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26-817m Updates to Clinical Policies - May 2026

Date: 06/29/26

Review updates including retired policies, effective May 2026

The medical policies listed in this update were approved for May 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.185

Skin and Soft Tissue Substitutes

  • In I.B., II.B., IV.C., V.C., VI.C., and VII.C., added that wound must be greater than 1 square centimeter.
  • Added to IV.B., V.B., VI.B. and VII.B. that the request is for up to 4 weeks of treatment at a time.
  • In I.K., II.E.6.b., IV.K.1., V.J.1., VI.I.1., and VII.J.1., noted that photographic evidence of wound size, including with a ruler for scale, is required.
  • In V.H., added that “the graft will be applied in a single layer …”
  • Corrected 03/26 revision log to note that codes Q4110, Q4188 and Q4432 were added to HCPCS code table 3.

CP.MP.244

Liposuction for Lipedema

  • Removed Criteria I.C. regarding subcutaneous nodules of adipose tissue.
  • Updated Criteria I.F. regarding conservative treatment to include “psychosocial support based on assessed need.”
  • Removed “for at least 6 consecutive months” in Criteria I.G.

CP.MP.247

Transplant Service Documentation Requirements

  • Updated note under criteria section I. stating “…transplant evaluations are effective for 6 months. After 6 months passes, a new authorization…” to “…transplant evaluations are effective for 12 months. After 12 months have passed a new authorization…”

CP.MP.58

Intestinal and Multivisceral Transplant

  • Added criteria under II.A.6-II.A.7, “Large desmoid tumors …”
  • Added retransplantation criteria under III.
  • Added CPT codes 44137, 48554.

CP.MP.242

Pulmonary Function Testing

  • Added the following to ICD-10 Table 1: G71.036, I27.841, I27.848, I27.849.

CP.BH.500

Behavioral Health Treatment Documentation Requirements

  • In Policy Statement I, removed “Centene Advanced Behavioral Health” and added the note, “Billed units not fully …”
  • In I.B., added the note, “If legal name differs from the preferred name …”
  • In I.E., added certification language: “Certification of the mental health diagnosis is rendered by …”
  • In I.F., added “… with applicable code.”
  • In I.K., clarified the statement by adding “duration” and “based on the member/enrollee’s current clinical presentation.”
  • Added I.L.4 and I.L.5 to attest to review of the treatment plan within state-approved guidelines and timeframes.
  • Added “evidenced based” to I.N.
  • Added new I.O. " Identification of all individuals who actively participated ..."; included an accompanied note to I.O. on PHII data.
  • Added note to I.P. “When progress is not demonstrated …”
  • Added I.Q. “Addenda created to supplement …” with an accompanied note to document that the addenda is intended to clarify or correct existing documentation.

 

Retired policies

Policy number

Policy title

CP.MP.126

Sacroiliac joint fusion

CP.MP.14

Cochlear implant replacements

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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: 06/29/2026