24-1349m Medical Policies - November 2024

Date: 12/30/24

Review the most recent changes to existing medical policies for procedures and services plus one retired policy

The medical policies listed in this update were approved for November 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 webpage.

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

Policy number and name	Change
CP.MP.145 – Electric Tumor Treatment Fields	Changed I.A.1.a.ii. From ≥ 60 to Karnofsky Performance Status of ≥ 70. Added I.A.1.b.ii. "Member has good performance status, as defined by a Karnofsky Performance status rating of ≥ 70.”
CP.MP.248 – Facility Based Sleep Studies for Obstructive Sleep Apnea	Minor rewording in Criteria I., I.A., and I.B.3. with no impact to criteria. Updated wording in Criteria I.B.9.a.v. and added addition of disorders that interfere with home sleep apnea testing (HSAT). Removed “moderate to-high-risk” verbiage in Criteria I.B.9.b. and updated outline of this criteria. Removed Epworth Sleepiness Scale criteria from I.B.9.b.i. Added Criteria I.B.9.b.ii.c) which states, “Diagnosis of hypertension.” Minor rewording in Criteria II. with no impact to criteria.
CP.MP.22 – Stereotactic Body Radiation Therapy	Updated I.I. and II.H. from “inoperable spinal tumors causing compression or intractable pain” to “spinal tumors.” Removed example of trigeminal neuralgia from criteria II.J. as already stated in II.E.

 

Retired Policy

Policy number	Name
CP.MP.151	Transcatheter Closure of Patent Foramen Ovale.

 

Additional information

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.