Medicare AdvantagePrior AuthHigh impact
26-818m Updates to Clinical Policies - May 2026
Health Net·CA · Dermatology, Wound Care, Bariatric Surgery +4 more·Prior Authorization
Effective date
May 1, 2026
We identified it
Jun 30, 2026
Summary
Health Net/Centene released May 2026 policy updates affecting prior authorization requirements, documentation standards, and billing codes across six clinical policies. Key changes include new wound size thresholds for skin substitutes, extended transplant evaluation validity from 6 to 12 months, retirement of two procedures (sacroiliac joint fusion and cochlear implant replacements), and enhanced behavioral health documentation requirements. Billing teams must implement these changes immediately as they affect claim authorization, code usage, and documentation workflows.
Action Required
By May 1, 2026: Billing team must implement the following changes: (1) For CP.MP.185 (Skin/Soft Tissue Substitutes): Update billing system to enforce wound size minimum of >1 square centimeter and require photographic evidence with ruler for scale before claim submission. Limit requests to 4 weeks of treatment at a time. Add Q4110, Q4188, Q4432 to active code tables. (2) For CP.MP.244 (Liposuction/Lipedema): Remove prior auth denial criteria for subcutaneous nodules and update to include psychosocial support documentation; remove 6-month minimum requirement for conservative treatment. (3) For CP.MP.247 (Transplant Documentation): Update authorization validity period from 6 months to 12 months in system; flag cases requiring reauth after 12 months instead of 6 months. (4) For CP.MP.58 (Intestinal/Multivisceral Transplant): Add retransplantation criteria and CPT codes 44137, 48554 to coverage tables. (5) For CP.MP.242 (Pulmonary Function Testing): Add ICD-10 codes G71.036, I27.841, I27.848, I27.849 to approved diagnosis codes. (6) For CP.BH.500 (Behavioral Health): Update documentation requirements to include legal name/preferred name reconciliation, mental health diagnosis certification, evidence-based treatment verification, and addenda documentation rules. (7) Immediately discontinue processing for retired codes: CP.MP.126 (Sacroiliac joint fusion) and CP.MP.14 (Cochlear implant replacements)—deny claims under these policies. Notify providers through system alerts and contact resources. Failure to implement will result in claim denials, authorization failures, and compliance issues.