26-1033m Updates to Clinical Policies – July 2026
Date:
08/27/26
Review updates including retired policies, effective June 2026
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 July 2026. For a complete description of the background, criteria, references and coding implications for the 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 physicians, practitioners and other providers how to practice. If required, physicians, practitioners and other 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
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Policy number and title
| Summary of changes
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HNCA.CP.MP.692
Acne Treatment
| - Medi-Cal policy.
- Coverage criteria for surgical acne extraction procedures (CPT 10040) when the member has a clinically diagnosed acne condition, has failed appropriate conservative treatment, and the lesions cause significant functional impairment, risk of irreversible skin damage, or other serious medical complications.
- Procedures such as laser treatment, chemical exfoliation and chemical peels for acne are considered not medically necessary.
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Updated policies
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Policy number and title
| Summary of changes
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HNCA.CP.MP.169 Cosmetic and Reconstructive Surgery
| - Added vulvectomy and labia reduction as not medically necessary for purely cosmetic reasons to Criteria II.MM.
- Added references to Acne Treatment policy for Medi-Cal members.
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CP.MP.82 NICU Apnea Bradycardia Guidelines
| - Updated Criteria I.A.1.b. to clarify clinically significant bradycardia.
- Updated verbiage in Criteria I.A.2. for clarity.
- Updated language in Criteria I.A.2.a. for clarity and included “with no evidence of another acute condition requiring inpatient management.”
- Updated formatting and added clarifying language in Criteria I.A.2.b.
- Removed previous Criteria I.A.3.b. regarding being discharged home with a cardiorespiratory monitor.
- Removed verbiage regarding cardiorespiratory monitor and providing stimulation in Criteria I.A.3.c.
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CP.MP.85 Neonatal Sepsis Management Guidelines
| - Updated Criteria I.A.1. to include level I nursery.
- Removed all instances of revenue codes throughout policy criteria.
- Background updated and added Table 1 regarding nursery level and corresponding revenue code.
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CP.MP.86 Neonatal Abstinence Syndrome Guidelines
| - Updated verbiage in Criteria I.A. for clarity.
- Removed use of the modified Finnegan Neonatal Abstinence Scoring Tool (FNAST) from Criteria I.A.1.
- Removed requirement for using the Eat, Sleep, Console (ESC) approach and added duration of treatment language in Criteria I.A.2.
- Added Note at the end of Criteria I.A.2. regarding assessment and management utilizing the modified FNAST or the ESC approach.
- Removed language regarding level II nursery in Criteria I.B.
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| - Added “with no significant clinical signs of withdrawal for 24 to 48 hours after applicable pharmacologic therapy” and removed language specific to morphine in Criteria I.C.2.
- Removed Note at the end of Criteria I.C.2. regarding the half-life of morphine and added this information to the Background section.
- Updated verbiage in Criteria I.C.4. to specify that parent(s) or caregiver(s) have received education regarding neonatal abstinence syndrome (NAS) and routine infant care and demonstrate understanding of and agreement with the plan of care.
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CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia
| - Under I., replaced “guidelines” with “criteria.”
- Under I.I., added “Ability to measure” and removed “will be measured.”
- Removed previous risk factors I.J.10., 12., 16. and 17.
- Under I.K. removed “TSB is within the levels noted in Table 1 below …” along with Table 1 and added “TSB level is equal …”.
- Removed “*Note: The TSB home phototherapy …”.
- Under II., removed “American Academy of Pediatrics” due to redundancy.
- Removed “The values in Table 1 …” and replaced with “at or above the “escalation of care.”
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CP.BH.200 Transcranial Magnetic Stimulation
| - Updated policy sections II.A and IV.A to include the U.S. Food and Drug Administration cleared Magstim Horizon 3.0 TMS Therapy Systems as an option for adolescents.
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CP.BH.300 Biodfeedback for Behavioral Disorders
| - In policy statement I and II, reduced the maximum amount of treatment sessions from “25” to “20.”
- In I.D., added “and no known clinical factors …”.
- In I.E., added “without inclusion of adjunctive intervention.”
- Added I.G.2. “Identification of the specific biofeedback modality.”
- In I.H., added “in accordance with applicable state law …”.
- In I.J. and II.E.1., added “learned self-regulation techniques.”
- In II.B. added, “symptom severity and clinical presentation.”
- In II.C., removed the 25% threshold.
- In II.D., added “and/or other evidence-based interventions …”.
- In III.C., added “and has improved to a level that no longer …”.
- Added III.G., “A transition plan has been implemented.”
- In III.H., added “can be maintained following” and “when clinically appropriate.”
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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 and Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, 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.
