing Dreams
Bed wetting
Tantrums
Poor performance in school/home
May re-enact events without anxiety relief
Somatic Complaints

Initial Assessment
Patients who present within hours or days after an acute trauma need to have their
medical, psychological, physical and emotional safety, housing, food, clothing and
social support concerns addressed first.
The appropriate setting depends on the nature of the trauma and available resources
(motor vehicle accident versus large scale natural disaster).
Respond to individual needs and capabilities as premature exploration of recent lifethreatening event can cause some persons to avoid needed medical care, whereas
others find it helpful
When the individual can tolerate a more extensive evaluation, obtain a full
psychiatric history including a detailed history of the exposure and the patients early
responses 5
Collect a history of all salient prior traumas, including patients age at the time and
the duration of the trauma
Consider augmenting the clinical interview with a validated, self-rated measure such
as the PCL-C (www.isu.edu/~bhstamm/tests.htm) or others as noted at the end of
this document6.

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Assess for:
Symptoms of PTSD
Safety, including risk of harm to self or others 7
Level of functioning, including self-care, occupational/educational and
interpersonal
Comorbid physical or psychiatric disorders, such as depression, substance use
and sexually transmitted diseases in rape victims
Personal characteristics such as usual coping skills, resilience and ability to
relate/attach to others
Behavioral risks such as impulsivity
Military experiences
Current stressors such as poverty legal system involvement
Current psychosocial situation, such as employment status, exposure to ongoing
violence, parenting or caregiver responsibilities

Most

Common Co-morbid Psychiatric Conditions in Patients with PTSD

Alcohol Abuse/Dependency
Depression
Substance Abuse/Dependency
Social Phobia
Generalized Anxiety Disorder
Mania
Panic Disorder

Most

Common Co-morbid Medical Conditions in Patients with PTSD

Respiratory
Dermatologic
Nervous system
Musculoskeletal
Gastrointestinal
Circulatory
Genitourinary
Infectious (STDs, in rape victims)
It is also important to realize that there are several physiological factors present that
may pre-dispose individuals with PTSD to a greater likelihood of developing medical
problems or of being more sensitive to pain.
TREATMENT INTERVENTIONS

4,8

Establish and maintain a therapeutic alliance

Evaluate/treat patient sensitively, in a safe environment
If appropriate or required by law, engage law enforcement or social service agencies
to address the patients safety (e.g., domestic, child or elder abuse)
Acknowledge the patients fears about reexposure to intolerable memories
Avoid patronizing statements or statements suggestive of an understanding of how
terrible things must have been unless you have experienced a very similar situation
Understand the treatment itself may be perceived as threatening or intrusive
Address the patients concerns and treatment preferences
Establish a plan for crisis management

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Understand the importance of age, gender, social, ethnic and cultural factors and
how these may influence symptom development as well as treatment adherence and
response

Goals of Treatment
Reducing the severity of symptoms
Preventing or treating trauma-related comorbid conditions that may be present or
emerge
Improving adaptive functioning and restoring a sense of safety and trust
Limiting the generalization of the danger experienced as a result of the traumatic
situation
Protecting against relapse of PTSD
Recognizing that the Medical and Psychological Co-Morbidities are significantly
impacted by the presence of PTSD and should be addressed concurrently.
Level of Care
PTSD is generally treated in an outpatient setting
The PIE approach to treatment (proximity to the front, immediacy of
treatment, expectation of recovery) was a major innovation of WWI and
WWII. It was never more than moderately successful during those wars.
An inpatient setting may be required if the patient is a danger to self or others
A substance use disorder setting may be needed if there is a comorbid chemical
dependency diagnosis, whether it preceded or followed the traumatic event 9
Level of care/treatment setting should be re-evaluated on an ongoing basis
Risk assessment should be performed on an ongoing basis
Treatment Strategy
The four basic elements of effective treatment are
Psychotherapy
Pharmacotherapy
Education and support
Coordination of care among all behavioral and medical treatment providers
If symptoms/impairments are mild to moderate and there is no cormorbid psychiatric
condition, consider a course of symptom-focused psychotherapy
If symptoms/impairments are moderate to severe, consider a combination of
medication and psychotherapy
Co-morbid disorders should be treated concurrently with the more life threatening
situations being given priority.
Initial Treatment Strategy
Relocation away from or mitigation of the current stressor to provide a sense of
immediate safety
o Immediately after a trauma, individuals may be suggestible and unusually
reactive: they may be very responsive to the emotional tone of helpers or
they may be very reactive to real or fantasized realities, such as rumors.
o Expressions of distress are often appropriate at this stage, and one should be
very careful not to classify them as symptoms' in the sense of being
indicative of a mental disorder. The appropriateness and the productiveness'
of the early response are more important indicators of disorder than the
intensity of the response.22

