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24-1109m Medical Policies - September 2024

Date: 10/16/24

Review the most recent changes to new and existing medical policies for procedures and services

The medical policies listed in this update were approved for September 2024. 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. That 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.

Updated Policies

CPT Copyright 2024 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Policy number and name

Change

CP.MP.108 –

Allogeneic Hematopoietic
Cell Transplant for Sickle
Cell Disease

  • Added note at end of Description regarding criteria related to Casgevy®.
  • Reformatted all notes in policy description.
  • Reformatted Criteria I.A. to specify ‘One of the following…’

CP.MP.180 –

Implantable Hypoglossal Nerve Stimulation

  • Added Criteria II. regarding drug induced sleep endoscopy (DISE) being medically necessary when completed to evaluate the appropriateness of a hypoglossal nerve stimulation device.
  • CPT code “42975” added.

CP.MP.202 –

Orthognathic Surgery

  • Updated Criteria I.A.1.b. from greater than 4 mm to 4 mm or greater.
  • Updated Criteria I.A.2.c. to include irritation of buccal or lingual soft tissues of the opposing arch.
  • Added clarifying language to Criteria I.A.3.b.

 

Retired Policies

Policy number

Name

CP.MP.53

Ferriscan R2-MRI

HNCA.CP.MP.456

Ultrafiltration for Heart Failure

 

Additional information

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569. Behavioral Health providers can call at 844-966-0298.
 

This information applies to Physicians, Participating Physician Groups (PPGs), and Behavioral Health Providers.

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



Last Updated: 10/16/2024