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25-591m Medical Policies - May 2025

Date: 06/18/25

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

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 May 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 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 name

Change

HNCA.CP.MP.65

Prolotherapy

  • It is the Plan’s policy that there is insufficient evidence to support the efficacy of prolotherapy for musculoskeletal pain or any other indication.

Updated Policies

Policy number and name

Change

CP.MP.244

Liposuction for Lipedema

  • Removed requirement for mandatory secondary review in policy statement I.
  • Updated conservative treatment requirement in I.F. from six months to three months.

CP.MP.210

Repair of Nasal Valve Compromise

  • Under I.C. added (e.g., sinusitis, …) and removed “including all of the following …”
  • Removed I.C.1.-I.C.4. Sinusitis…Under I.D. added (e.g., nasal cones, …) and removed D.1.-D.4. “Eight week trial …).

CP.MP.58

Intestinal and Multivisceral Transplant

  • Added clarifying language in Policy/Criteria section and in Criteria II.A.1.
  • Updated Criteria II.A.1.a. to include TPN induced liver injury for clarity and changed “peristomal” to “stomal.”
  • Added hospitalization requirement for clarity in Criteria II.A.1.c.
  • Separated Criteria II.A.1.c. into two criteria points.
  • Clarifying language added to Criteria II.A.1.d.
  • Updated “post-mesenteric” to “portomesenteric” in Criteria II.A.2.5.
  • Updated GFR from < 30 mL/min/1.73m2 to < 40 mL/min/1.73m2 in Criteria II.B.3.
  • Removed information about heart transplant waiting list from Criteria II.B.4.b.
  • Removed Criteria II.B.5. for other GI diseases.
  • Removed Criteria II.B.6. for acute liver failure or cirrhosis.
  • Removed Criteria II.B.12. contraindication regarding absence of an adequate support system.

CP.MP.87

Therapeutic Utilization of Inhaled Nitric Oxide

  • Merged changes and revision log entries from 11/24 and 7/24 policy versions.
  • Under I.A.6., changed oxygen index (OI) > 20 to > 25.
  • Moved I.A.7. to III.A.1.
  • Removed criteria under III.A.1.
  • Continues to require iNO as evidenced.

CP.MP.114

Disc Decompression Procedures

  • Updated language in Criteria I.C.1.b.ii. for clarity.
  • Updated Criteria I.C.1.b.ii.a) regarding physical therapy.
  • Updated language in Criteria I.C.2. for clarity.
  • Updated Criteria I.C.2.a. regarding physical therapy.
  • Added Table 1 – Medical Research Council Manual Muscle Testing Scale.

CP.MP.132

Heart-Lung Transplant

  • Updated criteria I.A.1.h.iv. and I.A.2.h.iv. from, “… could preclude heart failure in the future …” to “… could preclude heart transplant in the future ...”

CP.MP.188

Pediatric Oral Function Therapy

  • Updated “sensory issue” to “neurodevelopmental disability” in Criteria I.G. for clarity.
  • Added Criteria I.H. regarding limited food intake due to hypersensitivity.

 

Additional Information

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

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: 06/13/2025