MedicaidCoverageHigh impact
26-1033m Updates to Clinical Policies – July 2026
Health Net·CA · Dermatology, Pediatrics, Critical Care +2 more·Prior Authorization
Effective date
Jun 1, 2026
We identified it
Aug 28, 2026
Summary
Health Net/Centene updated seven clinical policies effective June 2026, including new coverage for surgical acne extraction (CPT 10040) under Medi-Cal, clarifications to neonatal care guidelines (apnea/bradycardia, sepsis, abstinence syndrome, hyperbilirubinemia), expanded TMS therapy device options for adolescents, and reduced biofeedback session limits from 25 to 20. Billing teams must update prior authorization requirements, remove outdated revenue code references from neonatal policies, and implement new coverage exclusions for cosmetic procedures.
Action Required
REQUIREMENTS:
1. By June 1, 2026 (already effective): Billing team must update system to add CPT 10040 (Extraction of comedo) to COVERED services under Medi-Cal only when clinical documentation shows: diagnosed acne condition, failed conservative treatment, and significant functional impairment/irreversible skin damage risk. All other acne procedures (laser, chemical peels, exfoliation) remain NOT covered.
2. By June 1, 2026 (already effective): Update prior authorization requirements in billing system for NICU policies (CP.MP.82, CP.MP.85, CP.MP.86, CP.MP.150) to remove revenue code references—these are now listed in policy background/tables only. Remove revenue code field requirements from neonatal prior auth submission forms.
3. By June 1, 2026 (already effective): Billing team must update Cosmetic and Reconstructive Surgery policy (HNCA.CP.MP.169) documentation to flag vulvectomy and labia reduction as NOT medically necessary for purely cosmetic reasons in Criteria II.MM. Train staff to deny claims for these procedures unless medically necessary documentation is provided.
4. By June 1, 2026 (already effective): Update behavioral health billing system to reflect maximum of 20 biofeedback sessions (CP.BH.300) instead of previous 25. Flag claims exceeding 20 sessions for denial. Notify behavioral health providers of session limit reduction.
5. By June 1, 2026 (already effective): Update TMS therapy policy (CP.BH.200) in system to include Magstim Horizon 3.0 as FDA-cleared option for adolescents. Revise prior auth criteria to accept this device.
6. Immediately (ongoing): Contact Health Net Provider Services for clarification on neonatal policy changes: Medi-Cal line at 800-675-6110 (no email) or behavioral health at 844-966-0298. Consequence: Claims submitted without updated authorization rules will be denied; neonatal claims with obsolete revenue code documentation may be rejected.