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26-1190m Updates to Clinical Policies – September 2026
Effective date
Sep 1, 2026
Identified
Oct 16, 2026
Summary
CalViva Health updated five clinical policies effective September 2026, including revised criteria for hospice services, obstetrical home care, durable medical equipment/orthotics/prosthetics, orthognathic surgery, and allogeneic hematopoietic progenitor cell therapy. Key billing-relevant changes include removal of two lower extremity prosthetic HCPCS codes (L8030, L8035) and AFO codes (L1933, L1952), clarified WCD approval increments, and updated DME coverage criteria. These changes apply to CalViva Health Medi-Cal members in Fresno, Kings, and Madera counties.
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What to do
Action · 5 steps
01Effective September 2026 (already in effect as of analysis date 2026-10-16): Billing team must immediately verify current applicability and update claim submission workflows for CalViva Health Medi-Cal in Fresno, Kings, and Madera counties.
02Stop billing removed lower extremity prosthetic codes L8030 and L8035, and AFO codes L1933 and L1952; verify whether any pending claims use these codes and contact CalViva Health at 888-893-1569 to confirm claim status and resubmission requirements.
03Update DME billing system to reflect criterion changes: WCD devices now approved in 30-day increments (clarify approval duration logic in authorization tracking), blood glucose monitors with voice synthesizer now require 'severe visual impairment' rather than 'legally blind' (update eligibility verification forms and prior auth request templates).
04Review orthognathic surgery prior authorization criteria changes (overjet and molar relationship thresholds now use ≥ instead of >); alert providers that requests using old thresholds may be denied.
05Providers should contact CalViva Health Behavioral Health line (844-966-0298) if questions arise on behavioral health policy changes.
If missed: Failure to remove deleted codes may result in claim denials for non-covered services.
Codes mentioned
L1933L1952L8030L8035
Original notice
26-1190m Updates to Clinical Policies – September 2026
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.