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20-947 Medical Policies - 3rd Quarter 2020
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Medical policies approved in the third quarter of 2020 may apply to CalViva Health Medi-Cal members in Fresno, Kings and Madera counties where no California DHCS policy is available. New policies cover respiratory viral panel testing, thymus transplantation and related criteria, while updated policies change criteria for services such as trigger point injections (now a maximum of four per year, down from six), sacroiliac joint fusion, sacral nerve stimulation and mechanical stretching devices. Some codes were added, moved or removed, including L8613 (removed) and L8692 (added) for bone-anchored hearing aids.
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What to do
Action · 5 steps
01If required, get prior authorization before the services are given.
02For Medi-Cal members, apply the appropriate coverage guidelines first, because they take precedence over these plan policies.
03Review the changed criteria before billing these services, including: trigger point injections, which have a maximum of four per year; sacroiliac joint fusion, which is investigational for all other indications; air ambulance transport, which is not considered medically necessary for the indications the policy lists; and the stretching device HCPCS codes listed in the Mechanical Stretching Devices policy as not supporting medical necessity.
04For the coding implications of each policy, log on to the provider website and select Medical Policies under Resources.
05Questions go to CalViva Health at 1-888-893-1569.
Codes mentioned
876328763386328L8613L8692E1399E1801E1806E1811E1815E1816E1818E1830E1831E1840E18411527115278H61.111H61.119O09.521O09.529G40.001G40.009G40.201G40.209G40.309G40.A09G40.409G40.509G40.802G40.909G40.911G40.919G40.813G40.814
Original notice
20-947 Medical Policies - 3rd Quarter 2020
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
Related changes
See all Health Net changes →20-944 Medical Policies - 3rd Quarter 2020MediumNo effective date · Prior Authorization20-946 Medical Policies - 3rd Quarter 2020MediumNo effective date · Prior Authorization23-013 Bill Correctly to Get Paid for Pulmonary Testing and Skin Substitute ClaimsHighEffective Mar 15, 2023 · Reimbursement23-014 Bill Correctly to Get Paid for Pulmonary Testing and Skin Substitute ClaimsMediumEffective Mar 15, 2023 · Prior AuthorizationBrowse every Health Net change in the policy list
Related policy hubs
Health Net policiesCA policy changesInfectious DiseaseOB-GYNPediatricsPain ManagementOrthopedicsPlastic SurgeryNeurologyPsychiatryWound CareVascular SurgeryPhysical TherapyDermatologyHematologyOncologyTransplant SurgeryEmergency MedicineGastroenterologyGeneral SurgeryCode 87632Code 87633Code 86328Code L8613Code L8692Code E1399Code E1801Code E1806Code E1811Code E1815Code E1816Code E1818Code E1830Code E1831Code E1840Code E1841Code 15271Code 15278Code H61.111Code H61.119Code O09.521Code O09.529Code G40.001Code G40.009Code G40.201Code G40.209Code G40.309Code G40.A09Code G40.409Code G40.509Code G40.802Code G40.909Code G40.911Code G40.919Code G40.813Code G40.814