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25-1123m Updates to Clinical Policies - September 2025

Date: 10/29/25

Review new and upcoming changes, effective September 2025

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

New Policy

Policy number and title

Summary

CP.MP.251

Radiation Therapy for
Skin Cancer

  • Policy developed and
  • Reviewed by external specialist.
  • Although surgical excision remains the primary treatment for skin cancer, radiation therapy serves an integral role in both definitive and adjuvant contexts. Radiation therapy is a fundamental treatment modality for skin cancers, offering curative potential in members/enrollees who are not candidates for surgery and reducing the risk of recurrence and metastasis when used as adjuvant therapy.

Updated Policies

Policy number and title

Summary of change(s)

CP.MP.108

Allogeneic Hematopoietic
Cell Transplants
for Sickle
Cell Disease

  • Removed age limit criteria from previous Criterion I.A.1.a. and previous Criterion I.A.2.a.
  • Added clarifying language to Criterion I.A.1.b. regarding high risk of stroke.
  • Removed first-degree relative donor requirement for cord blood as the source of stem cells for homozygous β-thalassemia in Criterion I.A.2.a.i.
  • Removed Criterion I.A.5. regarding provider specializing in treating thalassemia.
  • Removed serial blood and urine testing details in Criterion I.B.3.
  • Added Note at end of Criterion I. regarding younger recipients having better outcomes following allogenic hematopoietic cell transplant (AHCT).
  • Updated verbiage in Criterion II.C. for clarity.

CP.MP.107

Durable Medical Equipment
and Orthotics and Prosthetic Guidelines

  • Added Criterion I.A.1. “Equipment is necessary and reasonable…” along with corresponding note.
  • Added HCPCS codes E0680 and E0681 to non-pneumatic compression devices.

CP.MP.202

Orthognathic Surgery

  • Minor verbiage updates throughout policy with no impact to criteria.
  • Updated I.A.2.c. to "with impingement of palatal soft tissue."
  • Updated I.B.5.a. to Intolerant to or failed a trial of PAP and I.B.5.b to "Has failed....less invasive surgical procedures."

CP.MP.138

Pediatric Heart Transplantation

  • Updated verbiage in I.D.10. regarding liver disease and removed I.D.18.
  • "BMI ≥ 35 or BMI…" Edit made to now I.D.20. removing the sentence "Serial blood and urine…"
  • Removed Appendix A regarding BMI charts.

 

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.
 



Last Updated: 10/28/2025