MedicaidPrior AuthHigh impact
26-817m Updates to Clinical Policies - May 2026
Health Net·CA · Wound Care, Plastic Surgery, Bariatric Surgery +4 more·Prior Authorization
Effective date
May 1, 2026
We identified it
Jun 30, 2026
Summary
Community Health Plan of Imperial Valley updated six active clinical policies effective May 2026, with the most significant changes affecting skin/soft tissue substitutes (new wound size and photographic documentation requirements), liposuction for lipedema (removed nodule criteria, expanded conservative treatment), transplant services (extended evaluation validity from 6 to 12 months), intestinal/multivisceral transplant (added desmoid tumor criteria and new CPT codes), pulmonary function testing (added four ICD-10 codes), and behavioral health documentation (comprehensive requirements overhaul). Two policies were retired: sacroiliac joint fusion and cochlear implant replacements.
Action Required
By May 1, 2026: (1) BILLING TEAM: Update prior authorization system rules for CP.MP.185 to require wound documentation >1 cm with photographic evidence including ruler scale; limit authorizations to 4-week treatment periods. (2) CODING TEAM: Add CPT codes 44137 and 48554 to intestinal/multivisceral transplant billing logic; add ICD-10 codes G71.036, I27.841, I27.848, I27.849 to pulmonary function testing validation tables. (3) PROVIDERS: Update clinical documentation templates for skin/soft tissue substitutes to include wound photography with measurement scale and for transplant evaluations to reflect 12-month (not 6-month) validity period. (4) BEHAVIORAL HEALTH PROVIDERS: Implement new documentation requirements per CP.BH.500 including legal name verification, mental health diagnosis certification, evidence-based treatment attestation, and treatment plan review documentation per state guidelines. (5) ALL STAFF: Remove sacroiliac joint fusion (CP.MP.126) and cochlear implant replacement (CP.MP.14) from covered procedure lists; deny any claims submitted under these retired policies. For liposuction lipedema claims, stop requiring 6-month conservative treatment documentation but continue requiring psychosocial support assessment. Failure to comply will result in claim denials and potential compliance violations.