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Psychotherapy
Cognitive behavior therapy (CBT) has the greatest amount of empirical support
regarding the psychotherapeutic technique in treating the core symptoms of PTSD.
It may include the following approaches:
Targeting the distorted threat appraisal process to desensitize the patient to
trauma related triggers
Repeated cognitive imaging, virtual or actual re-exposure to the trauma/trigger.
The degree of threat exposure would be slowly advanced as dictated by the
tolerance and symptoms of the patient
May be augmented with relaxation training, breathing exercises and other selfsoothing techniques
Homework assignments so the patient can practice new skills outside of sessions
Also effective in treating comorbid depression and anxiety disorders
There is some evidence that the use of CBT given over a few sessions beginning
2-3 weeks after trauma exposure may speed recovery and prevent PTSD
Eye movement desensitization and reprocessing (EMDR) may be helpful as an
augmentation strategy with CBT, however there is no evidence that EMDR has
efficacy as a preventive intervention for PTSD
Long term studies are lacking though short term efficacy appears to be
supported in studies
Critical Incident Stress Management studies have demonstrated limited effects.
More benefit has been demonstrated with early efforts to engage (the patients
identified) community support and to address immediate needs of the patient14,15.
Recent studies have suggested that a change in therapeutic paradigm might be of
advantage; instead of teaching adaptation or interpretation mechanisms, the use of
therapeutic alone or in combination with pharmacologic methods to help extinguish
reactions and catastrophic memories may be of benefit23,24.
Psychopharmacology
There is some evidence that the use of propanolol shortly after exposure to the
triggering event (within 2 weeks) may lessen the severity or likelihood of the
development of PTSD.12,24
SSRIs are recommended as first-line medication treatment for PTSD (FDA approved
agents include sertraline and paroxetine but all are likely to be effective) because
they:
Ameliorate all three PTSD symptoms clusters (re-experiencing,
avoidance/numbing and hyperarousal)
Are effective treatments for psychiatric disorders that are frequently comorbid
with PTSD
May reduce symptoms that often complicate the management of PTSD, such as
suicidal, impulsive and aggressive behaviors
Note that the dosing must often start lower and may end up higher than typical
dosing regimens for the treatment of depression as individuals with PTSD may be
particularly sensitive to a worsening of anxiety early in treatment with rapid
titration
There is some evidence that tricyclic anti-depressants, SNRIs, and MAOIs may
also be effective.
Recently, it has been suggested that agents which can enhance the production of
Brain Derived Neurotrophic Factor (BDNF) may help prevent the progression of
PTSD and they may help to alleviate symptoms25
Benzodiazepines may be useful in reducing anxiety and improving sleep

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One must carefully weigh the risks and benefits of using these agents in
individuals with a history of substance abuse disorder and then one must closely
monitor their use thereafter
Worsening of symptoms upon discontinuation of these medications has been
reported
These agents do not address the core symptoms of PTSD but they can effectively
help to manage associated anxiety symptoms
These agents may also help to alleviate nightmares
Anticonvulsant agents (carbamazepine, valproic acid/divalproate, and lamotrigine)
have associated small but successful trials. A modest increase in BDNF levels has
been demonstrated with Valproic Acid and with Carbamazepine27
Atypical antipsychotics may be helpful for individual patients or when first-line
approaches have not been effective and for whom there is evidence of locked in
thinking or in whom psychotic symptoms are present. In addition, they may be
helpful at decreasing aggression (controlled trials have been done with risperidone
and quetiapine).There is also some evidence to suggest that these agents may
enhance BDNF (see SSRI section)26
Prazosin, trazodone, & cyproheptadine have been used to effectively decrease
nightmares

