25-1004m Medical Policies - August 2025

Date: 09/19/25

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

The medical policies listed in this update were approved for August 2025. These policies may apply to CHPIV 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

Policy number and title	Summary of changes
CP.MP.166 Sacroiliac Joint Interventions for Pain Management	Added note regarding criterion applicable to Medicare plans. Updated Criterion I. to specify that imaging guidance must be fluoroscopic or computed tomography. Added “posterior pelvic pain provocation test” to I.A.1.c. for clarity. Coding reviewed.
CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Injections	Added note in Description regarding policy for caudal or interlaminar epidural steroid injections. Removed anticoagulation therapy requirement in Criteria and added anticoagulation therapy as a note in Criteria. Updated Criterion II.D.3. from two months to three months regarding relief and functional improvement. Removed Criterion II.D.4. regarding length of time since last transforaminal epidural steroid injection (TFESI).
CP.MP.247 Transplant Service Documentation Requirements	Updated policy statement I. regarding transplant evaluations by removing “following the first human leukocyte antigen…”

 

Additional Information

If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141. Behavioral Health providers can call 844-966-0298.

 

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

This information applies to Medi-Cal in Imperial County.