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26-1191m Updates to Clinical Policies – September 2026

Date: 10/15/26

Review updates, effective September 2026

The medical policies listed in this update were approved for September 2026. These policies may apply to Community Health Plan of Imperial Valley 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 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.

Updated policies

Policy number and title

Summary of changes

CP.MP.54

Hospice Services

  • Updated Criteria II.G.4. to specify prothrombin time (PT) > 5 seconds “over control.”

CP.MP.91

Obstetrical Home Care Programs

  • In I., updated page numbers in table of contents.
  • In I.E.1., revised to “one initial home or virtual visit, with additional phone or virtual follow-up as needed.”
  • In Table 1 in Background, added ondansetron and note regarding its use.
  • Updated Betamethasone therapy via intermittent injections section and added section regarding Makena injections in Background.

CP.MP.107

Durable Medical Equipment and Orthotics and Prosthetics Guidelines

  • Under section Cardiac Equipment, Wearable Cardioverter- Defibrillator (WCD), added “and will be approved in 30-day increments” for clarity.
  • Under Section Diabetes Care Equipment, under “Blood glucose monitor with integrated voice synthesizer,” replaced “are legally blind” with “have a severe visual impairment.”
  • Section Heat, Cold & Light Therapy Equipment, under “Ultraviolet panel lights” moved “panel lights should be considered …” to “Note.”
  • Removed “Ankle-foot Orthotics (AFO)” and applicable criteria including HCPCS codes L1933, L1952.
  • Removed “Prosthetics and additions: Lower Extremity” and applicable criteria including HCPCS codes L8030, L8035.
  • Consolidated language in section on Vacuum erection devices.
  • Added section “External Lower Extremity Sensory Prosthetic Device (Walkasins®).”
  • Removed “Volara™” from “Intrapulmonary percussive ventilation devices.”
  • Added section “Oscillation and Lung Expansion (OLE) Therapy Devices.”

CP.MP.202

Orthognathic Surgery

  • Updated Criterion I.A.1.a. from an overjet of > 5 mm to ≥ 5 mm.
  • Updated Criterion I.A.1.b. from a maxillary/mandibular anteroposterior molar relationship discrepancy of > 4 mm to ≥ 4 mm.
  • Added Note at the end of Criteria I.A.1. stating that the values represent two or more standard deviations from published norms.
  • Added clarifying language in Criterion I.A.3.b. and Criterion I.B.5.a.

CP.MP.249

Allogeneic Hematopoietic Progenitor Cell Therapy

  • Updated Description section to include TREGZI.
  • Added Criteria III. to include medically necessary criteria for TREGZI.
  • Background and reference list updated to include TREGZI information to align with updated criteria.

 

Need help? Contact us

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 and Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Imperial County.



Last Updated: 10/14/2026