Education and Support

Educate about the natural course of PTSD, as well as the broad range of normal
stress-related reactions
Clarify that symptoms may worsen by reexposure to traumatic stimuli,
perceptions of being in unsafe situations or remaining in abusive relationships
Consider providing ongoing education for individuals or groups whose occupation
involves likely exposure to traumatic events, such as military personnel, police,
firefighters, emergency medical responders and journalists
Educate about the treatment interventions and the time interval before
improvement may be noticed
Help the patient address issues that arise during treatment in the areas of family
and social relationships, living conditions, general health and
occupational/academic performance
Assess level of function on an ongoing basis
Improve medication adherence by emphasizing
When and how to take the medication
The necessity to take the medication even after feeling better
The need to consult with the physician before changing or stopping the
medication
Steps to take if problems or questions arise
Approaches for Patients Who Do Not Respond to Initial Treatment
Review the initial treatment plan, including its goals and rationale
Review the patients perceptions of the effects of treatment
Review the patients understanding of and adherence to treatment
Review the patients reasons for nonadherence if this is a factor
Review for the presence of a comorbid psychiatric or medical condition that has
emerged since treatment began, or was missed initially
Review the possibility of underlying personality disorders or traits that may be
interfering with treatment
If psychotherapy alone has not been effective, consider adding a medication
If medication alone has not been effective, consider adding psychotherapy

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If a medication has been effective at reducing some but not all of the core symptoms
of PTSD, consider augmenting with a second medication targeting that/those
symptoms specifically
If an SSRI has not been effective at reducing core symptoms, consider switching to a
different SSRI, a tricyclic antidepressant or a monoamine oxidase inhibitor

Resources for Patients and Professionals

1.
Gift from Within (www.giftfromwithin.org ) founded by Frank M. Ochberg, MD,
primarily for patients
2.
National Center for PTSD (www.ncptsd.va.gov ) a VA website that includes an
Information Center with Fact Sheets and videos, resources for patients and
professionals
3.
Sidran (www.sidran.org ) with resources for patients and professionals
4.
Trauma Pages (www.trauma-pages.com), resources for patients and
professionals
5.
General Information from the National Institute of Mental Health:
http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorderptsd/index.shtml
6.
An interactive tutorial from the National Institute of Mental Health:
http://www.nlm.nih.gov/medlineplus/tutorials/ptsd/htm/index.htm
7.
From the United States Dept of Veterans Affairs:
http://www.ptsd.va.gov/public/index.asp
Resources for Professionals
1. PCL-C (www.isu.edu/~bhstamm/tests.htm).
2. American Psychiatric Association Practice Guidelines:
http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm
3. The National Center for PTSD
http://www.ncptsd.va.gov/ncmain/publications/publications/nchdouts_gp.jsp)United
States Department of Veterans Affairs National Center for PTSD:
http://www.ptsd.va.gov/index.asp
4. Common Tests and Screening Tools for PTSD:
a. Screening tools include:
b. Primary Care PTSD Screen
c. PTSD Symptom Scale Self-Report
d. Screen for Posttraumatic Stress Symptoms
e. Self-report screening instruments include:
f. Posttraumatic Diagnostic Scale
g. Davidson Trauma Scale
h. Detailed Assessment of Posttraumatic Stress
i. Structured or semi-structured interviews include:
j. Clinician-Administered PTSD Scale (CAPS)
k. Structured Clinical Interview for DSM-IV (SCID)
l. Diagnostic Interview Schedule for DSM-IV (DIS-IV)
m. PTSD Symptom ScaleInterview Version (PSS-I)
n. Structured Interview for PTSD (SIP)
o. Traumatic-event exposure instruments include:
p. Combat Exposure Scale
q. Deployment Risk and Resiliency Inventory
r. Vietnam Era Stress InventorySpecific Stressor Subscale
s. Womens Wartime Stressor Scale
t. Symptom severity instruments include:
u. PTSD Checklist (PCL)

