25-1357m Updates to Clinical Policies - November 2025
Date:
12/18/25
Review upcoming changes, effective November 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 November 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.
New Policy
|
|---|
Policy number
and title
| Summary
|
|---|
HNCA.CP.MP
Testing for Drugs of Abuse
| - Reinstating the Testing for Drugs of Abuse policy for Med-Cal
members only. - Use ASAM non-profit criteria for Commercial/Marketplace members.
|
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Updated Policies
Policy number and title
| Summary of change(s)
|
|---|
CP.MP.145
Electric Tumor Treating Fields
| Changed I.A.1.a.ii and b.ii. from Karnofsky Performance Status (KPS) rating of
≥ 70 to ≥ 60.
|
CP.MP.248
Facility-Based Sleep Studies for Obstructive Sleep Apnea
| - Description updated to include titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS).
- Added clarifying language in Criterion I.B.6. with no impact on criteria.
- Updated verbiage in Criterion I.B.7. for clarity with no impact to criteria.
- Added Criterion IV. to include titration PSG for HNS.
- Added “non-Medicare” verbiage in Criterion V. for clarification.
- Background updated to include information regarding titration PSG for HNS. Coding and descriptions reviewed. References reviewed and updated. Reviewed by internal specialist and external specialist.
|
CP.MP.144
Mechanical Stretching
Devices for Joint Stiffness
and Contracture
| - Added “toe” to criteria under I.
- Under I.A.1.a., added “therapist.”
- Reworded criteria under I.A.1.c. with no impact to criteria.
- Added CPT codes E1820, E1828, E1829, E1830, E1832 to ‘HCPCS codes that support coverage criteria table.’
|
CP.MP.188
Pediatric Oral Function Therapy
| - Updated Criterion I. to specify initial pediatric oral function therapy.
- Added Criterion I.B. regarding adequate treatment for any contributing underlying medical conditions … and documentation of an individualized treatment plan …
- Added Criterion II. regarding requirements for continuation of pediatric oral function therapy.
|
CP.MP.185
Skin and Soft Tissue Substitutes for Chronic Wounds
| - In policy statement I., specified that criteria is applicable to “up to four initial applications …”
- Under Criterion I.F., removed “FDA approved” and replaced with “labeled.”
- Added criteria I.G – I.I.
- Created new policy statement II. and criteria for “beyond the initial four applications and up to a total of eight …”
- In III.A., added that non-medically necessary indications include usage not listed in section II. of the policy.
- Added the following to the table of HCPCS codes that do not support medical necessity: A2036, A2037, A2038, A2039, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397.
- Removed Q4104 and Q4106 from list of codes not supported by medical necessity criteria, as they are on the preferred product list.
|
CP.MP.247
Transplant Service Documentation Requirements
| - Added notes under Description regarding plan-approved criteria for medical necessity criteria for solid organ and stem cell transplant requests and criteria applicable to Medicare plans.
- Added transplant consultation to Criterion I.
- Updated verbiage in Criterion I.A.2. for clarity.
- Changed criteria I.A.2.a.-c. into a note.
- Added additional note under the third bullet for Criterion I.A.2. regarding evaluation requests for sickle cell anemia and beta thalassemia.
- Updated Criterion I.B. to specify initial and subsequent autologous stem cell transplants or initial and subsequent allogeneic stem cell or solid organ transplant listing requests.
- Updated verbiage in Criterion I.B.4. for clarity.
- Removed body mass index (BMI)I from Criterion I.B.5.e. since BMI is addressed in Criterion I.B.3.c.
- Updated Criterion I.B.5.g. to include lumbar puncture when clinically indicated.
- Verbiage updated in Criterion I.B.6. for clarity.
- Updated verbiage in Criterion I.B.7. to “breast cancer screening,” “cervical cancer screening,” and “colon cancer screening” and removed note that routine health screenings per standards of care are not required for autologous stem cell transplants.
- Removed “including cardiology” from Criteria I.B.8.
- Added Criterion I.B.9. regarding cardiology testing/clearance.
- Removed verbiage specifying only solid organ or allogeneic stem cell transplants in Criterion I.B.11.
- Updated verbiage in criteria I.B.11., I.B.11.f., and I.B.11.h. for clarity.
- Updated verbiage in criteria I.D., I.D.2., and I.D.3. for clarity.
- Background updated with no impact to criteria. References reviewed and updated. Reviewed by internal specialist.
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Need help? Contact us
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.
