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26-1192m Updates to Clinical Policies – September 2026
Effective date
Sep 1, 2026
Identified
Oct 16, 2026
Summary
Health Net updated five clinical policies effective September 2026, including changes to hospice services criteria, obstetrical home care visit requirements, durable medical equipment coverage (including removal of ankle-foot orthotics and lower extremity prosthetics codes, and addition of new device categories), orthognathic surgery measurement thresholds, and allogeneic hematopoietic progenitor cell therapy to include TREGZI. Billing and prior authorization workflows must be updated to reflect removed HCPCS codes, new approval increments for wearable cardioverter-defibrillators, and revised clinical criteria.
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What to do
Action · 9 steps
01Already effective September 2026: Billing team must verify implementation of the following changes across all affected Health Net plans in California.
02Remove HCPCS codes L1933, L1952 (ankle-foot orthotics) and L8030, L8035 (lower extremity prosthetics) from billing and prior authorization systems, and deny or redirect claims for these removed benefits.
03Update prior authorization workflows for wearable cardioverter-defibrillators (cardiac equipment) to reflect 30-day increments approval language.
04Update clinical criteria in billing/PA systems for obstetrical home care (CP.MP.91) to reflect one initial home or virtual visit with phone/virtual follow-up as needed.
05Implement new orthognathic surgery criteria (CP.MP.202) changing overjet threshold to ≥5mm (previously >5mm) and maxillary/mandibular discrepancy to ≥4mm (previously >4mm).
06Add TREGZI criteria to hematopoietic progenitor cell therapy policy (CP.MP.249).
07Confirm current applicability of all changes and verify no conflicting benefit contract language overrides these policies.
08Contact Health Net Provider Services using the line-of-business-specific phone numbers provided if clarification is needed.
09Changes apply to Ambetter IFP/PPO/HMO, Health Net employer group plans, and Medi-Cal in specified California counties (Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare, Tuolumne).
Codes mentioned
L1933L1952L8030L8035
Original notice
26-1192m Updates to Clinical Policies – September 2026
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.