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v. Impact of Events Scale-Revised

w. Mississippi Scale for Combat-related PTSD
x. Los Angeles Symptom Checklist
Review History
MHN Clinical Policy Committee
National Medical Advisory Council
MHN Clinical Policy Committee
National Medical Advisory Council
MHN Clinical Leadership Committee
National Medical Advisory Council
MHN Clinical Leadership Committee
National Medical Advisory Council

February 13, 2007

March, 2007
February 10, 2009
March 2009
February 3, 2011
February 9, 2011
December 2012
February 2013

References
1.
American Psychiatric Association (2000), Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition, Text Revision. Washington, D.C., American
Psychiatric Association Press.
2.
Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB: Post-traumatic stress
disorder in the National Comorbidity Survey: Archives of General Psychiatry
1995, Vol. 5: 10048-1060
3.
The Expert Consensus Guideline Series (1999): Treatment of Posttraumatic
Stress Disorder. Journal of Clinical Psychiatry, Vol. 40, Supplement 16.
4.
American Psychiatric Association (2004), Practice Guideline for the Treatment of
Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. American
Journal of Psychiatry, Vol. 161, No. 11
5.
American Psychiatric Association (2006), Practice Guideline for Psychiatric
Evaluation of Adults, 2nd Edition. American Journal of Psychiatry, Vol. 163, No. 6
6.
Weathers FW, Litz BT, Huska J, Keane TM: PTSD Checklist (PCL) for DSM-IV.
Boston National Center for PRSD, Behavioral Science Division, 1994.
7.
American Psychiatric Association (2003), Practice Guideline for the Assessment
and Treatment of Patients with Suicidal Behaviors. American Journal of
Psychiatry, Vo. 160, No. 11
8.
American Psychiatric Press (2004). Treating Patients with Acute Stress Disorder
and Posttraumatic Stress Disorder: A Quick Reference Guide. Washington D.C.,
American Psychiatric Association Press.
9.
American Psychiatric Association (2006). Practice Guideline for the Treatment of
Patients with Substance Use Disorders, 2nd Edition. American Journal of
Psychiatry, Vo. 163, No. 8.
10.
Kessler, R.C. (2000). J Clin Psychiatry. 2000;61 Suppl 5:4-12; discussion 13-4.
11.
Barrett, D.H., Doebbeling, C.C., Schwartz, D.A., Voelker, M.D., Falter, K.H.,
Woolson, R.F., & Doebbeling, B.N. (2002). Posttraumatic stress disorder and selfreported physical health status among U.S. military personnel serving during the
Gulf War period. Psychosomatics, 43, 195-205.
12.
Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of secondary prevention of
posttraumatic stress disorder with propranolol. Biol Psychiatry. Jan 15
2002;51(2):189-192.
13.
Binder EB, Bradley RG, Liu W, et al (2008). "Association of FKBP5 polymorphisms
and childhood abuse with risk of posttraumatic stress disorder symptoms in
adults". JAMA 299 (11): 1291305.

