25-1212m Updates to Clinical Policies - October 2025
Date:
11/18/25
Review upcoming changes, effective October 2025
The medical policies listed in this update were approved by Centene’s Corporate Clinical Policy Committee and/or Health Net’s Medical Advisory Council (MAC) for October 2025. 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 a medical policy.
- If there are any conflicts between medical policy guidelines and related member benefits contract language, the benefits contract will apply.
CPT Copyright 2024 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
Updated Policies
|
|---|
Policy number and title
| Summary of change(s)
|
CP.BH.104
Applied Behavioral
Analysis (ABA)
| - Updated autism spectrum disorder diagnosis information in I.A. to include identification of severity level, intellectual impairment, language impairment and known medical, genetic, or environmental factors.
- Added clarifying timeframe components for treatment initiation to I.B.1.a.
- Added “diagnostic interview/evaluation has been conducted within 12 months of the authorization request if the comprehensive diagnostic evaluation (CDE) was conducted more than three years ago and less than five years ago, meeting all the following ..." to I.B.1.a.ii.
- Added clarifying conditions to determine the need for a diagnostic reevaluation to I.B.1.b.
- Added CDE documentation requirements to I.B.2.
- Separated assessment tools (primary and parent caregiver) and clarified the need for two assessment tools including at least one primary clinician tool in I.B.2.c.vi.
- Added physical health concerns to I.B.3.
- Added specific provider recommendation information to I.C.
- Added signature requirements to I.D.
- Added clear verbiage regarding visual representation to I.E.2.b.vi. Removed “FBA assessment” and replaced with distinctive “maladaptive and skills acquisition assessments” to I.E.2.b.vi.a) and b).
- Added a note to I.E.2.b.vi.b) viii) indicating the need for an additional direct skills assessment if Vineland is used.
- Added clarifying details to the individualized treatment plan to
I.E.2.c. i-iii. - Added a dedicated crisis plan to I.E.2.c.iv.
- Added detailed school-based criteria to I.E.2.c.v.
- Added detailed criteria to justify treatment hours to I.E.2.c.vii.a)-c).
- Revised treatment hours from "focused ABA (10-25) comprehensive ABA (30-40)" to "does not exceed six hours per day up to 30 hours per week" to I.E.2.c.vii.d) i) 1). Added clinical justification for hours beyond 6 days, 30 hours per week to I.E.2.c.vii.d). i). 2). Added "treatment takes into consideration developmental level..." to I.E.2.c.vii.d).ii).
- Replaced “hours of supervision” with “Adaptive Behavior Treatment with Protocol Modification, for at least 2 hours per week or 10% of direct service” in I.E.2.c.ix.
- Added coordination of care to I.E.2.c.x.
- Added detailed parent/caregiver training to I.E.2.c.xi.
- Added detailed transition planning to include discharge consideration to I.E.2.c.xii.
- Added the need for an updated behavior assessment to I.E.3.c.
- Added documentation of percentage of scheduled successful sessions with a note if attendance falls below 80% to I.E.3.d.
- Added continuation of parent caregiver training to I.E.3.e.Added coordination of care and communication to I.E.3.f.
- Removed reference of “supervision hours, qualitative and quantitative data” from the updated treatment plan and replaced with clear guidance on “transition planning and titration plan” in I.E.3.g.
- Added detailed criteria for progress/lack of progress with goals to I.E.3.i. and j.
- Added clarifying information regarding lack of clinically significant progress to II.C.
- Replaced "orientation and mobility" with "physical therapy" in III.B.7.
|
HNCA.CP.MP.55
Assisted Reproductive Technology
| Added Assisted Hatching as medically necessary per the Department of Managed Care All Plan Letter 729, Treatment of Infertility, under Female Reproductive System, #8.
|
CP.MP.37
Bariatric Surgery
| - Updated Description to include single-anastomosis duodenoileal bypass (SADI)/single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S).
- Added SADI/SADI-S to Criterion I.A.1.a.i. and to Criterion I.A.1.a.ii.
- For age ≥ 18 and body mass index ≥ 27.5 and < 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults or ≥ 30 and < 35 kg/m²: removed indication I.A.1.a.ii.a) for continued obesity despite prior attempts at weight loss.
- Removed Criterion I.A.1.b.i. regarding BMI ≥ 40 kg/m² for age < 18 years.
- Removed severe comorbidities listed in Criterion I.A.1.b.ii. for age < 18 years with BMI ≥ 35 kg/m².
- In Criterion I.B.1, changed “Medical clearance by member/enrollee’s primary care physician if no current cardiac or pulmonary comorbid conditions or clearance by cardiologist and/or pulmonologist for those with such conditions” to “medical evaluation from a physician other than the surgeon ...”
- SADI-S added to Criterion II.B. as a medically necessary procedure following conversion from laparoscopic adjustable gastric banding (LAGB).
- Removed SADI from Criterion III.I.
- Background updated so that SADI/SADI-S is no longer listed as an investigational procedure.
- Added CPT code 43999 for SADI-S procedure.
|
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the Health Net provider portal.
Behavioral health providers can call 844-966-0298.
Provider Services
This information applies to Physicians, Participating Physician Groups (PPGs), and Behavioral Health Providers.
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.
