26-073 Updates to the Prior Authorization Requirements
Date: 01/26/26
Changes to codes requiring prior authorization, effective April 1, 2026
As part of our ongoing work to improve the prior authorization (PA) process for physicians, practitioners, other providers and members, Health Net, on behalf of CalViva Health, is sharing some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.
How to access prior authorization requirements
Use either option below to access the Medi-Cal PA requirements list:
- Go to the Provider Library > Medi-Cal > Prior Authorization Requirements (on the left side).
- Go to Prior Authorizations and select Fresno, Kings and Madera counties – CalViva Health.
Additions, effective April 1, 2026
The below services, procedures, equipment or outpatient pharmaceuticals require PA beginning April 1, 2026.
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Category | CPT/HCPCS code |
|---|---|
Reconstructive and cosmetic surgery, services and supplies: Eye or brow procedures | 14060 |
Reconstructive and cosmetic surgery, services and supplies | 21235, 31254, 31256, 31267 |
Outpatient surgery: wrist or thumb surgery | 25447 |
Cardiac procedures: transluminal angioplasty on an additional unilateral tibial or peroneal artery | 37232 |
Cardiac procedures: intravascular stent | 37236, 37237, 37238, 37239 |
Balloon angioplasty | 37246, 37247, 37248, 37249 |
Outpatient surgery: laparoscopic myomectomy | 58545 |
Outpatient surgery: thyroid | 60240, 60252, 60500 |
Neurostimulator | 64555, 64561, 64568 |
Cardiac procedures: percutaneous transluminal coronary angioplasty additional artery branch | 92921 |
Electroencephalogram
| 95700, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95721, 95722, 95723, 95724, 95725, 95726 |
Hyperbaric oxygen therapy | 99183, G0277 |
Unlisted services and procedures | 99199 |
Enteral nutrition products | B4104, B4105 |
Outpatient pharmaceuticals: Nulojix® | J0485 |
Durable medical equipment (DME): incontinence supplies | T4525, T4526, T4527, T4528, T4529, T4530, T4533, T4543 |
Removals, effective April 1, 2026
The below services, procedures, equipment or outpatient pharmaceuticals no longer require PA beginning April 1, 2026.
Category | CPT/HCPCS code |
|---|---|
Outpatient elective surgery: pediatric members ages 0-20 | 11105, 11106, 11107, 26055, 29848, 52000, 52005, 52204, 52351, 54161, 54640, 64718, 64719, 64721 |
DME: adults − items with a total Medi-Cal purchase price greater than $1,500 | A4322, E0600 |
Pediatrics: DME for pediatric members | E0730 |
DME: wheelchair accessory | E0950, E0956 |
Orthotic | L2330 |
Prosthetic | L8420, L8440, L8470, L8480, L8485 |
Wound care | 13131, 13132, 13133, 13153,13160, 97602, 97605, 97606, 97607, 97608, 97610 |
Genetic counseling | S0265 |
Need help? Contact us
If you have questions regarding the information contained in this update, contact CalViva Health at
888-893-1569. Behavioral Health providers can call 844-966-0298.
This information applies to Physicians, Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.