MedicaidPrior AuthHigh impact
26-1032m Updates to Clinical Policies – July 2026
Health Net·CA · Dermatology, Plastic Surgery, Pediatrics +2 more·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Aug 28, 2026
Summary
Community Health Plan of Imperial Valley released 1 new clinical policy and 6 updated policies effective July 2026 affecting prior authorization requirements and coverage criteria for acne treatment, neonatal care, behavioral health, and phototherapy. Key changes include new acne treatment guidelines, revised neonatal sepsis/abstinence syndrome protocols, reduced biofeedback session limits, and new TMS system approval. Billing teams must update authorization workflows and stop billing certain procedures as medically unnecessary.
Action Required
By July 1, 2026: 1) BILLING TEAM - Update prior authorization system to reflect new acne treatment policy (HNCA.CP.MP.692): CPT 10040 (surgical acne extraction) now requires prior auth documentation of failed conservative treatment, clinically significant functional impairment, and risk of irreversible damage. Laser treatment, chemical exfoliation, and chemical peels remain non-covered and should be denied. 2) BILLING TEAM - Remove laser acne, chemical exfoliation, and chemical peel procedures from covered services in billing software. 3) PROVIDER TEAMS (Dermatology/Plastic Surgery) - Update documentation templates to capture required criteria for acne extraction (conservative treatment failure, functional impairment, skin damage risk). 4) BILLING TEAM - Update biofeedback billing limits: maximum treatment sessions reduced from 25 to 20 sessions (CP.BH.300). Adjust authorization templates to reflect new caps. 5) PRIOR AUTH TEAM - Add new TMS device option (Magstim Horizon 3.0) to approved adolescent TMS authorization criteria (CP.BH.200). 6) NICU/PEDIATRIC BILLING - Review and update neonatal sepsis (CP.MP.85), neonatal abstinence syndrome (CP.MP.86), neonatal apnea/bradycardia (CP.MP.82), and phototherapy (CP.MP.150) authorization criteria per policy updates; remove outdated revenue code references and update clinical scoring tool requirements. 7) VULVOVAGINOPLASTY CODING - Vulvectomy and labia reduction procedures now classified as non-medically necessary for cosmetic purposes (CP.MP.169); coordinate with providers on appropriate coding and prior denial expectations. Failure to implement will result in claim denials and authorization delays.