26-629 Updates to Prior Authorization Requirements
Date: 05/20/26
Incontinence supplies change, effective now, and new codes, effective April 1, 2026
This provider update includes prior authorization (PA) requirement changes for Community Health Plan of Imperial Valley.
These changes apply to services, procedures, equipment and outpatient pharmaceuticals (submitted under the medical benefit).
Refer to the changes below.
How to access prior authorization requirements
Use either option below to access the Community Health Plan of Imperial Valley PA requirements:
- Go to Prior Authorizations and select Imperial County – Community Health Plan of Imperial Valley (CHPIV).
- Go to the Provider Library > Medi-Cal > Prior Authorization Requirements.
Change, effective immediately
PA is only required for incontinence supplies beyond 186 units per calendar month or the $165 per month benefit limitation — whichever is greater.
Category | HCPCS code |
|---|---|
Incontinence supplies | T4521, T4522, T4523, T4524, T4525, T4526, T4527, T4528, T4529, T4530, T4533, T4543 |
Additions, effective April 1, 2026
The below services, procedures, equipment and outpatient pharmaceuticals require PA as of April 1, 2026, per new CPT and HCPCS codes issued by the Centers for Medicare & Medicaid Services.
Category | CPT/HCPCS code |
|---|---|
Advanced imaging − CT
| G0680 |
Genetic testing | 0616U, 0617U, 0618U, 0619U, 0620U, 0621U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U, 0628U, 0629U, 0630U |
Neuro and spinal cord stimulators, including procedures | C8007, C8008, C8011, C8012, |
Outpatient pharmaceuticals − Inlexzo® | J9183 |
Outpatient pharmaceuticals − Keytruda Qlex® | J9277 |
Outpatient pharmaceuticals − Lynozyfic™ | J9601 |
Outpatient pharmaceuticals − Camcevi ETM®
| J9003 |
Outpatient pharmaceuticals − Immune Globulin Yimmugo® | J1553 |
Outpatient pharmaceuticals − Denosumab agents | Q5161, Q5162 |
Outpatient pharmaceuticals gene therapy − Car-T Papzimeos™ | J3404 |
Outpatient pharmaceuticals gene therapy − Itvisma® | C9309 |
Orthotics − custom | A8005, A8006 |
Proprietary laboratory analyses | 0614U, 0615U |
Prosthetics
| L5992 |
Skin substitutes and biologicals | A2040, A2041, A2042, A2043, A2044, A2045, G0681, G0682, G0683, G0684, Q4418, Q4419, Q4421, Q4422, Q4423, Q4424, Q4425, Q4426, Q4427, Q4428, Q4429, Q4435, Q4436, Q4437, Q4438, Q4439, Q4440 |
CPT Copyright 2025 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
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, Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Imperial County.