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26-357m Updates to Clinical Policies – February 2026

Date: 03/20/26

Review upcoming changes, including concert genetic testing policies, effective February 2026

The medical policies listed in this update were approved for February 2026. 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..

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 change(s)

CP.MP.249

Allogeneic Hematopoietic Progenitor Cell Therapy

  • Updated Criterion I. to include severe aplastic anemia as a medically necessary indication for Omisirge.
  • Background updated to reflect updated criteria.
  • References updated.
  • Reviewed by internal specialist.

HNCA.CP.MP.55

Assisted Reproductive Technologies

Policy updated to reflect benefit changes for large group commercial plans and select small group commercial plans.

CP.MP.136

Home Birth

Removed previous criteria I.C. through I.I. and created new criteria I.C.1. through I.C.8.

CP.MP.180

Implantable Hypoglossal Nerve Stimulation

Updated verbiage in Criterion I. from “all of the following criteria” to “either of the following criteria.”

CP.MP.141

Non-myeloablative Allogeneic Transplant

  • Added Criterion I.A.9. for Hodgkin lymphoma.
  • Updated verbiage in Criterion I.A.10.a. for clarity.

CP.MP.102

Pancreas Transplant

  • Under Criterion I.A.1., specified “type I” and removed “(members/enrollees with requirements…).
  • Under I.B.1.a., replaced “require” with “required” and “room” with “department.”
  • Under I.B.2.c., removed “(does not have to be…)” and added “or dialysis dependent.”
  • Under. I.B.3.c.ii., added “specified as greater than 500 mg/day.”
  • Moved contraindications under I.B. to I.C.

CP.MP.162

Tandem Transplant

  • Updated Criterion I.A.2. to include ovarian germ cell tumors.
  • Updated Criterion I.A.3. from neuroblastoma characteristics from the International Neuroblastoma Staging System (INSS) to characteristics from the International Neuroblastoma Risk Group Staging System (INRGSS) and Children's Oncology Group (COG) neuroblastoma high-risk disease group.
  • Background updated to reflect information regarding INRGSS.

 

Concert genetic clinical policy updates

New policies added:

  • Concert Genetic Testing: Nutrition and Metabolism
  • Concert Genetic Testing: Identity and Forensics

Updated policies:

  • Cardiovascular
  • Dermatology
  • Endocrinology
  • Gastroenterology
  • General Approach to Genetic and Molecular Testing
  • Hematology
  • Hereditary Cancer
  • Immunology and Rheumatology
  • Multisystem Genetic Conditions
  • Nephrology
  • Neurology
  • Oncology: Algorithmic Assays
  • Oncology: Cancer Screening and Surveillance
  • Oncology: Hematologic Malignancy
  • Ophthalmology
  • Orthopedics
  • Otolaryngology
  • Preimplantation Genetic Testing
  • Prenatal Diagnosis
  • Prenatal Screening
  • Respiratory
  • Solid Tumor Molecular Diagnostics
  • Toxicology and Pharmacogenetics
  • Transplant

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.



Last Updated: 03/19/2026