MedicaidPrior AuthHigh impact
26-1031m Updates to Clinical Policies – July 2026
Health Net·CA · Dermatology, Pediatrics, Critical Care +1 more·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Aug 28, 2026
Summary
CalViva Health updated 7 clinical policies effective July 2026, including new coverage criteria for acne treatment (CPT 10040), refined neonatal care guidelines (apnea/bradycardia, sepsis, abstinence syndrome, hyperbilirubinemia), expanded TMS therapy device options for adolescents, and reduced biofeedback treatment sessions from 25 to 20 maximum. Prior authorization requirements apply to multiple procedures under these policies for Medi-Cal members in Fresno, Kings, and Madera counties.
Action Required
By July 1, 2026: (1) Billing team must implement prior authorization requirement for CPT 10040 (surgical acne extraction) for CalViva Health Medi-Cal members in Fresno, Kings, and Madera counties when medical necessity criteria are met (failed conservative treatment, significant functional impairment, risk of irreversible damage). Update billing system and encounter forms accordingly. (2) Clinical staff must update neonatal care protocols for policies CP.MP.82, CP.MP.85, CP.MP.86, and CP.MP.150 to reflect new documentation and assessment requirements—specifically removing cardiorespiratory monitor discharge criteria, removing FNAST/ESC mandatory requirements, and updating TSB measurement language. (3) Psychiatry/Behavioral Health providers must update TMS device roster to include Magstim Horizon 3.0 as approved option for adolescents (policy CP.BH.200). (4) Behavioral Health providers must reduce maximum biofeedback sessions from 25 to 20 and add documentation requirements for specific modality identification and learned self-regulation techniques per policy CP.BH.300. (5) Providers must verify member contract language supersedes policy guidelines; escalate any conflicts to compliance. Claims for acne laser treatment, chemical exfoliation, and chemical peels will be denied as non-medically necessary. Failure to obtain prior authorization for CPT 10040 will result in claim denials.