Skip to Main Content

23-1243m Medical Policies - September 2023

Date: 10/30/23

Check out the new policies and the latest changes to existing medical policies for procedures and services

The medical policies listed in this update were approved for September 2023. These policies may apply to CalViva Health members if there are no available medical policies from the California Department of Health Care Services. For a complete description of the background, criteria, references, and coding implications for the medical policies, go to Medical Policies.

Purpose of medical policies

Medical policies offer guidelines to help determine medical necessity for certain procedures, equipment and services. They are not intended to give medical advice or tell providers how to practice. If required, providers must get prior authorization before services are given.

Medical policies vs. member contract

All services must be medically needed unless the member’s benefit plan coverage document states otherwise. This document defines member benefits in addition to eligibility requirements, and coverage exclusions and limits.

  • For Medi-Cal plans, appropriate coverage guidelines take precedence over these plan policies and must be applied first.
  • If legal or regulatory mandates apply, they may override medical policy.
  • If there are any conflicts between medical policy guidelines and related member benefits contract language, the benefits contract will apply.

New Policies

Medical policy

Policy statement

CP.MP.250 –

Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy

This policy describes the medical necessity criteria for Lantidra (donislecel), an allogeneic pancreatic islet cellular therapy, used for the treatment of type 1 diabetes in those who are unable to reach target hemoglobin A1c (HbA1c).

HNCA.CP.MP.679 – Palliative Care Eligibility Criterial

This policy describes eligibility criteria for adult and pediatric members.

Updated Policies

Policy number and name

Change

CP.MP.101 –

Donor Lymphocyte Infusion

Updated all criteria in statements I. and II.

CP.MP.248 –

Facility-Based Sleep Studies for Obstructive Sleep Apnea

Corrected I.B.8.a.i. to require either continuous, chronic nocturnal oxygen use or moderate to severe pulmonary function impairment instead of both.

CP. MP.69 –

Intensity-Modulated Radiotherapy

  • Added Criteria I.G.9. uterine neoplasms.
  • Added Criteria I.G.10. pancreatic cancer.
  • Added Criteria I.G.11. stage III non-small cell lung cancer.

CP.MP.57 –

Lung Transplantation

Revised adult and pediatric criteria to align with International Society for Heart and Lung Transplantation (ISHLT) 2021 consensus document. 

CP.MP.246 –

Pediatric Kidney Transplant

  • Description updated to include source information for policy criteria.
  • Updated Criteria I.A.1. from glomerular filtration rate (GFR) ≤ 15 mL/min/1.73m2 to GFR < 15 mL/min/1.73m2 to align with Kidney Disease: Improving Global Outcomes (KDIGO) guidance and Organ Procurement Transplant Network (OPTN) guidance.
  • Updated Criteria I.A.2. to include members/enrollees with chronic kidney disease (CKD) stage 4 with GFR < 30 mL/min/1.73m2 who are expected to reach end stage renal disease (ESRD) to align with KDIGO guidance and OPTN guidance.
  • Updated contraindications in I.B. consistent with KDIGO guidelines.

CP.MP.133 –

Posterior Nerve Stimulation for Voiding Dysfunction

Revised policy statement and all criteria verbiage in Criteria I.

CP.MP. 166 –

Sacroiliac Joint Interventions for Pain Management

  • Added [thrust tests may not be recommended in pregnant members/enrollees or those with connective tissue disorders] to I.A.1.c. for clarity.
  • Updated time requirements in I.A.1.d.i. and iii. to reflect four weeks.

Inactive policies

The following policies have been retired:

Policy number

Policy name

N/A

ADHD Clinical Practice Guideline

CP.MP.158

Ambulatory Surgery Center Optimization

Additional information

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

 



Last Updated: 10/26/2023