MedicaidDocumentationHigh impact
26-816m Updates to Clinical Policies - May 2026
Health Net·CA · Dermatology, Wound Care, Bariatric Surgery +3 more·Prior Authorization
Effective date
May 1, 2026
We identified it
Jun 30, 2026
Summary
CalViva Health has updated six medical policies effective May 2026, including new documentation and treatment duration requirements for skin substitutes, updated lipedema surgery criteria, extended transplant evaluation validity from 6 to 12 months, new ICD-10 codes for pulmonary function testing, expanded behavioral health documentation requirements, and retired two policies (sacroiliac joint fusion and cochlear implant replacements). Billing teams must implement these changes immediately to avoid claim denials and ensure compliance with prior authorization requirements.
Action Required
By May 1, 2026: Billing and clinical teams must implement the following changes: (1) For CP.MP.185 (Skin and Soft Tissue Substitutes): Update billing system and prior authorization templates to require documentation of wound size greater than 1 square centimeter with photographic evidence including ruler scale; limit treatment requests to 4-week intervals; add new HCPCS codes Q4110, Q4188, Q4432 to billing system. (2) For CP.MP.244 (Liposuction for Lipedema): Remove subcutaneous nodules criterion from prior authorization logic; update conservative treatment documentation to include psychosocial support; remove the 6-month consecutive treatment requirement from approval criteria. (3) For CP.MP.247 (Transplant Service Documentation): Update authorization validity period from 6 months to 12 months in system; set automatic alerts at 11-month mark to prompt new authorization requests. (4) For CP.MP.58 (Intestinal and Multivisceral Transplant): Add CPT codes 44137 and 48554 to billing system; update prior authorization forms to include large desmoid tumor criteria and retransplantation criteria. (5) For CP.MP.242 (Pulmonary Function Testing): Add ICD-10 codes G71.036, I27.841, I27.848, I27.849 to system code lists for medical necessity validation. (6) For CP.BH.500 (Behavioral Health Documentation): Update documentation templates to include all new requirements (legal vs. preferred name notation, mental health diagnosis certification, treatment plan review attestation per state guidelines, evidence-based designation, individual participation identification, addenda documentation protocol); communicate changes to behavioral health providers and update submission checklists. (7) Stop billing and filing claims for retired policies CP.MP.126 (sacroiliac joint fusion) and CP.MP.14 (cochlear implant replacements); create system alerts to deny submissions on these codes. Providers must obtain prior authorization before rendering services. Failure to comply will result in claim denials and member billing complications.