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Health NetMedicaid · Prior Auth · Prior Authorization · CA · Transplant Surgery, Wound Care, Pediatrics +4 moreMedium impact

25-1359m Updates to Clinical Policies - November 2025

Act
by Nov 1, 2025
Effective date
Nov 1, 2025
Identified
Jun 20, 2026

Summary

CalViva Health updated multiple clinical policies for November 2025, including changes to prior authorization requirements for electric tumor treating fields, sleep studies, mechanical stretching devices, pediatric oral function therapy, skin/tissue substitutes, and transplant documentation. Key changes include new coverage criteria, expanded code coverage, and updated documentation requirements.

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What to do

by Nov 1, 2025 · 5 steps
01Billing team must update prior authorization requirements for affected policies.
02Add new HCPCS codes E1820, E1828, E1829, E1830, E1832 to mechanical stretching device coverage criteria.
03Remove Q4104 and Q4106 from non-covered skin substitute codes list.
04Update skin substitute billing to reflect new 4-application initial limit with potential extension to 8 applications.
05Verify CalViva Health members meet updated criteria before submitting claims.

Codes mentioned

E1820E1828E1829E1830E1832A2036A2037A2038A2039Q4383Q4384Q4385Q4386Q4387Q4388Q4389Q4390Q4391Q4392Q4393Q4394Q4395Q4396Q4397Q4104Q4106

Original notice

25-1359m Updates to Clinical Policies - November 2025
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
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Related changes

See all Health Net changes →
25-1357m Updates to Clinical Policies - November 2025MediumEffective Nov 1, 2025 · Prior Authorization25-1358m Updates to Clinical Policies - November 2025MediumEffective Nov 1, 2025 · Prior Authorization20-947 Medical Policies - 3rd Quarter 2020MediumNo effective date · Prior Authorization20-944 Medical Policies - 3rd Quarter 2020MediumNo effective date · Prior AuthorizationBrowse every Health Net change in the policy list

Related policy hubs

Health Net policiesCA policy changesTransplant SurgeryWound CarePediatricsOncologyPhysical TherapyPM&R (Physical Medicine & Rehab)Sleep MedicineCode E1820Code E1828Code E1829Code E1830Code E1832Code A2036Code A2037Code A2038Code A2039Code Q4383Code Q4384Code Q4385Code Q4386Code Q4387Code Q4388Code Q4389Code Q4390Code Q4391Code Q4392Code Q4393Code Q4394Code Q4395Code Q4396Code Q4397Code Q4104Code Q4106

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