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Carlier, IVE; Lamberts RD; van Uchelen AJ; Gersons BPR (1998). "Disasterrelated post-traumatic stress in police officers: A field study of the impact of
debriefing". Stress Medicine 14 (3): 1438.
Mayou RA, Ehlers A, Hobbs M (2000). "Psychological debriefing for road traffic
accident victims. Three-year follow-up of a randomized controlled trial". Br J
Psychiatry 176: 58993.
Yehuda R (2001). "Biology of posttraumatic stress disorder". J Clin Psychiatry 62
Suppl 17: 416.
Carlson, Neil R. (2007). Physiology of Behavior (9 ed.). Pearson Education, Inc.
Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild Traumatic
Brain Injury is U.S. Soldiers Returning from Iraq.(2008) NEJM 358:453-463.
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat
Duty is Iraq and Afghanistan, Mental Health Problems, and Barriers to Care
(2004). NEJM 351:2=12-22.
Bayer CP, Klassen F, Adam H. Association of Trauma and PTSD Symptoms with
Openness to Reconciliation and Feelings of Revenge Among Former Ugandan and
Congolese Child Soldiers (2007). JAMA 298:555-559
Smith p, Yule W, Perrin S, Tranah T, Dalgleish T, Clark DM. Cognitive-Behavioral
Therapy for PTSD in Children and Adolescents: A preliminary Randomized
Controlled Trial (2007), J Am Acad Child & Adolescent Psychiatry 46: 1051-1061.
http://www.ptsd.va.gov/professional/pages/survivors-aftermath-trauma.asp,
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Schiller D, Monfils MH, Raio CM, Johnson DC, Ledoux JE, Phelps EA, Nature. 2010
Jan 7;463(7277):49-53. Epub 2009 Dec 9; Preventing the return of fear in
humans using reconsolidation update mechanisms.
Brunet A, Orr SP, Tremblay J, Robertson K, Nader K, Pitman RK; J Psychiatr Res.
2008 May;42(6):503-6. Epub 2007 Jun 22. Effect of post-retrieval propranolol on
psychophysiologic responding during subsequent script-driven traumatic imagery
in post-traumatic stress disorder.
Bergera , William, Mehraa , Akhil, et. Al., Neuro-Psychopharmacology and
Biological Psychiatry; Serum brain-derived neurotrophic factor predicts responses
to escitalopram in chronic posttraumatic stress disorder; Volume 34, Issue 7, 1
October 2010, Pages 1279-1284.
Gewirtz, Jonathan C, Chena, Andrew C, et. Al., Pharmacology Biochemistry and
Behavior, Modulation of DOI-induced increases in cortical BDNF expression by
group II mGlu receptors; Volume 73, Issue 2, September 2002, Pages 317-326.
Bennett, G.D., Wlodarczyk, B, et. Al., Reproductive Toxicology, Valproic acidinduced alterations in growth and neurotrophic factor, Volume 14, Issue 1,
January-February 2000, Pages 1-11
Fukuchi, M, Nii, T, et. Al., Neuroscience Research, Valproic acid induces up- or
down-regulation of gene expression responsible for the neuronal excitation and
inhibition in rat cortical neurons through its epigenetic actions, Volume 65, Issue
1, September 2009, Pages 35-43.
Important Notice

General Purpose.
Health Nets National Medical Policies (the Policies) are developed to assist Health Net in
administering plan benefits and determining whether a particular procedure, drug, service or supply is
medically necessary. The Policies are based upon a review of the available clinical information
including clinical outcome studies in the peer-reviewed published medical literature, regulatory status
of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based
guidelines and positions of select national health professional organizations. Coverage determinations

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are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and
exclusions of the members contract, including medical necessity requirements. Health Net may use
the Policies to determine whether under the facts and circumstances of a particular case, the proposed
procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug,
service or supply is medically necessary does not constitute coverage. The members contract defines
which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps.
Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date
determined by Health Net. For information regarding the effective dates of Policies, contact your
provider representative. The Policies do not include definitions. All terms are defined by Health Net.
For information regarding the definitions of terms used in the Policies, contact your provider
representative.
Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members.
No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to
members. Members should consult with their treating physician in connection with diagnosis and
treatment decisions.
No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug,
service or supply. Members and providers should refer to the Member contract to determine if
exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply.
Policy Limitation: Members Contract Controls Coverage Determinations.
The determination of coverage for a particular procedure, drug, service or supply is not based upon
the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the
members contract, and requirements of applicable laws and regulations. The contract language
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conflicts with the Policies, the Members contract shall govern. Coverage decisions are the result of the
terms and conditions of the Members benefit contract. The Policies do not replace or amend the
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Members contract shall govern.
Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service or supply is subject to
applicable legal and regulatory mandates and requirements. If there is a discrepancy between the
Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall
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Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits
and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid
members shall not be construed to apply to any other Health Net plans and members. The Policies
shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and
regulation.

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