25-473m Medical Policies - April 2025

Date: 05/21/25

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

The medical policies listed in this update were approved for April 2025. 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.

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.175 Air Ambulance	Description and Criteria I.B.1. were updated to include water ambulance. Criteria I.B.2. was updated for clarity.
CP.BH.500 Behavioral Health Treatment Documentation Requirements	Updated policy statement I. to reflect “all” behavioral health treatment records…and all of the following elements, “as applicable.” Reworded Criteria I.D. and I.E., for clarity. Added Criteria I.H. “Each service encounter…” and I.I. “Results of required screenings…” Moved the previous Criteria I.M. “Plan for ongoing treatment…” under Treatment plan in I.K.1. Added Discharge summary criteria in I.P.1–4.
CP.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention	Changed ‘both’ to ‘all of the following’ in Criteria I. Removed contraindications I.B.1.–I.B.11. Thrombocytopenia or known coagulation… Added Criteria I.C. “Ability to tolerate short-term anticoagulants.” Removed Note: Warfarin may be required…
CP.MP.146 Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins	Removed “only” from Criteria I.D.1. Removed requirement of a documented lidocaine allergy from Criteria I.D.2.
CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds	Removed note under Description to refer to MC.CP.MP.185 for Medicare plans. Updated and replaced the previous Criteria I.A. through I. with new Criteria I.A. through G. Coding updated to reflect the addition of a preferred product list in Criteria I.E. Also updated and replaced the previous Criteria II.A. through C. with new Criteria II.A. through G.
CP.MP.247 Transplant Service Documentation Requirements	Added requirements in Criteria I.C. for post-transplant follow-up visits. Added a ‘Note’ under Criteria I.C.2. regarding other requests.

 

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.

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